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objectives research on life stressors and adverse life events has a long tradition few studies have addressed this topic in connection to very old people life stressors especially major life stressors experienced by clients of home care services in the community have rarely been the subject of studies considering this gap we investigated the prevalence of mlss in home care clients we examined the effects that mlss have on their mood and health status as well as the impact of clients social resources on mlss and their outcomes method we used assessment data from 2884 home care clients in six european countries the methodological basis was the comprehensive and standardized interrai home care assessment results fifteen point four percent of the samplethat consisted of women and men with an average age of 8289 yearsexperienced an mls in the last 6 months before the assessment they were more depressed than persons without these experiences and their health status indicated a higher level of instability and deterioration at reassessment after 6 months the situation changed despite the fact that both outcomes of the mlss depression and health status became worse in the reassessmentsample home care clients without mls were more affected by the worsening especially that of depression the expected buffering impact of social resources was low discussion although this study worked with limited information on mlss it could contribute to closing various knowledge gaps the study shows that the mlss represent a prevalent problem in a population of home care clients and that this problem has negative consequences for their mood and the stability of their health status furthermore this research took up the situation of very old and vulnerable adults who have previously rarely been considered in studies on major critical life events and stressors introduction research on critical life events and life stressors has generated a respectable body of knowledge however when studies on life stressors in health sciences and psychology are considered more closely knowledge gaps become obvious since the nineteenseventies researchers have investigated events that cause a considerable change of life they have concentrated not only on negative and stressful experiences but also on positive life changes such as the birth of a child jobrelated advancement etc both types of changes have been recognized as having a pathogenic impact on the life course and overall health both have been identified as powerful risk factors for cardiovascular disease and hypertension researchers have developed typologies of people in middle age problems of behavior regulation coping and overcoming the stressors entered the research agenda yet the risk of functional dependency in older people as a consequence of the life events was not considered in those days later the association between critical life events and depression moved to the foreground critical life events as flash points of mental illnesses became an important subject of studies on clinical populations for instance on small samples of hospitalized psychiatric patients mazure reported on 14 studies on life events and stressors completed between 1980 and 1990 most of them worked with ∼33 participants the largest one with 227 participants larger samples were addressed by some communitybased studies the common targets were younger females university students or children the researchers developed diagnostic instruments and treatment strategies just for these groups over time a large number of possible life stressors has been described death of a family member or close relative or other important person divorce or separation from partner loss of a friend legal problems serious health crises eg notification of a serious diagnosis or financial problems major stressors in older age include bereavement financial loss new physical illness or disability of oneself or of a family member change in living situation and interpersonal conflict bellingtier et al relate mlss to the subjective experience of age despite this tradition and the large amount of existing studies neither a unified definition of the term major life stressor nor a consistent concept exist a variety of terms overlap some authors speak about traumatic events having the potential to affect psychological wellbeing about critical life events or about adverse life experiences p 291 294 still others use uncontrollable events that have adverse biological and behavioral outcomes or the terms loss and exit events such variety reflects an ambiguity of concepts accordingly a comparison of outcomes is difficult and the evaluation of different stressors for individual people is hardly possible above all the effects of shortterm acute stressors which probably constitute the majority of the mlss are less known studies with community dwellers in their normal environment are scarce research concentrates on the clinical environment of hospitals on educational institutions or on laboratory settings as a consequence little is known about the meaning of life stressors for older people in their everyday environment researchers distinguish between acute and chronic stressors p 174 chronic stressors are conceived as discrete events and conditions or constellations of related events that persist over time in the healthy population both acute as well as chronic stressors seem to be associated with depression with chronic stressors having a pronounced impact as far as elderly people who already suffer from depression are concerned both chronic and acute stressors seem to predict an increase in depression however in the context of longterm care the topic of chronic stressors has almost exclusively been investigated in informal or professional caregivers of the elderly care receivers not the elderly themselves some studies have stressed a buffering or moderating effect of social support in the stress depression relationship p 177 independent causal effects were found in older women with depressive symptoms and in bereaved or physically disabled persons tennant who summarized corresponding findings underlined that buffering effects of social support and social relations were identified in children adolescents and young people such as university students against this background of existing research our paper will direct the attention to issues that have not played a big role in available studies life stressors in to date rather invisible clients of home care very old and functionally dependent people who live in the community and are not institutionalized thus we focus on the naturalistic context of longterm care which is the prevailing form of care provision in european countries our research questions are how prevalent are major life events in an international sample of home care clients does the level of the home care clients dependency reduce the frequency of mlss recorded by the assessment do the mlss affect mood and health status of the home care clients do social resources buffer against negative mlsoutcomes immediately and over the course of 6 months materials and methods we used data from 2884 home care clients who underwent a standardized geriatric assessment and two reassessments the first one after 6 months and the second one after 1 year this paper is based on the baseline and the first reassessment the study was carried out in six european countries belgium finland germany iceland italy and the netherlands more details about the entire ibencproject are described elsewhere some information on the sampling procedure should be given here in a first step typical home care organizations were selected in the participating countries in a second step receivers of home care home nursing and home help were recruited only persons who were 65 years of age and older and who already were clients of the service for at least 14 days were included persons with explicitly negative prospects for the next 6 months were excluded ie clients receiving palliative care or end of life care and people facing an impending ending of home care because of the admission to a hospital or nursing facility in this way a possible reduction of the samples between t 0 and t 1 was to be prevented in the netherlands the exclusion criterion probability of nursing home admission in the next 6 months was implemented particularly strictly thus this sample contains fewer cognitively impaired clients than samples from other countries moreover access to home care for less impaired persons was relatively easy at the time of the assessment in the netherlands the fact that the dutch sample contains less severe cases is reflected by some results therein it is apparent that the mean score of cognitive performance in the sample of the netherlands is below zero which means cognitively capable and independent in decision making the geriatric interrai hcassessment contains up to 320 variables covering health and functional status cognition mood social capabilities and behavior basic information on demography living arrangement and living environment is also included four sections are dedicated to the provision of health care the assessments were carried out by professional nurses who provided the normal everyday care in some countries routine data were used this term means that the data were collected in the course of regular health care and nursing to ensure good quality of data a special training was offered to this staff additionally research nurses were available to support the nurses during the process of data collection the procedure of the interrai hc assessment is special the assessors link three to four sources of information their professional evaluation of the status and situation of the individual selfreports of the persons under study information documented in clients records and sometimes also the evaluation by other persons involved with the case of the client for the purposes of this paper only selected variables and scales were analyzed the scales are constructed with interrai hcvariables major life stressor in the last 90 days is a dichotomous variable participants reported whether or not they had experienced a major life stressor in the last 90 days the assessment manual describes the mls as an episode of severe personal illness death or severe illness of a close family member or friend loss of the persons home major loss of income or assets being a victim of a crime eg robbery or assault usually such experiences disrupt or threaten to disrupt a persons daily routine and impose a readjustment the following measures were considered dependent variables or outcomes in the present paper depression rating scale drs describes the mood status of the clients it ranges from 0 to 14 a score of 3 indicates minor and higher scores indicate major depressive disorder the chess scale is a sixpoint scale that helps to identify individuals whose health status is highly unstable and who are at risk of serious decline it ranges from 0 to 5 and the highest levels predict mortality hospitalization negative subjective health ratings and other health deterioration the demographic characteristics considered in the present manuscript were age gender marital status and living arrangement clients dependency was measured by adl and iadl indices as well as by frequency and amount of home care and help services iadl performance reflects the level of actual execution of the instrumental tasks of daily life by the client the score ranges from 0 to 48 functional performance in elementary activities of daily life is measured by the adl hierarchy scale with seven levels starting with 0 and ending with 6 services we took the frequency and amount of services that help with completion of the everyday tasks as further indicators of dependency we selected variables indicating the frequency of home health care and homemaking our question was on how many days of a week do clients receive these services additionally we used variables indicating the amount of both services social resources were measured by six variables mutual visits with a family member and longstanding friends possible responses ranged from never to more than 30 days ago to 30 days ago etc up to in the last 3 days social interaction with family member and longstanding friends by telephone email etc the characteristics and response categories were the same as for the variable visits availability of a strong relationship with the family which makes it possible that the person feels able to rely on family members living arrangement number of informal helpers believes in improvement potential this variable contains two perspectives the clients own belief that heshe will improve hisher status and physical performance on the one hand and the beliefs of the professional caregivers in the improvement potential of the client on the other hand potentially stressful factors we used the pain scale that measures the intensity and frequency of pain during the last three days before the assessment it ranges from 0 to 3 problems in social relations were measured by three continuous variables conflict or anger with family or friends fear of a family member or close acquaintance neglect abuse or mistreatment possible responses were never more than 30 days ago 30 days ago etc up to in last 3 days cognitive status was measured by the cognitive performance scale with seven levels and especially based on daily decision making but including shortterm memory and other items as well the first level is 0 the highest level is 6 results the entire study sample contained 2884 home care clients 674 of which were women the proportion of participants from the six countries ranged from 146 in iceland to 182 in belgium the average of the adlhscore in italy was almost 4 which means extensive need for help the average adlhscore of the entire sample of all countries was only m 187 which indicates limited need for help the italian sample showed similar levels of impairment of the performance in instrumental activities and in cognition in contrast the dutch home care clients were almost independent in adlh and an average cpsscore that indicates that the cognitive performance of the dutch home care clients was practically unimpaired prevalence of major life stressors within 90 days before the assessment at baseline 1540 of the clients reported that they experienced an mls in the past 90 days before the assessment the frequencies differed significantly from country to country χ 2 12502 p 0001 3120 of the dutch home care clients experienced an mls this figure is far above average in contrast the proportion of finnish home care clients who experienced a major stressor was below average with 750 the likelihood of experiencing an mls was higher in the netherlands than in germany or 297 se 017 association of mlss and demographic characteristics home care clients who experienced a major life event in the last 90 days were slightly and significantly younger their average age amounted to m 8218 years whereas persons who did not report an mls were m 8302 years old on average f 510 p 005 this association was not found in all participating samples in those samples where the proportion of mls reports was especially high or especially low no significant association between mls and age was found the prevalence of mlss did not differ between men and women likewise there was no significant difference by living arrangement however among the divorced and separated clients the number of persons who reported an mls was higher than in those who were married and single χ 2 1069 p 005 factors which potentially could be experienced as stressful we focused on pain and on problems of social relations the average painscore of home care clients without the experience of an mls was m 079 the average painscore of clients with mls was higher 557 p 0001 we ran a logistic regression with mls as the outcome and pain as the predictor the higher the painscore the greater the likelihood was that participants reported an mls or 130 se 005 wald χ 2 3015 p 0001 there was no interaction between painscore and the belonging to a countryspecific subsample ie the effect of pain on likelihood of reporting an mls did not differ by country problems of social relations which potentially could be stressful we focused on three variables as far as persisting conflicts with family or friends were concerned their presence was relatively more frequent in clients with mls than without χ 2 2734 p 0001 however it was irrelevant when such conflicts took place the temporal distance between the conflicts and the assessment was not related to the occurrence of the mlss physical dependency does not reduce the probability of assessed mlss cognitive impairment does we ran a logistic regression with mls as outcome and with adlh scale and iadl performance scale as predictors adlhscore and iadlscore were unrelated to the probability of reporting an mls a different picture emerged when impairment of cognitive performance was considered the logistic regression with mls as outcome and cps as predictor showed that the likelihood of reporting an mls decreased with increasing cpsscore or 087 se 004 wald 1390 p 0001 we did not find an interaction between cps and country ie the effect of cps on reporting of mls did not differ between the country subsamples a logistic regression with mls as outcome and frequency and amount of services as predictors showed the higher the number of days of home health care in the past 7 days was the greater was the probability that mls would be recorded in the assessment or 105 se 002 wald 479 p 005 the higher the number of minutes of homemaking services in the past week was the higher was the probability that mls would be captured by the assessment or 100 se 008 wald 2089 p 0001 outcomes of experiencing the mls depression as outcome a clear difference was identified in mood status home care clients who experienced mls were more depressed than those who did not we conducted an independent samples ttest participants with mls had a higher drsscore than participants without mls t 873 p 0001 stability of health status as outcome the chessscore as an indicator for the instability and decline of health status showed differences between home care clients with and without mls we conducted an independent samples ttest clients with mls had a higher chessscore than clients without mls t 781 p 0001 influence of social resources on mlsoutcomes the majority of the home care clients maintain social relations with family members friends and other significant persons only 460 never cultivated mutual visits with these people only 640 never communicated on the phone via email etc 4880 had such mutual visits in the last 3 days before the assessment 1670 in the last week 1000 in the last 2 weeks and 460 a longer time ago the communication by phone or digital tools occurred with about the same frequency 4700 communicated during the last 3 days 1300 in the last week 710 in the last 2 weeks and the rest a longer time before they underwent the interrai hcassessment home care clients with mls reported more recent visits and interactions fifty six point six percent participated in a visit in the last 3 days and 5870 communicated with a close person in the last 3 days neither only two single social variables seemed to have some buffering impact on depression on the one hand it was the number of informal helpers the more informal helpers participants had the less depressed they reported being after a major life event b 033 se 016 f 438 p 005 on the other hand the selfevaluation of the improvement potential played a role drsscore was higher if clients did not believe that their physical function could improve whereas in participants with mls drs was higher if they thought that their physical function could improve b 088 se 034 f 647 p 005 no meaningful influence of social resources on health status in terms of buffering was identified visits b 001 se 004 f 445 p 005 had little effect on health status instability since the effect size was very small and the confidence interval of the parameter estimates included 0 the item other interactions with family and close friends seemed to have a detrimental effect b 005 se 004 f 915 p 005 but again the effect size was very small and the confidence interval included 0 changes over the course of 6 months we examined changes over the course of 6 months ie from baseline to the first reassessment in persons who survived and were not discharged during these 6 months were some of the social resources from baseline still important for buffering against depression and the instability of health status at the first reassessment first we examined changes of the drsscore from baseline to the first reassessment it clearly increased from t 0 to t 1 m d 030 sd 205 t 654 p 0001 however the drsscore increased more in participants without mls than in participants with mls at t 0 this difference was statistically significant t 247 p 0014 afterwards we tested what effects social resources exhibited with regards to changes in drsscore of people who experienced mlss and those who did not our attention was directed to the following variables strong relationship with the family living together with one or more other people mutual visits with familyfriends interaction by phone or email number of helpers own and staff s assessment of a potential for improvement these resources did not play a role in a second step we controlled for changes of the chessscore from baseline to the first reassessment it changed similarly to the drsscore health status became more unstable over the course of 6 months between the assessments t 0 and t 1 as the chessscore went up m d 015 sd 088 t 738 p 0001 in participants without major life event the chessscore increased whereas in participants with mls at t 0 the chessscore decreased or more accurately it almost stayed the same changes in chessscore differed significantly between participants with and without mlss t 403 p 0001 we tested what role social resources played for effects of mls on changes in the chessscore across the whole sample there was no effect of social resources on changes in chessscore from t 0 to t 1 for people who reported mls at baseline the availability of social resources played a role the more social resources in form of mutual visits with family or other social contacts these clients had the more their chessscore increased from t 0 to t 1 it means that the health status became more unstable just in those home care clients with mls at t 0 who had social resources at their disposal in clients without mls at baseline social resources were unrelated to changes in chessscore b 011 se 005 f 428 p 002 we investigated if this could have been the result of the worsening of cognitive performance whichas we could show in section 33was related to the assessment of a smaller portion of mlss this seemed to be the case the general linear model of the reassessment data showed a predictive role of the cpsscore on the chessscore both without the mls at baseline b 012 se 002 t 930 p 0001 and with the mls at baseline b 012 se 004 t 296 p 0005 the same association was not found with regards to the drsscore which decidedly was not dependent on development of cognitive performance over the course of 6 months since the baseline assessment discussion this contribution that is based on a european collaborative study shed light on very old people who receive longterm care while living in the community not in a longterm care institution we investigated to what extend they were burdened by mlss and which consequences it had for them according to our assessment 1540 of study participants experienced an mls within 90 days prior to the assessment the differences between countrysamples were substantial in particular the dutch home care clients were very different from the clients in other countries the mls was assessed in almost one third of them this finding may be caused by the slightly different sampling by the researchers in the netherlands whoas we already explaineddid not include clients with a higher level of cognitive impairment into their sample for several reasons but this assumption must be handled with caution we indeed saw that the likelihood of reporting an mls decreased with the increase of cognitive impairment yet we did not find any effects of cpsscore on reporting of mlss in individual countries we asked if community nurses who collected the data for the ibencstudy paid sufficient attention to the mlss even of very dependent clients we assumed that a high level of dependency could be distracting of such adverse experiences two considerations lead us to this assumption on the one hand not much research on how wellcommunity nurses assess life stressors has been published until today préville et al underlined that psychological distress and signs of depression are not easily detected by home care nurses since these problems often are masked among older adults particularly among frail elderly on the other hand studies on life stressors in the context of longterm care rather rarely focus on carereceivers much more often the caregivers are the focus providing care for an ill or disabled relative represents a burden for the informal caregivers for instance spouses or adult children are frequently exposed to stressors that may place many caregivers at risk for depression research on these problems of caregivers seems to be more important for practical reasons of developing support strategies for them in this context the home care receivers seem to slip the attention of researchers however we could not confirm our primary assumption that a higher level of dependency could reduce the proportion of mlsreports the functional dependency of the clients was unrelated to the mlsreports with a higher frequency and greater amount of professional care and help it was more likely that mlss were reported and recorded in the assessment more service seemed to be an indicator for higher level of dependency yet it may be that clients have a better opportunity to verbalize critical events and stressors visávis the care staff if they get more services equally they may be able to report their mlss also to assessors only cognitive dependency showed different effects two possibilities should be considered impaired cognition may be straining and may therefore redirect staff s attention away from problems like adverse life experiences or because of their reduced cognitive capacity clients with higher levels of cognitive impairment are not capable of expressing their critical experiences and mlss we saw almost no significant association between demographics and the prevalence of mlss age differences were small and gender differences were nonexistent even if some authors argued that older women are especially vulnerable to life events and stressors our assumption that mlss will have negative consequences was confirmed fully the drsscore of home care clients who experienced mlss was higher than the drsscore of clients without such experiences our data could not answer the question about causality however this question remains open in many studies because the onset of depression is dependent on a multiplicity of factors including genetic factors large numbers of life stressors and critical life events are listed nevertheless it remains difficult do decide which of them definitely causes depression and which of them is the major life stressor the explanation varies between individuals life contexts and different stages of life andaccording to a review of studies it varies also between types of depressive disorders we considered the painstatus of the home care clients to be what is called the precipitating or incubating factor that precedes the life stressor experiences indeed we identified the painscore as a predictor the higher the painscore was the greater was the likelihood that participants would report an mls our results could confirm our assumption that persistent interpersonal conflicts with family members and other significant acquaintances may be considered chronical life stressors they seemingly promote the appearance of the mlss in our sample and may have the function of social precursors p 204 we were interested in the issues of social resources that could moderate the negative consequences of the mlss however activities of maintaining social contact and interaction did not have a significant impact on outcomes depression and health status instability both scores became worse during the time between the baseline assessment and the first reassessment this development was significantly associated with the occurrence of mlss in the last 90 days before the baseline assessment but the direction of the association was surprising the drsscore and also the chessscore increased in home care clients who had not experienced an mls whereas they were almost unchanged in clients with mlsexperience at baseline this may be the phenomenon described by tennant who underlined that an effect of stressors often dissipates with the passage of time p 175 this phenomenon was reported in connection to the acute stressors which may be similar to stressors which we call major life stressors in our investigation strengths and limitations our article reports on a study that has various strengths and weaknesses the sample was not composed to be representative for the countries yet it reflects typical home care services the typical composition of their body of clients and finally typical individual clients who are taken care of by the community services in six european countries for a relatively long time the sample was recruited in a naturalistic environment of communitiesa situation which is rare as some life events researchers have stated moreover the number of study participants is larger than in many other studies especially in studies dealing with stressors of older adults eg we believe that the large sample size improves the information value of our analysis the target group of our study are older home care clients ie older than 80 years on average such a population was rarely targeted by studies on life stressors and critical life events even studies that proclaim aging and older adults in their title mainly investigated much younger people for example those around 55 years of age or people who were about 77 years old kraaij et al undertook a metaanalysis of studies on negative life events in elderly persons it included 25 studies but only three of them dealt with participants who were just reaching 80 years of age few studies focused on receivers of longterm care in the community as our study did richardson et al investigated applicants for services provided by the aging services provider network here clients of nonmedical services like advocacy meals delivery transportation and care management were targeted receivers of care or nursing were explicitly not included existing studies in the longterm care environment either targeted the institutionalized population of nursing homes or the professional and informal caregivers of older people one weakness of our study is that our information on the mlss is limited since we only used a dichotomous variable indicating whether or not the client experienced a major life event in the last 90 days before the assessment this weakness should be considered in view of the large diversity of the concepts of life stressors and life events in an assessment like ours no collection of information on details and different characteristics of life stressors was possible conclusion our analysis offers a first approach to the impact of mls in this special population and is therefore an appropriate point of departure for research on this subject continuing research into mlss should take up the issue of the time passage between the mls and the impact on health and wellbeing of individuals dependent on care it should attempt to determine immediate as well as later consequences and those factors that are appropriate to reduce the deterioration of very old people dependent on care data availability statement the datasets generated for this study are available on request to the corresponding author ethics statement the studies involving human participants were reviewed and approved by the ethics committees of the institutions of all contributing study directors the patientsparticipants provided their written informed consent to participate in this study funding the data were collected within the ibencstudy funding by the european commission with the framework of the european union projects in the 7th framework programme under the id 305912 we acknowledge support from the german research foundation and leipzig university within the program of open access publishing 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

garmshomolová et alperspective future research on mlss has to take up the issue of the time passage between the mls and the impact on health and wellbeing of individuals dependent on care it has to determine immediate as well as later consequences and identify those factors that are appropriate to reduce the mlseffects on very old people dependent on care

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introduction background as the population of youths who identify as transgender and genderdiverse youths continues to grow 1 the need for genderaffirming care in pediatric settings substantially exceeds availability leaving many tgd youths who are interested in receiving this care without access to it 2 given that the existing research suggests that access to genderaffirming care during adolescence is associated with improved mental health outcomes 3 4 5 6 7 8 increasing the availability of this care for tgd youths is critical currently the provision of genderaffirming care is largely limited to specialty clinics located within pediatric hospital systems in large urban areas 9 10 11 12 13 14 15 one way to improve the access and remove the barriers to genderaffirming care is by providing such care in the primary care setting however only a few pediatric primary care providers have received training in genderaffirming care 13 14 15 and many are unaware of how to create affirming environments and discuss treatment options available to tgd youths therefore pediatric pcps need opportunities to receive education from and consult gender specialists prior work telehealth has the potential to meet these needs and is an umbrella term that describes both patienttoprovider audiovideo visits and specialisttopcp consultation methods such as teleeducation electronic consultation and telephonic consultation teleeducation platforms connect cohorts of pcps with specialists via the web for live didactic education and case consultation sessions this modality which has been used to facilitate genderaffirming care provision to tgd adults 1617 increases provider knowledge and improves pcps clinical confidence 18 electronic consultation uses storeandforward electronic dialogue to provide patientspecific specialisttopcp consultation this modality which has also shown great promise in facilitating genderaffirming care provision in primary care for tgd adults 19 20 21 22 has led to increased provider knowledge along with decreased barriers to accessing specialty care 23 24 25 finally telephonic consultation which is the most common of these consultation models typically involves pcps calling an oncall specialist to discuss a specific case over the telephone 26 these informal consultations often referred to as curbside consultations have raised concerns among specialists regarding the quality of care patient safety documentation and compensation 2627 goal of this study given the increasing prevalence of gender diversity 1 the inaccessibility of pediatric genderaffirming care among many youths 212 and the lack of training among pediatric pcps we must develop specialisttopcp telehealth platforms to guide pcps in providing genderaffirming care these platforms are critical because they can provide remote training and consultation thus broadening the reach of pediatric genderaffirming care services to diverse and underresourced settings and populations to our knowledge no prior studies have been conducted with pediatric pcps about how best to use specialisttopcp telehealth platforms such as teleeducation telephonic consultation and electronic consultation to support them in providing genderaffirming care to tgd youth thus the purpose of this qualitative study was to explore pediatric pcps perspectives regarding optimal ways to provide telehealthbased support to facilitate genderaffirming care provision in pediatric primary care settings methods recruitment potential participants were identified from a list of community pediatric providers across washington wyoming alaska montana and idaho who had either previously called or emailed the seattle childrens gender clinic team for support with a patient management question or attended continuing medical education training provided by scgc in the 2 years before recruitment the participants were recruited via email by a member of the research team who provided an overview of the proposed study invitations to participate in the study were sent to 69 potential participants via email of these 69 individuals 20 completed a screening survey that was used to determine study eligibility eligibility criteria included the following currently in practice delivering ambulatory primary care to patients aged 18 years and able to complete an hourlong audiovideo interview via zoom 28 of 20 individuals who completed the survey 15 agreed to participate in a semistructured interview with a member of the research team trained in qualitative research data collection demographic information was collected from the screening survey and included participants age race ethnicity gender identity years in practice and practice location the number of tgd youths they have seen in their practice and the number of patients they have referred to scgc details regarding teleeducation preferences were collected using semistructured interviews based on guides developed with input from 3 pediatric pcp stakeholders and a community advisory board of tgd youths and their parents the interview guide consisted of 2 parts the first part explored pcps perspectives regarding their role in providing genderaffirming care and the barriers they have faced in the primary care setting the second part of the interview presented 3 different telehealth modalities using standardized definitions and each participant was asked to xsl • fo renderx share their perspectives on the following the benefits and drawbacks of each modality which modality would be most effective in supporting them in providing genderaffirming care in the primary care setting and the most important characteristics or outcomes of a successful platform the data presented in this paper are limited to those collected in the second portion of the interview data analysis interview transcripts were automatically generated via zoom with an embedded transcription software and were cleaned and corrected by 2 trained research coordinators then the transcripts were independently coded by 2 members of the research team using a codebook consisting of 64 codes that was developed in partnership with a pcp stakeholder who is currently providing genderaffirming care to tgd youths themes were then iteratively generated using a reflexive thematic analysis framework 29 coding was performed using the qualitative analysis software dedoose 30 ethics approval the participants provided informed consent to participate in the study and received a gift card worth us 20 for their participation all study procedures were approved by the scgcs institutional review board before recruitment results participant characteristics interviews were completed with 15 pediatric medical providers including advanced practice providers pediatricians and family medicine physicians currently providing outpatient clinical care to youths aged 18 years the participants represented a wide range of years in practice with onethird having practiced for 10 years and 40 having practiced for 5 years nearly half of the participants practiced in an urban area whereas the remaining practiced in rural and suburban environments roughly half of the participants indicated that they had seen 15 tgd patients whereas onethird indicated that they had seen ≤10 tgd patients finally 40 of the participants indicated that they had referred 5 patients to a gender clinic for care with the remaining 60 stating that they had referred ≤5 patients perspectives on the proposed telehealth platforms teleeducation platform with respect to the advantages of the teleeducation platform the following themes were identified developing a network with other pcps that facilitates shared learning receiving comprehensive didactic and casebased learning having scheduled education sessions and increasing provider confidence in delivering genderaffirming care textbox 1 themes primary care providers identified as benefits and drawbacks of the teleeducation platform benefits xsl • fo renderx important to increase their knowledge about genderaffirming care provision i think one of the main benefits is feeling connected to other providers in your community or beyond your communitythere can be a lot of isolation in primary care when youre providing services that arent provided by everybody so i think thats really awesome the community aspect of it and i think that hearing other people talk about their cases is really valuablelistening to my colleagues present is always something thats really interesting to me and i feel like i learned a lot that way in addition the pcps appreciated that the teleeducation sessions typically took place at a scheduled time making it easier for them to coordinate with their clinical schedules the participants particularly those who already had some training in genderaffirming care felt that having access to teleeducation would help increase their confidence in providing genderaffirming care especially during the early stages of providing such care especially in a time when youre doinginformation gathering to see if its something that is transferable to your clinic environment teleeducation can be really valuablehonestly if something like this in the beginning had existed i would have been very likely to take it on in terms of the drawbacks of the teleeducation platform the pcpidentified themes were as follows requiring a significant time commitment and not allowing for realtime patientspecific consultation regarding time some pcps noted not feeling that they would be able to commit enough time to participate this was especially true for providers who reported seeing a fewer number of tgd patients and those practicing in close proximity to a gender clinic pcps also cited concerns that participating in the teleeducation platform would decrease their clinical productivity in a system where we are paid on productivityme taking two hours to go to a teleeducation thing is six patients that im not seeing right which is25 of my patient load for the day which is 25 less pay right andits not really about the money butim held to a productivity standard if im not meeting thati think you would lose people because you either have to do it before or after work or they have to do it instead of seeing patients pcps also mentioned feeling that it would be very difficult to schedule the sessions at a time that is mutually convenient for a large group of providers finally pcps noted that in comparison with electronic and telephonic consultation the cadence with which scheduled teleeducation sessions take place would limit their ability to receive support regarding patientspecific management questions the teleeducation session is probably happening once a month or every other month so if you had a case and it just happened last week youre now waiting two months to present this patient electronic consultation with respect to the advantages of the electronic consultation model themes were identified convenient and efficient communication documentation in the electronic health record ability to bill for provider time and sufficient time to synthesize information textbox 2 themes primary care providers identified as the benefits and drawbacks of electronic consultation benefits • theme 1 convenient and efficient communication • we have patients constantly throughout the day but we have a few minutes here and there where we can finish up typing and talk to this person so having electronic consultation would be amazing because i could just quickly type in my question and then knowing that no ones expecting an immediate response i could go back and see some patients and could carry on with my day and then when the consultation comes back in i can use my few minutes between the next patient and look at it we as primary care providers seem to have like three to five minutes here and there throughout the day we dont have a full twenty minutes or half an hour to be on the phone conducting a telephonic consultation • theme 2 documentation in the electronic health record • so i think having the electronic record to be able to refer back to would be awesome because maybe the question you asked about for one patient will apply to a patient in the future so then you can just reference back to it i think thats a huge strength • theme 3 ability to bill for provider time • you know so youve got some people that are like on a cerner platforms some are on epic some on all scripts some are next gen you know were still not in this place where we have standardized the utility of our electronic health records and they dont talk to each other so i think that that could be problematic • 1b using an unfamiliar ehr to submit clinical questions • the thing that was uncomfortable for me initially and ive done a few electronic consultations with a psychiatrist now is that i as the doc have to talk to the family about how this is going to be billed to their insurance • theme 5 may be less helpful for providers who lack baseline knowledge regarding genderaffirming care • i probably wouldnt really use the electronic consultation right now becauseim not serving that many patients but once i had more of a baseline education and i have more of a population that im serving it could be very helpful pcps noted that unlike telephonic consultation electronic consultation gave them the flexibility to submit the consultation question and review the response at times that were convenient for them which was especially helpful in ensuring that the consultation did not detract from the existing patient care responsibilities pcps also noted the benefit of receiving timely specialist recommendations in writing which is not often possible with telephonic consultations similarly the participants found the documentation of both their consultation and the specialists response in the ehr to allow them to refer back to it in the future should a similar question arise for another patient to be particularly helpful in addition a few providers noted that the electronic consultation had the potential to allow both themselves and the specialist receiving the consult to be reimbursed for their time which is not possible with telephonic consultations finally some pcps noted feeling that the act of submitting an electronic consultation would help them to better communicate their clinical questions to the specialist multiple pcps cited concerns about being unfamiliar with the ehr used by specialists in their area and that making an electronic consultation system available only to those who use a specific ehr would make it inaccessible for many pcps in addition specific concerns arose about the textbased electronic consultation communication which some felt could feel impersonal make it challenging to relay the specific nuances of a case or lead to miscommunications between providers the participants also discussed concerns that electronic consultation may not provide opportunities to engage in backandforth dialogue with a specialist as opposed to telephonic consultation and regarding limited opportunities for networking with other providers as would be possible with teleeducation another concern reported by pcps regarding electronic consultation was not having the ability to receive an answer to their clinical question in real time as they would be able to do with telephonic consultation finally some providers expressed discomfort with the idea of having to inform patients and families that they would be billed for the electronic consultation this was illustrated well by a provider who had previously used an electronic consultation platform for psychiatry i i hate talking about money right i just want to take care of patients so i expected talking about billing for the electronic consultation with a psychiatrist to be a very uncomfortable conversation where i say you know i can reach out to our pediatric psychiatrist but this is a special consult and it will be billed to your insurance and i just felt kind of gross and icky its almost like the familyfeels like they have to say yes finally a few pcps noted that they felt that electronic consultation would be most useful if they had strong foundational knowledge regarding genderaffirming care which they could receive through other continuing medical education such as the teleeducation platform telephonic consultation with respect to the advantages of telephonic consultation three themes emerged having a dialogue with a specialist receiving compensation for pcps time and helping with acuity or complex cases textbox 3 themes primary care providers identified as the benefits and drawbacks of telephonic consultation benefits • theme 1 having a dialogue with a specialist • 1a can ask additional clarifying questions • talking with someone over the phone sometimes its beneficial because theyll ask followup questions that you didnt ask that can be a learning tool but then also identify maybe some blind spots that maybe should be identified before people provide a specific answer which i think is somewhat of a safety net for catching some of the clinical biases that we might have in medical decision making • 1b can relay nuances of the patients situation • i think the obvious benefits again are timeliness and being able to sort of convey the nuances of the story or the patient i think that having a conversation is better than a template when youre talking about patients • 1c already comfortable using this modality • i think one of the benefits is its a model were familiar with and we already do it and so it seems pretty easy to be able to you know call the childrens provider to provider line and now i can ask for a gender specialist instead of just an endocrinologist • 1d receive a response in real time • when were in conversation with families we can let them know hey i dont have an answer to your question right now but i know who to call and i know that theyre going to get back to me by five oclock and then therefore i will get back to you today or tomorrow morning • theme 2 receiving compensation for primary care providers time • as our coders and billers have told usif we do the consult the same day thats part of our coding to have for the visit and so it could be you know the charge can be captured in that sense as well • theme 3 helping with high acuity or complex cases • i think this one would be better for those more like you said life and death situations or more severe like i dont want to maybe theyre not like actively suicidal and i dont need to send them to the emergency department but like im very worried about them and i dont want to wait 2448 hours to hear back drawbacks • theme 1 challenges with using the phone for communication • 1a the timing of callbacks is unpredictable and may be inconvenient more specifically pcps felt that telephonic consultation allowed them to ask clarifying questions and convey subtleties of the patients case which may be difficult to communicate via textbased methods such as electronic consultation in addition pcps reported that the timeliness of the consultation was very reassuring and allowed them to provide a timely response to a patient or their family instead of waiting days for an electronic consultation or even weeks for teleeducation finally pcps noted increased comfort in using telephonic consultation platforms given that it is a model that many had previously used with respect to the drawbacks of telephonic consultation 3 themes emerged the challenges associated with using the phone for communication most effective platform pcp perspectives regarding which platform would be most effective in supporting them in delivering genderaffirming care in the pediatric primary care setting were relatively mixed with nearly equivalent numbers of providers preferring teleeducation electronic consultation and telephonic consultation in addition multiple pcps indicated a preference for using a hybrid of the 3 models citing that a single platform alone may not be sufficient to support them in delivering genderaffirming care characteristics of a successful platform the 10 characteristics pcps felt were most important for the success of platforms for supporting pcps in providing genderaffirming care to tgd youths are shown in table 2 table 2 characteristics pediatric primary care providers felt were most important for the success of a platform for facilitating genderaffirming care provision in the primary care setting representative quotes platform characteristics reliability • if you guys say its 2448 hours and people are not responding to me for a week im going to stop im going to just start using the telephone instead specifically pcps desired platforms that provided reliable and timely consultative support as well as those that were engaging and nonjudgmental in addition the participants indicated that successful platforms were those that provided practical information could scale up to having the specialist conduct a formal consultation with the patient if necessary and could further adapt as terminology and pediatric genderaffirming care delivery evolve finally pcps desired platforms that were comprehensive integrated and accessible to all providers and not just those using a specific ehr when asked what would make them more likely to continue using a particular platform pcps cited patient satisfaction community building and incentives for participation first and foremost pcps frequently indicated that being able to improve the care they provide to tgd youths would motivate their use of these platforms finally pcps mentioned that being able to receive incentives such as continuing medical education or the maintenance of certification credits would motivate them to use a platform this was especially true for teleeducation platforms as many participants acknowledged that such incentives could offset the significant time commitment required for participation i discussion principal findings the results of this qualitative study suggest that pediatric pcps desire opportunities to both obtain foundational knowledge and receive timely consultative support from gender specialists regarding patientspecific concerns the variation in these results stems from the wide variation in pcps training and experience in providing genderaffirming care for tgd youths and the current options for training and consultation in this area are quite limited 13 14 15 to meet the increasing demand for genderaffirming care services for tgd youths we must develop a diverse suite of telehealthbased training and consultation services to meet the needs of pcps with different levels of experience and training in this area this specialisttopcp support is critical for facilitating greater pcp independence in genderaffirming care provision as well as for expanding the access of tgd youths to pediatric genderaffirming care services increasing requests for specialisttopcp telephonic consultation during the covid19 pandemic 31 have led many large pediatric health systems to reconsider whether these services are providing the best quality care to patients and sustainable for pediatric specialists 3233 although informal telephonic or curbside consultations remain the most common form of pediatric specialisttopcp telehealth support our findings suggest that it may not be the ideal modality to support pcps in providing pediatric genderaffirming care although our findings indicate that pcps perceived telephonic consultation as having some important benefits such as the timeliness of response and wider accessibility they also noted many drawbacks these drawbacks which include limited compensation for consultation services raise concerns about the sustainability of telephonic consultation systems and indicate a need to develop new modalities to provide specialisttopcp support consequently several providers in our study expressed a desire for an electronic consultation platform to support the provision of genderaffirming care in the pediatric primary care setting this modality may be particularly useful in overcoming some of the barriers that exist with telephonic consultation systems including the lack of written documentation inconvenience of receiving unscheduled phone calls difficulty in exchanging laboratory data and lack of pcp and specialist compensation in particular electronic consultation may be a helpful modality to increase the capacity of pcps to submit nonurgent questions to support their tgd patients and to ensure that questions are routed directly to providers with expertise in genderaffirming care electronic consultation may also increase the capacity of pcps and specialists to exchange comprehensive and patientspecific information review objective data and document recommendations in writing to facilitate the provision of ongoing care despite these benefits there are some challenges to developing specialisttopcp electronic consultation platforms several pcps indicated that they desired an electronic consultation platform within the ehr used in their practice because of both its convenience and their familiarity with its functionality however this remains logistically challenging given the heterogeneity of ehrs used by pediatric pcps across the united states and the reluctance of ehr vendors to adopt sustainable medical applications reusable technologies application programming in accordance with defined standards for fast healthcare interoperability resources 234 this is likely why many of the existing specialisttopcp electronic consultation platforms such as those used by the veteran affairs health system 161721 are available to only pcps who work within the same health system as that of the specialists providing the consultation ensuring that pediatric genderaffirming care provision is accessible and equitable will require the use of modalities that are widely accessible to providers in diverse clinical practice settings 35 teleeducation may also be a particularly useful modality for pcps whose practices are located farther from a pediatric gender specialist or who are seeing an increasing number of tgd patients 18 regarding geography providers located farther from pediatric multidisciplinary gender clinics may be more inclined to dedicate time to formal education sessions as they serve patients who face additional accessand travelrelated barriers to receiving specialty care given that this platform would provide them with an opportunity to receive more comprehensive foundational knowledge providers in remote areas may be more willing to invest time upfront despite the clinical sacrifices knowing that it would facilitate care for their patients finally patient volume specifically the number of tgd youths seen in their practice may impact their interest in a teleeducation platform on the one hand the increasing number of tgd patients may encourage pcps to gain more formal experience working with this population alternatively a pcp who already sees many tgd youths in their practice could be more inclined to use telephonic or electronic consultation as they are more likely to have developed foundational knowledge and skills through practice limitations this study should be interpreted within the context of the following limitations although diversity existed with respect to participants primary practice locations and years in practice and the number of patients they referred to a gender clinic the participants were relatively homogeneous with respect to gender identity and race and ethnicity in addition both our response rate and decision to recruit pcps who had previously sought support may limit the generalizability of our findings although the providers in our study may be more likely to use a telehealth platform for support in providing genderaffirming care than those who have not sought out this support we are confident that these data reflect the perspectives of pcps who are the most motivated to use a telehealth platform for support in providing care for tgd youths in the primary care setting furthermore although our interview guide was intentionally designed to obtain pcps perspectives about both the advantages and disadvantages of each modality it is possible that social desirability bias affected our findings finally given that specialisttopcp telephonic consultation systems are currently in use in many pediatric hospital systems it is likely that the pcps in our study had more experience using this modality than electronic consultation or teleeducation which could in turn have affected their responses conclusions in summary our findings suggest that beyond the current telephonic consultation model electronic consultation and teleeducation may provide important alternative training and consultation platforms to support pediatric pcps in providing genderaffirming care to tgd youths improving specialisttopcp support in these ways is critical for facilitating greater pcp independence in genderaffirming care provision and promoting widespread access to pediatric genderaffirming care services for tgd youths authors contributions gms nfk pga wp ts dac and lpr provided substantial contributions to the conception or design of the work kmb gms and nfk provided substantial contributions to the acquisition analysis or interpretation of data for the work kmb gms nfk pga and ts were involved in drafting the manuscript wp dac lpr gms and nfk were involved in critically revising the manuscript for important intellectual content all the authors provided final approval of the manuscript version to be published and agreed to be accountable for all aspects of the work and involved in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved conflicts of interest none declared multimedia appendix 1 definitions used to describe each telehealth platform to the interview participants docx file 13 kbmultimedia appendix

background access to genderaffirming care services for transgender and genderdiverse youths is limited in part because this care is currently provided primarily by specialists telehealth platforms that enable primary care providers pcps to receive education from and consult specialists may help improve the access to such services however little is known about pcps preferences regarding receiving this support objective this study aimed to explore pediatric pcps perspectives regarding optimal ways to provide telehealthbased support to facilitate genderaffirming care provision in the primary care setting methods pcps who had previously requested support from the seattle childrens gender clinic were recruited to participate in semistructured 1hour webbased interviews overall 3 specialisttopcp telehealth modalities teleeducation electronic consultation and telephonic consultation were described and the participants were invited to share their perspectives on the benefits and drawbacks of each modality which modality would be the most effective and the most important characteristics or outcomes of a successful platform interviews were transcribed and analyzed using a reflexive thematic analysis frameworkthe interviews were completed with 15 pediatric pcps the benefits of the teleeducation platform were developing a network with other pcps to facilitate shared learning receiving comprehensive didactic and casebased education having scheduled education sessions and increasing provider confidence the drawbacks were requiring a substantial time commitment and not allowing for realtime patientspecific consultation the benefits of the electronic consultation platform were convenient and efficient communication documentation in the electronic health record the ability to bill for provider time and sufficient time to synthesize information the drawbacks of this platform were electronic health recordrelated difficulties textbased communication challenges inability to receive an answer in real time forced conversations with patients about billing and limitations for providers who lack baseline knowledge with respect to telephonic consultation the benefits were having a dialogue with a specialist receiving compensation for pcps time and helping with high acuity or complex cases the drawbacks were challenges associated with using the phone for communication the limited expertise of the responding providers and the lack of utility for nonemergent issues regarding the most effective platform the responses were mixed with 27 415 preferring the electronic consultation 27 415 preferring teleeducation 20 315 preferring telephonic consultation and the remaining 27 415 suggesting a hybrid of the 3 modelsa diverse suite of telehealthbased training and consultation services must be developed to meet the needs of pcps with different levels of experience and training in genderaffirming care beyond the widely used telephonic consultation model electronic consultation and teleeducation may provide important alternative training and consultation opportunities to facilitate greater pcp independence and promote wider access to genderaffirming care

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background hivaids caregiving in subsaharan africa it is now recognized that women and girls are the principal caregivers in the vast majority of homes and bear disproportionate responsibility for the psychosocial and physical care of family and community members 1 2 3 womens invisible unremunerated health care burden derives from multiple inequities that must be tackled at the root to meet the growing need for sustainable community and homebased hivaids care in subsaharan africa gender inequities are particularly acute in hiv aids caregiving where women and girls make up the informal care workforce it has been estimated that two thirds of primary caregivers in households in south africa are female one quarter of whom are over 60 years of age and 7 of whom are under 18 4 a 2008 joint united nations programme on hiv aids expert group meeting report presented the following illustrative statistics in south africa 91 of caregivers are female and women carry out eight times more care work than men 68 of volunteers working in three districts in uganda are female and two thirds of people living with hivaids in thailand are nursed at home by a parent usually their mother 56 womens greater responsibility for care results in greater social physical and psychological stress and lost opportunities for education careers and income 78 further community health workers and other hiv aids caregivers have found their jobs are not seen as legitimate vis à vis the formal health system resulting in less access to support and traininganother inequity 9 10 11 nonrecognition of the material needs of the informal hivaids workforce such as water soap and gloves also puts the caregivers safety at risk it has also been observed that the women and girls engaged in volunteer unpaid caregiving also experience longerterm disadvantages having less access to social protections such as insurance social security leave or pensions because these are typically tied to paid employment status 12 a zambian observer has noted that the burden of hiv and aids care has dehumanized women it has feminized poverty and turned women into workhorses in the name of volunteering and caring for the community 13 at the time of this study lesotho had the third highest hiv prevalence in the world 14 and the fourth highest rate of tuberculosis incidence with a growing problem of multidrugresistant tuberculosis these high rates have created an enormous caregiving burden on both the formal and informal health workforces the 2006 lesotho network of people living with hivaids fiveyear strategic plan indicated that the number of people living with hivaids was high and steadily growing with about 55 of cases in 2005 being females aged 1549 of which 75 were aged 1529 the lenepwha strategic plan also noted that these women who were currently caregivers would experience mortality which would exacerbate the caregiving burden 15 hivaids caregiving as occupational segregation key contributors to this caregiving burden include global health worker shortages and regional migration economic crisis and structural adjustment policies that have weakened public health and social security systems and transferred caregiving to households and communities and inadequate and delayed donor and government funding for hiv prevention and treatment 1617 but at the heart of womens disproportionate inequitable hivaids caregiving burden lies gender inequality and the traditional gender roles and stereotypes that come into play in mens and womens responses to the epidemic when viewed this way the unequal sharing of responsibilities between women and men results from and is sustained by the widespread existence of gender status beliefs and stereotypes the difficulties associated with changing norms around the organization of family caregiving 18 inadequacies in policy program approaches that have left a caregiving void into which women have stepped as almost exclusive default care providers and a lack of political will mens and boys entry into hivaids caregiving in meaningful numbers would offer an important opportunity both to increase the equity and sustainability of national and communitylevel hivaids caregiving responses and mitigate health workforce shortages especially for societies with high hiv prevalence 19 20 21 however the roles currently played by men and boys as providers of such unremunerated and often unsafe care have been poorly documented and understood including their willingness to perform this job while there is positive evidence that some men are entering the hiv aids caregiving job with a range of incentives and social supports 2223 longterm results from interventions to increase their numbers in hivaids caregiving are still elusive mens significant and sustained engagement in caregiving is by no means inevitable since hiv aids caregiving appears to be a gendersegregated occupation making an impact in this vital area health workforce planning requires a better understanding of the dynamics of gender segregation gender segregation is a pervasive and widely documented form of social inequality and labour market rigidity in which women and men are expected to work in culturally defined occupational roles dominated by their gender 2425 typically women are vertically segregated and confined to a narrower range of work in marginal lowerstatus and less wellpaid jobs women often hold caring and nurturing occupations such as nurses social workers and teachers and remain horizontally segregated from men who are typically concentrated in technical diagnostic managerial or strengthbased jobs scientists physicians managers police officers fire fighters coal miners gender segregation is also one of the most profound and enduring dimensions of labour market inequality compared with segregation by race or class 26 its durability reflects two deeply rooted ideological tenets the first tenet is gender essentialism which posits that men and women have a basic unchanging essence so that for example women are perceived as more naturally competent in personal service nurturance and social interaction while men are more competent at mechanical or managerial tasks the second tenet is male primacy which represents men as naturally dominant and more statusworthy than women 27 an example of male primacy is illustrated in a study that was recently conducted in soweto where male respondents stated they did not participate in hivaids caregiving activities even when they felt they should because of the fear that they would lose respect among their peers if they did so 28 gender essentialism and male primacy are aspects of stereotyping that operate in gendered social systems which define men and women as different in socially significant ways 29 social inequality is organized around these gender differences in hierarchies where superior and inferior status is attached to men and women through stereotyping gender stereotypes contain status beliefs of different than and better than which attach to the type of work each gender does these stereotypes and status beliefs act as barriers to women achieving positions of power and to men assuming positions of lesser social significance by tying supposed innate traits to tasks gender essentialism creates occupational ghettos which impede the crossover of men into femaleidentified jobs and vice versa 30 a key challenge for human resources for health and hivaids program planners and policymakers then is not only to forge multisectoral multilevel strategies to deal with the structural economic and political factors that have contributed to the acute hivaids caregiving burden carried by women and girls but to understand and anticipate the entrenched tendency of societies to segregate men and women into different work based on gender ideologies and to assign different values to these differences early stage work has focused on ways to increase mens participation in a range of activities that are typically femaleidentified there is a growing body of evidence related to male stereotyping that suggests that mens genderrelated attitudes and practices can change in relatively short periods of time 31 a recent review of fiftyseven male involvement programmes published by the world health organisation found evidence to suggest that some were effective in transforming harmful gender attitudes and behaviour while many of the other programmes were regarded as promising 32 however none of these studies demonstrated how to significantly increase the equal sharing of domestic or caregiving labour hivaidsrelated or otherwise especially over the long term this early stage work has focused on more involved or competent fatherhood partner assistance during obstetric emergencies improved communication shared decisionmaking among partners increasing fp and condom use and reported reductions in sexual partners and severe intimate partner violence interventions with men are admittedly limited in size impact and sustainability and have relied on mens voluntary participation 33 the extent to which gender equality gender essentialism and male primacy were key targets of these interventions is not clear it has been observed that domesticity as an ideology is socially and culturally constructed and closely linked to patriarchy subordinatedominant hierarchical positioning in gender power relations and an artificial private public distinction that render the domestic roles of mother wife and homemaker as key constructions of womens identity in africa 34 it thus seems advisable to target feminine as well as masculine stereotypes for change in 2008 the capacity project partnered with the lesotho ministry of health and social welfare in a study of the gendered division of labour and the gender dynamics of hivaids caregiving in three districts of lesotho to account for mens apparent absence in hiv aids caregiving and investigate ways in which they might be attracted and recruited into the community homebased care workforce methods lesothos gender and development policy had recognized the problem of gender stereotyping and recommended that the government should advocate for the improvement and expansion of gendersensitive homebased health care service delivery with particular attention to hivaids affected and infected persons to alleviate the burden of responsibility on women 35 observers having noted mens de facto absence in these services the study objectives were to determine the perceived need to bring basotho men into chbc and support for hiv aids determine the feasibility of engaging them as providers of chbc and support for hivaids especially the genderrelated and cultural factors to be addressed to increase male involvement based on an analysis of gender relations in lesotho and identify factors that facilitate or hinder substantive and sustained male involvement in chbc and support for hivaids lesotho is a landlocked country within south africa with a population of 18 million the country has four distinct ecological zones the lowlands foothills mountains and the senqu valley a large percentage of the population 762 resides in rural areas where poverty is most prevalent the country depends mainly on subsistence farming manufacturing and remittances from migrant labor in south african mines primary health care was adopted as a strategy for health service provision in lesotho in 1979 nineteen health service areas were delineated on the basis of the catchment populations the government of lesotho also subsidizes the provision of health services by the christian health association of lesotho and a limited number of other nongovernmental organizations chal provides approximately onethird of health care through a network of eight health service area hospitals and 73 health centers chal facilities tend to be located in sparsely populated remote and underserved populations the most basic level of phc service provision is at the communityvillage level where an estimated 4800 volunteer community health workers are the first line health providers 36 data collection took place during february and march 2008 to achieve broad stakeholder participation and representation data were collected in villages health clinics and hospitals across three districts in lesotho chosen to represent two ecological zones to contain both rural and urban sites and to achieve ministry of health and social welfare and chal representation accordingly the study recruited a stratified sample of voluntary nonproject affiliated participants and used qualitative methods including 25 key informant interviews with village chiefs nurse clinicians and hospital administrators and 31 focus group discussions with community health workers village men and women exminers and hivpositive men and women focus group participants were recruited at district health centers and through interview participants in order to reach both community health workers people living with hivaids and community members not directly affiliated with the health center that could be potential patients or chws of the total 244 study participants 70 were women and 30 were men table 1 shows the study respondents and data collection tools the interview and focus group guides were developed specifically for this study to address the studys research questions pilot tested in a rural village and revised according to pilot findings interview questions focused on the need for and feasibility of involving men in chbc and what factors facilitate or hinder their participation interviews and focus group discussions were audiotaped transcribed translated and coded for analysis transcripts were imported into nvivo8 qualitative data analysis software and a codebook was developed according to thematic categories deriving from the four study objectives outlined above and by gender analysis domains particularly the beliefs attributed knowledge perceptions and stereotypes regarding men and women in caregiving household and domestic division of labour and caregiving practices and the use of time and space including whether some spaces were off limits to men as hivaids caregivers code categories were also derived from a close reading of themes in respondents narrative language and concepts to elicit indigenous categories of meaning and local knowledge about gender caring and hivaids coding involved breaking interview transcripts into discrete text units interpreting their meaning and assigning a code and deductively and inductively establishing relationships among codes to form constructs to test the validity of the codebook and coding strategies preliminary code reports were reviewed and compared to transcripts by alternate studyteam members concordance of the coding was assessed and inconsistencies resolved through consensus the results presented here represent the range including contradictions and surprises that emerged within themes of participant responses and perceptions about gender and caring labor the study design and instruments were approved by the ministry of health and social welfare human subjects review and all participants provided informed consent results perceived need for men in chbc study participants uniformly perceived a need to increase the number of chbc providers to deal with the heavy workload from increasing numbers of patients and that because of insufficient new entries the current volunteer workforce was overloaded some villages had one health volunteer or none at all leaving large gaps in care provision respondents who were themselves chbc providers noted that it took a great deal of time to care for the sick leaving little time to earn money or provide for their own families and that young volunteers often got fed up from being overworked and undersupplied they expressed the need to increase the number of people involved in caring for sick people including people affected by hivaids statements in the mens groups reflected a dual perception of womens traditional work and circumstances which demand flexibility and cooperation from men there was recognition on the part of some men that changing times require a change in caregiving practices illustrated by this observation from one of the focus groups in our tradition there are things which are the responsibility of women and caring for sick people is one such thing it is obvious though that because of changing times and new diseases both men and women should unite against hivaids gender beliefs stereotypes and hivaids caregiving gendered division of household labour the study demonstrated differences between beliefs about the appropriate work of men and women and the real gendered division of labour in households including tasks that may be associated with chbc some male focus group respondents reported high rates of doing household tasks such as obtaining water and firewood preparing food and washing clothes fewer men reported providing child care and even fewer reported being engaged in caring for the sick in the family but overall the data showed that men considered themselves to be already involved in some femaleidentified domestic and household activities associated with chbc the data also showed that women engaged in tasks associated with chbc at higher rates than men further contrary to the widelyheld belief that earning money was mens work more women than men reported earning money on a regular basis together the data suggested that there was some gender integration of domestic and household tasks associated with chbc which represents an opportunity to reinforce mens practice and skills in these areas gender stereotypes and status beliefs related to caregiving shared beliefs about essential male and female traits and gender status reinforced the inequitable division of hiv aids caregiving labour in lesotho both male and female respondents cast women as natural family caregivers with inherent traits of nurturance altruism sympathy patience and selfsacrifice that extended into voluntary community care according to female focus group respondents women are able to bring up a childable to sweettalk patients good at begging submissively till he does what he is asked to do and naturally are kind and patient according to male key informants women have courage sympathy and patience they do not choose people but help anybody who needs care some respondents also recognized that women are socialized to be caregivers in the context of family life and that men are not as illustrated by the following women in nature are nurturing they have the responsibility of bringing up children taking care of the hometaking care of the sick but it doesnt mean that men dont equally have the same skills its just that they havent been practicing them it is the same as wanting to know why men do not cook traditionally that has always been a womans role it does not mean that there is anything to prevent them from doing it its just that they dont perceive it as their own whether considered innate or by socialization caregiving was seen as a source of competence power and identity for basotho women illustrated by the following focus group statement me as a mother womanam in charge of the sick in my household in contrast men are not understood by nature or socialization to be caregivers illustrated by the following remarks from community focus groups men are people who are angry quickly and they get fedup the male taking care of the sick they are there but they are very rare and ever since we grew up we know that sick people have been cared for by women in the families they are doing it with all their strength because it has been like that men are not interested if they do they are very few men have to go out and bring money home their tasks take them away from home acceptability of men as caregivers while much of the data reflected both male and female respondents perceptions that men are capable of doing various chbc tasks and that men would accept the caregiver role under certain conditions there was a widelyheld perception that the extent to which men would be accepted as caregivers was circumscribed by tradition and especially by culturallydefined male traits that were substantially negative for example men face traditional prohibitions against entering the room of a nursing mother providing care to a daughterinlaw or entering the place of womens traditional dancespaces where women need to be alone equally important however both male and female informants appeared to mistrust mens motives female focus group respondents expressed a high degree of anxiety about their bodies being exposed to men and womens vulnerability to sexual exploitation in the care setting since men are perceived as capable of dishonesty hypocrisy untrustworthiness and unscrupulousness when it comes to sex illustrations of this from the village womens focus group discussions include it is not acceptable really because men are not trustworthy people because he can pounce upon you irrespective of your condition no matter how sick you are men have promiscuous minds they think of nothing but adultery when they see womenand it is because men misbehave that is how god has created them he is capable of making a mistake and mention that he is helping the female patient the study found that men who would participate in chbc might also face contempt and suspicion from both men and women that their motives are really to womanize when asked what might be some positive or negative reactions to mens participation in chbc the following points emerged men are discouraged by being mistaken as lovers to sick women this gentleman you see with us here today has been ridiculed is it not the one who runs around with women they despise him thats the problem they speak ill of him saying he a womanizer and whose wife or daughter are you going to play with status and hivaids caregiving the study also found that hivaids caregiving is understood to include undesirable and lowstatus tasks associated with womens labor as for example in this focus group observation when my stomach is running a man will not wash those clothes but women can do that men run away interestingly first aid experience related to mining in south africa was a maleidentified skill that was perceived to be technical and superior to womens familyrelated caregiving since it was associated with saving lives and featured the masculine traits of courage dignity bravery and discretion first aid was seen to involve the control of bleeding and was distinct from womens natural caregiving in the domestic sphere it was something that men did better than women and that gave men superiority over women as illustrated by the following i think men are much better women know nothing about safety so we are above them and the same example of controlling bleeding applies here women do not know blood vessels so that is where we become better caregiving as first aid was a source of competence and superiority apparently compatible with the gender identity of basotho men who had worked in the south african mines apart from its voluntary and lowstatus nature study respondents pointed to the role of public ridicule in suppressing mens public displays of hivaids caregiving for example some people in the villages ridicule them saying they are inquisitive and pretending to be nurses who are not paid who cannot provide medication for them peer pressure also stigmatized men who crossed into the ridiculous feminine social identity of caregiving and were no longer available for masculine pursuits i once heard men ridicule another for taking an under five child for immunizations what have you done with her mother where is she and they were laughing womens ridicule also suggested that some women might be resistant to mens appropriating womens social identity as caregivers as when a focus group participant observed that other women ridicule them saying they take womens work and it is theirs it should be noted however that other female respondents felt that mens involvement would increase solidarity and ease the caregiving burden nevertheless the perceived advantages of men as caregivers included mens physical strength to lift turn and transport patients the notions that male patients feel more comfortable being bathed by other men that men keep secrets that men communicate better with men that men have courage and can venture into dangerous places and that some men are skilled at first aid there was a strong preference by both men and women for involving men as samesex providers for men and for not involving men as providers of intimate care for women outside their families all this represents an opportunity to bring men into hivaids caregiving if they are willing mens willingness and gendered expectations male respondents did not report being unwilling to accept the hivaids caregiver role but cited as impediments womens traditional caregiving responsibility their own reticence to intrude on what they perceive as womens preserve of community health work and their interest in paid work and incentives female focus group respondents including people living with hivaids and community health workers also pointed to the fear of stigma as a barrier to mens participation however an expectation that men be moneyearners served as a prime barrier to mens participation in chbc even in times of unemployment while women may work for free men will not and voluntary work such as caregiving is to be avoided because it is inconsistent with an ideal conception of mens status as breadwinners this was the case even when women were engaged in breadwinning at higher levels than men as appeared to be the case in the study sample illustrations of the strength of the male breadwinning expectation include the following from the community mens focus group discussions the job without incentives is a mockery no man wants to work without incentivesand if only some small amount of money could be given i am sure men would be interested other respondents were aware of the importance of pay in mens caregiving it looks like men have a problem because caring for the sick is done by volunteers men want to be paid for whatever work they do at present there is no pay people are working for nothing that is why they cannot provide care without pay because they are the ones who fend for the families and men are always breadwinners for their families so if homebased care is offered free men will not participate in fact the main incentive they are looking for is money it is very sad when a father gets home at the end of the day claiming to have been doing some work yet he is not going to get a pay to take care of his family generally the study communities appeared to expect women to work for free in the community as they do at home and to exempt men from voluntary chbc work even if they were unemployed and had discretionary time ways to increase mens participation the researchers asked focus group participants and key informant interview respondents to suggest ways to increase mens participation in hivaids caregiving there appeared to be wide support for the idea that training men could offset the fear that men would sexualize caregiving and increase their acceptability by association with the skill and professionalism of nursing examples of this included you will meet no problem in the village if you help a woman provided we are trained because you will be going there with your head high as you have the required knowledge for that work and what i have observed is that public understands services which include mens involvement yet it used to be women only in hospitals for instance people see male nurses who are even young agewise i can only recommend that men be trained well so that they can fit well into the system study participants thus appeared to believe that if men could be supervised by a recognized health worker encouraged and given financial incentives they might become more widely accepted as caregivers and more interested in getting involved in hivaids caregiving perhaps most importantly the ministry of health and social welfare established a financial incentive for community health workers at 43 per month before the completion of the study which presumably will attract both more men and women into this job table 2 summarizes opportunities and challenges for mens involvement in hivaids caregiving results dissemination study results were disseminated in a twoday meeting with the ministry of health and social welfare and other stakeholders in september 2008 including national and district partners to discuss study findings and validate recommendations for recruiting training supporting and retaining men as hivaids caregivers in ways that did not disadvantage the women who still carry the burden of care the meeting included an orientation to gender concepts presentation of lesothos 2003 gender and development policy and consensus on policy and program actions at national and district levels elements of which would constitute the foundation of a strategic plan for the national community health worker program the ministry of health and social welfare later disseminated results to groups involved in the revision of the national gender and development policy and to the national curriculum development center discussion the study results highlighted a nexus of gender stereotypes and status beliefs related to men and women perceptions of their natural roles and related social expectations and sanctions that kept women in voluntary hivaids caregiving and kept men out of it the findings support the notion that hivaids caregiving is a gendersegregated job in which unpaid womens work in family structures is reproduced as unpaid care for others in the community the findings also support the contention that gender essentialism and male primacy figured in mens striking underrepresentation in hivaids caregiving activities expressions of gender essentialism included men are people who are angry quickly and they get fedup and women in nature are nurturing there was evidence of what has been referred to as the discourse of deficient and noncaring men 37 illustrated by the womens focus group statement that men are not trustworthy people at the same time there was evidence of male primacy including mens objection to volunteer work the emphasis on the superiority of mens first aid skills and the general expectation that men cannot be expected to work for free even when unemployed can womens work be desegregated a question must be posed here what is required to mitigate the gender essentialism and male primacy that sustain occupational segregation in caregiving labour and to develop robust formal and informal workforces capable of providing critical and chronic hivaids care opinion seems to range from pessimism regarding the extent to which womens jobs can be desegregated to cautious optimism these perspectives should be kept in mind in hivaids and health workforce policy program design planning and implementation and research pessimists contend that gender stereotypes status assumptions and cognitive biases play such a powerful role in the organization of social relations and that gender is such a fundamental organizing principle of status distribution and inequality in society that attempts to meaningfully desegregate femaleidentified health jobs will fail since men lose respect status discretionary time and money for doing womens work 38 the devaluation of women and by extension the activities and characteristics associated with women is deeply inscribed in the cultural norms within a gender hierarchy 39 there will be greater resistance to change that involves men taking on traditionally female activities than to change that involves women taking on traditionally male activities because taking on womens jobs typically represents significant losses whereas assuming male activities usually represents an improvement of status for women 40 a related argument is that both men and women have deep interests in maintaining a clear and reasonably stable framework of gender beliefs and stereotypes that define and differentiate who men and women are in this line of reasoning gender is so deeply embedded in social relations and institutions that few people are likely to tolerate serious disruptions to the basic system of sex labeling that underpins any gender system 41 the notion that both men and women have an interest in maintaining a clear framework of gender beliefs and stereotypes appears to be supported by some of the present study results as for example in the way public ridicule of men functioned to maintain gender boundaries in caregiving however there is another body of opinion regarding the tractability of gender essentialism one that might be called cautiously optimistic which points to the need for strategies to delegitimize the stereotypes that underpin occupational segregation in very specific ways this body of opinion is represented by what has been referred to earlier as early stage work the lesotho study findings lent themselves to cautious optimism both in female respondents desire for more solidarity and in the male study respondents selfreports that they were already assuming femaleidentified tasks and that they believed themselves capable of performing or learning chbc tasks given training public legitimacy supervision and monetary incentives the study demonstrated that gender segregation was linked to social consciousness which is amenable to change mens psychological flexibility was evidenced by the focus group observation that in our tradition there are things which are the responsibility of women and caring for sick people is one such thing it is obvious though that because of changing times and new diseases both men and women should unite against hivaids the study recommendations therefore included the interventions to act on this flexibility address resistance to desegregation and delegitimize gender essentialist and male primacy stereotypes for example • change perceptions of the value of caring labor and homebased care through a public relations campaign that communicates the benefits of hivaids caregiving to society or offer public honours and appreciation awards to longtime chbc providers with acknowledgment coming from high levels to create a recognition opportunity that others would strive for • recruit men for caregiving through traditional leaders courts and means associations • make hivaids and domestic caregiving more attractive to men and boys starting with early childhood education and public campaigns that communicate the value of hivaids caregiving to society • design training programs that are genderintegrated and that include mens and womens critical thinking about gender roles stereotypes and the equal sharing of responsibilities introduce male role models already engaged in chbc include mentoring and peer support interventions • review chbc and primary and secondary school curricula to eliminate gender stereotyping and • offer men and women the same financial and non financial incentives training would presumably render men more socially acceptable as caregivers and bring about changes in mens and womens beliefs and practices offering men and financial incentives would presumably render hiv aids caregiving as breadwinning for men while at the same time place value on the womens work already done by female caregivers strategies to increase gender equity in hivaids programs there are four roughly discernable strategies that go to the heart of gender inequality and that are useful to consider for increasing gender equity in hivaids service delivery programs they all assume the tractability of gender essentialism but differ in the comprehensiveness of approach focus of interventions and likely effectiveness interventions may be included in more than one category these strategies are summarized in table 3 the first strategy is the most comprehensive it would require establishing a new social consensus that directly challenged the ideology of difference inherent in gender essentialism and the gender hierarchies inherent in male primacy this strategy would involve societywide agreement that sociallyconstructed gender differences are counterproductive and that it is especially desirable to eliminate essentialist beliefs 42 this strategy would also require a farreaching set of reforms and innovative measuresto address the inequalities that pervade the distribution of responsibilities 43 the strategy calls for immediate concerted and direct efforts to change the social systems that produce these inequalities since the problem isnt how we train children to fit into the world the problem is the world into which we fit them into 44 an example might include bringing to scale a mass mobilization technique such as stepping stones which has been widely used in subsaharan africa to transform social norms and relationships around hivaids reproductive health genderbased violence and alcohol abuse through gender and age group dialogues the stepping stones approach enables the possibility of reconciliation between those in society wanting change and those resisting change so that women and men are engaged together in the process of transformation of gender roles and relations 45 while a strategy that aims for changing social consensus might be the most effective in achieving longterm gender equity in the region arriving at such a consensus would require considerable resources political and social will and great acumen to counter likely strong resistance less daunting is a second mens participation strategy which involves early deliberate and sustained public education and social support regarding the value of caregiving and gender equality use of male role models and the recognition of mens contributions as a way of shifting social norms and prompting other men to do the same meninclusive policies and political and civil society activism to change current attitudes and practice in favor of mens and womens equal sharing of the burden of hivaids care this strategy draws on recent early stage work promoting male involvement in parenting reproductive health and family planning it is reasonable to suppose that this early stage work may have some impact on mens participation in hivaids caregiving but less reasonable to suppose that gender equity will increase in meaningful sustainable ways if programmes do not directly address the gender essentialist and male primacy ideologies that underpin the gender segregation in hivaids caregiving this strategy also seems limited in terms of its power to change gender power relations and the social construction of womens gender identity an aspect that needs to be considered given the positive social value the basotho women and men placed on womens caregiving the authors call attention to the need to explore womens internalization of gender essentialist and male primacy notions and their experiences of caregiving inequalities and attempts to share the burden points often lost in the discussion of mens participation in caregiving this suggests a third womens empowerment strategy that is both promising and problematic given that the quadruple burden placed by aids care on women weaker health social exclusion lack of education and reduced economic power makes it more difficult for women to advocate for change and engage in efforts to transform their lives and communities womens engagement in advocacy and activism is crucial to achieving gender equality yet those who are fully occupied caring for relatives who are sick with aids are less able to participate in such activism 46 womens empowerment however is central to social equality peace and development 47 zambian gender activist sara longwe has stressed that the quiet but determined patriarchal opposition to policies of gender equality requires mobilization for womens empowerment to overcome the many forms of gender discrimination that stand in the way of development 48 interventions in a womens empowerment strategy should address claims that the unequal gender division of rights and duties is either natural or godgiven or too difficult to change 49 in a womens empowerment strategy change efforts would explicitly target the underlying causes of the unequal sharing of responsibilities and the development of womens critical consciousness the outcome of which would be womens and girls greater ability to claim their social and labour rights for example increasing womens self assertiveness to challenge the dominance of male interests that puts women at risk has become an important priority for hivaids work in the zambian organization thandizani which has successful expanded its homebased care program increased its referrals to health facilities and brought about a greater reported sharing of household tasks and family responsibilities between husbands and wives 50 such an empowerment strategy holds promise for longterm change and greater equity as recent work in the sociology of gender is suggests an incremental approach which posits that while patriarchal privilege permits men to avoid domestic and caregiving work it is nevertheless possible for men and women to make small changes in how they as individuals participate in social systems to affect cultural systems in the longer term 51 examples of this incremental strategy might be to involve men in nonpersonal care tasks or in currently maleidentified tasks as initial steps toward a more equal involvement of men and women in all caring tasks however this type of incremental action is unlikely to impact the gender segregation of hivaids caregiving especially in isolation whatever the strategy or strategies chosen potential resistance to the desegregation of hivaids caregiving cannot be ignored strategies should target both men and women at some point and should be as comprehensive as possible they should challenge gender essentialism gender status beliefs such as male primacy and the relative power and privilege attached to men and women starting in childhood change strategies should be carefully crafted implemented and evaluated using behavioural indicators further change efforts should include government policies and programs that distribute the caregiving burden among familieshouseholds markets notfor profit and nonprofit community organisations and the government 52 finally central to any and all effort to increase gender equity hivaids and human resources policymakers activists and programmers must recognize the gendered nature of chbc the inequalities and inequities in caregiving labour and the attendant psychological physical and economic impact on women policymakers and program managers must immediately address womens and girls shortand longterm disadvantage by providing the current female caregiving workforce with access to social protections offering training and supplies for caregiving services and committing political will and resources to redress the lost opportunities for education career and income entailed by hivaids caregiving limitations of the study time and resource constraints limited the information that could be collected our sample was a convenience sample and was not selected randomly this limits the generalizability of findings however we did find a convergence of opinion across data collection methods regions and informant type we do not have quantitative and comparative information on male and female labour in asking why men are not involved in homebased care we did not measure how many caretakerheaded households there were nor did we directly measure mens absence in hivaids caregiving therefore we do not know the extent to which is associated with male outmigration abandonment death of a spouse or divorce further research there are several areas of research suggested by this study and by the state of current practice first this study brought to the fore cultural prohibitions against men entering a room where a nursing mother resides does this prohibition apply to proximity with newborn babies and if so what are the implications for mens participation in prevention of mothertochild transmission services or in services for the most vulnerable children second though much is presumed there is little hard evidence on the ways to desegregate maleand femaleidentified jobs research is therefore needed in the area of gender desegregation in order to increase gender equity in hivaids caregiving conclusions hivaids caregiving is an occupationally segregated job at the core of which lie notions of gender essentialism male primacy and gender inequality there is table 4 lines of further research major questions do prohibitions against men entering a room where nursing mothers reside apply to proximity with newborn babies and if so what are the implications for mens participation in prevention of mothertochild transmission services or in services for most vulnerable children what is the potential for social and global media to change attitudes and norms around mens caregiving and the equal sharing of domestic labour especially among children and young men and women who are targeted by early stereotyping what are the features of a multisectoral approach that successfully reduces gender essentialism what social interventions change gender status beliefs for longterm reductions in gender inequality what methods make unpaid invisible labour and its costs more visible to policymakers what methods demonstrate the contribution of womens unpaid invisible caregiving labour to national budgets what is better practice in gender equalityoriented caregiving policy what is the effectiveness of quotas for male caregivers what are the politics of and resistance to equal sharing of responsibilities in a given setting what is the effectiveness of school programs that provide role models and caregiving skills to boys what strategies and conditions are effective in raising female caregivers critical consciousness and mobilizing women as agents of change for increased gender equity in hivaids caregiving evidence to support a range of views about the possibility of changing these conditions if there is to be more equitable sharing of the hivaids caregiving burden and any longterm solution to health worker shortages health and hivaids policymakers planners and human rights activists need to directly address these core gender issues in their strategies authors contributions cjn and lf conducted the formative research conceptualized the study designed oversaw and gave input to all aspects of methodology data analysis interpretation dissemination and report writing and reviewed and revised this publication lnm managed the study in lesotho er analyzed data and reviewed and revised the publication all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background gender segregation of occupations which typically assigns caringnurturing jobs to women and technicalmanagerial jobs to men has been recognized as a major source of inequality worldwide with implications for the development of robust health workforces in subsaharan africa gender inequalities are particularly acute in hivaids caregiving 90 of which is provided in the home where women and girls make up the informal and mostly unpaid workforce mens and boys entry into hivaids caregiving in greater numbers would both increase the equity and sustainability of national and communitylevel hivaids caregiving and mitigate health workforce shortages but notions of gender essentialism and male primacy make this far from inevitable in 2008 the capacity project partnered with the lesotho ministry of health and social welfare in a study of the gender dynamics of hivaids caregiving in three districts of lesotho to account for mens absence in hivaids caregiving and investigate ways in which they might be recruited into the community and homebased care chbc workforce methods the study used qualitative methods including 25 key informant interviews with village chiefs nurse clinicians and hospital administrators and 31 focus group discussions with community health workers community members exminers and hivpositive men and women results study participants uniformly perceived a need to increase the number of chbc providers to deal with the heavy workload from increasing numbers of patients and insufficient new entries hivaids caregiving is a gendersegregated job at the core of which lie stereotypes and beliefs about the appropriate work of men and women this results in an inequitable unsustainable burden on women and girls strategies are analyzed for their potential effectiveness in increasing equity in caregiving conclusions hivaids and human resources stakeholders must address occupational segregation and the underlying gender essentialism and male primacy if there is to be more equitable sharing of the hivaids caregiving burden and any longterm solution to health worker shortages policymakers activists and programmers must redress the persistent disadvantages faced by the mostly female caregiving workforce and the gendered economic psychological and social impacts entailed in hivaids caregiving research on gender desegregation of hivaids caregiving is needed

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introduction universal access has been one of the main challenges for health systems worldwide currently it has assumed so significant role that it is under discussion its inclusion as one of post2015 millennium development goals ensuring universal access is extremely relevant for human life and it means a great challenge for the countries and professionals of this field 5 the meaning of access to the health actions and services that people need involves values such as justice and equity which could not be incorporated into the concept of coverage the universal coverage concept often refers to the amount of the population covered by health services which does not mean that this number of people use the service or that the health service is able to meet the multiple and complex health needs the work of health professionals lies in the service sector involves a relationship between subjects of the same nature and the work outcomes depends on collaboration between those who care and those who are cared furthermore like the work of other sectors of the economy it is heavily influenced by specific conditions under which it is performed the manner in which its done and under what work conditions and labor relations the special characteristics of work in health care and the importance of workforce for its development are recognized by the global health workforce alliance and world health organization in the debate on coverage and universal access these organizations prepared a report in which they state a universal truth no health without a workforce therefore to achieve the goal of universal access to health it is necessary to focus on who does the work how it is performed and under what conditions in different historical and social scenarios in this sense the analysis of the workloads present in the way of working is a promising way to guide the provision of care to userspatients and thus improve the quality of access to health services workloads are elements found in the work process that synthesize the mediation between work and wear of the worker workloads interact with each other and with the body of who does the work they do not act individually but in combination with each other and determine the condition in which the worker faces the global logic of the labor process as strategic for universal access to health services in the fhs has been growing significantly in brazil and in march 2015 37944 family health teams had been deployed in 5319 municipalities with a national population coverage of 6056 which represents almost 118 million people the fhs has expanded the access to health services and strengthened the principle of universality nonetheless the country is still facing serious problems to ensure universal access equitable and comprehensive to all individuals the way of doing the work as well as the complexity of the work environments and conditions available for its completion interferes with the quality and safety of the health care results at all levels of care the nursing team represents the largest category among healthcare professionals and plays a central role in health services and in the assurance of users safety in the fhs nursing professionals are present in all teams and their work has an impact on the quality of care thus to identify the workloads present in their routine helps to guide managers in the strengthening of positive factors and in the search for actions to reduce them contributing to the viability of universal access although nursing is essential for access and operation of health services there are still major imbalances and gaps in the availability distribution composition qualification and productivity of nursing professionals which has implications in terms of quality and safety of services provided excessive workloads in the daily routine of the services worsened by poor working conditions negatively affect the results satisfaction and health of these professionals literature points out complex internal and external challenges to the profession as well as challenges at other levels such as historical cultural gender and field knowledge and fighting for appreciation of the important role that nursing plays in the health system this study was based on the observation that health workforce is critical to achieving universal access and that the fhs is the preferred policy to achieve this pires dep machado rr soratto j scherer ma gonçalves asr trindade ll goal and in this context nursing plays a relevant role in the healthcare sector and in the fhs consequently the aim of this study was to identify the workloads of nursing professionals of the family health strategy analyzing their implications for the effectiveness of universal access for the analysis of the research results theoretical approaches of labor process and workloads were associated method this is a qualitative study in which it was used methodological triangulation with data from semistructured interviews document analysis and observation the selection of participants was based on the following inclusion criteria nursing professionals working in the fhs teams that were distinguished by developing a good quality work according to the information supplied by the managers at least one municipality per region and only fhs teams that had a core team of professionals recommended by the ministry of health it regarding the data collection the description of the quantity and distribution of the interviews observation notes and documents examined are shown in table 1 this study included 23 nursing professionals of which nine were nurses 13 nursing technicians and a nursing assistant who worked in ten health teams of five municipalities in total the number of participants was considered sufficient according to the data saturation criterion ie the inclusion of new participants and teams was suspended when no new explanations interpretations or descriptions of the phenomenon studied were found among the participants most were women aged between 30 and 49 years professional experience of at least 5 years and experience in the fhs from one to five years regarding the employment contract there was a strong predominance of permanently assigned employees with working hours of 40 hours per week results the results were sorted into two analytical categories way of working in the fhs and increase in the workloads and way of working in the fhs and reduction of the workloads way of working in the fhs and increase in the workloads of the nursing professionals with regard to the increase in the workloads in all three regions of the country the major components identified are shown in figure 1 created by using the atlasti software in the three regions of the country the workload associated with excess of demand and territory overestimated were the most significant elements for the increase in the workloads of the nursing professionals as illustrated by the following report the workload gets intense it´s too much service to be carried out at the same time we often leave work so tired and still under the impression that we did not accomplish all that was under our responsibility we and we go on with the same team to assist the families of our areas and others that are discovered my team is incomplete lacking a nursing technique i have been working only with a nurse and a doctor in my team i am alone so this complicates matters the work intensifies so we cannot do the work the way we want due to the lack of a nursing technician failures in the care network and in the organizational and physical infrastructure have also been very pires dep machado rr soratto j scherer ma gonçalves asr trindade ll significant producing increase in the workloads as shown in the following reports sometimes the patients problem resolution depends on other administrative levels and then way of working in the fhs and reduction of the workloads with regard to the way of working in the fhs considering the reduction of the workloads teamwork has been found as the most significant as shown in that what is feasible is changed therefore there is an interaction a very tight integration between the members of the team in addition to teamwork the relationship with the user and presence of the community health agents are elements that contributed to the reduction of the workloads signaling identityaffinity of the nursing professionals with the model of the fhs discussion in this study the results showed a predominance of situations that increase the workloads of the nursing professionals among the elements that contributed to the increase of the workloads are several elements related to the working conditions and management of the health system of which the fhs is part the problem of working conditions has been repeatedly recognized as a serious problem in the health field in brazil and particularly in nursing including deficits in the quantity and quality of the workforce excessive working hours deficits in the salary and problems in the work environment deficits in working conditions negatively influence the health of the nursing professionals and results of the assistance provided by these professionals with regard to the work overload even considering the involvement of subjective aspects it was identified that there is a discrepancy between demand and teams ability other aspects related to working conditions identified in this research indicate that there are unsatisfactory objective conditions which interact with each other resulting in the increase in the workloads overloaded nursing professionals that in addition perform their work in adverse conditions tend to suffer damage to their health which increases the work absenteeism resulting in greater overload on those who remain this situation negatively influence the effectiveness and quality of results in health care the service might be available and even represent that formally there is coverage however the population that uses the service faces barriers and limited or inefficient care another factor that contributed to the increase in the workloads were the problems in the relationship of nursing professionals with users in particular due to their unmet needs and insecurity of these professionals to act in areas of violence increased workloads cause dissatisfaction wear and even illness on who does the work and difficulty to perform a creative and effective work which interferes in the possibilities to ensure access from the perspective of a comprehensive care universal access is related to providing assistance to the entire population at all levels of the system considering the complexity of the needs in health it includes the environment where the work is carried out method of organizing work and how care is provided as well as the relationship established between professionals and users it is worth mentioning that health work is highly dependent on labor force therefore any initiative in this field requires focusing on who performs the work the absence of geographic economic sociocultural organizational or gender barriers has been recognized as required for universal access in this study it was identified economic sociocultural and organizational barriers in the phc scenario in the country which has generated increased workloads of the nursing professionals and hampered the effectiveness of the fhs as a potentiating policy of universal access pires dep machado rr soratto j scherer ma gonçalves asr trindade ll on the other hand the elements that contribute to the reduction of the workloads found in this study show that there is an affinity of the nursing professionals with this kind of care model among these aspects are the teamwork establishment of bond between professionals and users and the presence of the cha which are the main elements of the fhs factors that contribute to the reduction of the workloads can contribute to the permanence of professionals in this care model since they are also positive for a closer approximation with the way of working required in the fhs fhs is inspired by the phc internationally recognized as a strategy for achieving the universal access to health the identity with the work and search for recognition and appreciation of the work reinforce the capacity to act of the collective offering prospects of coping of the adverse side of the work contexts to believe that work has been carried out in the right way promotes satisfaction and even in inappropriate situations helps in the reduction of the workloads in brazil the definition of universal right to health and access to health services has ocurred in a scenario of valuation of the citizens rights which occurred during the implementation of the federal constitution in 1988 the current challenge relates to dealing with complex problems arising from the demographic and epidemiological transition and insufficient public investment in health greater public investment in health can contribute to improving working conditions the operation of the network and hence universal access fhs integrates the sus as a privileged strategy for its accomplishment however the everyday of services has increased the workloads of the teams which complicates their work as well as the resolution of the problems of the users conclusion fhs adopts the principles of the phc internationally recognized as central in the search for equity and universal access in this research the nursing professionals recognized these precepts as positive however deficits in the working conditions and in the health system management have adversely affected the workloads which hinders the effectiveness of the fhs increased workloads particularly the overload on the nursing professionals affect the efficiency and quality of care the way the user is assisted and cared in the health services and consequently the quality of access in the contexts where the research was conducted aspects that increase the workloads contribute to hinder the access to the health services from the perspective of universality equity and resolution the role prescribed for the family health teams is extremely ample requiring longitudinality in care polyvalent knowledge and professional training for an intersectoral intervention the research results show that it is necessary to invest in strategies that strengthen the teamwork professional autonomy of nursing professionals and incorporation of technologies that contribute to the efficacy of care and reduction of the work overload these strategies may help to empower these professionals for their daily routine as well as to participate politically in the management of the healthcare services and social control aiming at the implementation of measures to strengthen the profession and improve universal access these results also contribute to the development of the nursing as a healthcare profession and as a discipline of scientific knowledge by providing knowledge about the work of these professionals within the scope of the most significant public policies prevailing in brazil which corresponds to the priority strategy of the who to universal access it is worth mentioning that this study was carried out with an intentional sample which limits its generalization however it is important to note that even intentionally including teams considered as of good quality deficits in the working conditions and in aspects related to the system management were significant these findings suggest that more studies in this same perspective might be promising for further investments in health and advancement of knowledge in nursing and health

objective to identify the workloads of nursing professionals of the family health strategy considering its implications for the effectiveness of universal access method qualitative study with nursing professionals of the family health strategy of the south central west and north regions of brazil using methodological triangulation for the analysis resources of the atlasti software and thematic content analysis were associated and the data were interpreted based on the labor process and workloads as theorical approaches results the way of working in the family health strategy has predominantly resulted in an increase in the workloads of the nursing professionals with emphasis on the work overload excess of demand problems in the physical infrastructure of the units and failures in the care network which hinders its effectiveness as a preferred strategy to achieve universal access to health on the other hand teamwork affinity for the work performed bond with the user and effectiveness of the assistance contributed to reduce their workloads conclusions investments on elements that reduce the nursing workloads such as changes in working conditions and management can contribute to the effectiveness of the family health strategy and achieving the goal of universal access to health

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introduction maternal newborn and child health are global health priorities postpartum care and health services need to be responsive and accessible to mothers and their infants international policy recommendations and initiatives call for early and unified postpartum intervention to ensure the short and longterm physical emotional and social wellbeing of mothers families and children 12 in particular timely access to social support and health care services has been identified as a priority for new parents to improve outcomes 1 social interactions have been identified as an essential form of support for new parents 3 4 5 however the mandatory isolation imposed by the covid19 pandemic has led to unprecedented changes in the support and social interactions available to families and has resulted in rapid shifts in health systems and service approaches availability and accessibility the postpartum period is a time of great transition and stress for mothers and families the potential for negative health outcomes exists if the needed supports and resources are not available 12 in canada policy recommendations and government initiatives encourage programs and services for mothers and families particularly those who face challenging life circumstances to promote physical emotional and social wellbeing 6 7 8 9 10 11 as described in qualitative studies conducted in the united states of america 12 and belgium 13 and a qualitative synthesis including studies conducted globally 14 various avenues to access support and information are available in the postpartum period these include public health services home visitation programs physician and primary care provider offices midwives family resource centers grass roots dropin centers private online forums and informal conversations with other parents in studies on health outcomes of mothers in the postpartum period researchers have focused on measures such as breastfeeding rates hospital admissions and physical health indicators of mothers and infants 15 while these outcomes are significant mothers also reported that parental confidence parenting ability and stress were important but these factors are less often a focus in research 16 researchers reported that mothers want and need validation and reassurance about their parenting practices in person from other mothers and health care providers whom they deem as trustworthy and nonjudgemental 1617 inperson interaction was perceived to better enable interpersonal connection and social support when compared to virtual options 17 social support encompasses tangible and psychological resources to support selfefficacy selfesteem and subsequent coping in response to challenges 18 aston et al 1619 and price et al 17 showed that social support for new parents that includes empathy and sharing of ideas and information with other parents and health care professionals helps parents build confidence other researchers found that social support was essential to improve outcomes related to breastfeeding and maternal mental health 3 4 5 20 21 22 23 however the complex relational social and experiential aspects of the postpartum period are often deemphasized devalued and unprioritized within the health care system 2425 given the integral role of social support resources and health services for mothers and families during their infants first year social isolation can put families and infants at risk for poor physical and mental health outcomes 2627 the canadian social and health systems response to the covid19 pandemic led to public health orders including unprecedented lockdown and isolation to minimize infectious disease spread however there is no evidence to guide the implementation of health services and social supports that meet families with infants needs in this novel and rapidly changing context significant alterations in delivery and access to a multitude of facetoface pregnancy and postpartum supports have occurred 26 28 29 30 the canadian response to covid19 provides an opportunity to examine how families experience caring for an infant in isolation understanding these experiences is needed to inform evidencebased support and resources that are responsive to family needs and promote mental and physical health and wellbeing the purpose of our study was to explore the effect of selfisolation in response to the covid19 pandemic on mothers access to social and health care systems support during their infants first year we explored how mothers experienced their infants first year how the covid19 pandemic affected access to support including health care services and how mothers constructed their experiences personally socially and institutionally materials and methods design we used a qualitative design guided by feminist poststructuralism as described by weedon 31 this approach was selected as it provides a way to examine how participants experiences were personally socially and institutionally constructed through different subjective positions such as gender race ethnicity sexual orientation class socioeconomic status culture and abilities 31 32 33 34 feminist poststructuralist methodology prompts us to examine how different beliefs values and practices are constructed through relations of power across individuals institutions and social contexts 31 32 33 34 35 discourse analysis 3136 was used to examine and deconstruct meaning in the language of participants personal experiences members of our research team have previously used feminist poststructuralism and discourse analysis to examine social justice issues in the health care system through the exploration of subjective positions and their influence on beliefs values practices and relations of power between health care providers and patients in maternal and infant health 1617192437 feminist poststructuralism thus provides a relevant lens through which to examine mothers experiences of their infants first year during the mandatory isolation imposed due to covid19 the consolidated criteria for reporting qualitative research was followed setting in nova scotia canada the study setting a state of emergency was declared because of covid19 beginning on 22 march 2020 individuals were instructed to isolate in their homes and to cease all nonessential activities outside of the home nova scotia also required that all individuals who traveled from outside of the province complete a mandatory selfisolation for 14 days upon entering the province which limited the ability to travel interprovincially health care services were limited to essential and emergency services restrictions were put in place to limit visitors to inpatient settings and virtual care was implemented in many contexts such as primary care public health programming shifted to covid19 response and a hold was placed on postpartum followup data collection we obtained ethics approval from the research ethics board of iwk health we recruited a convenience sample through social media platforms twitter facebook and instagram we shared social media posts that specifically targeted mothers in nova scotia who gave birth during the early covid19 pandemic on our research teams website and social media platforms we also shared the recruitment notice with provincial family resource centers parenting groups and health care organizations we collected data using an online qualitative survey directly hosted on our research teams secure website potential participants reviewed an online letter of introduction and completed the consent form by checking a consent box before proceeding to the survey we maintained participant confidentiality by removing all identifying information from survey responses and by using passwordprotected files we only included nonidentifying demographic data in the online questionnaire participants were not able to withdraw study data once they submitted their questionnaires aligned with our methodology 31 and previous research conducted by our research team 1617 the survey consisted of three openended questions tell us about your experience at home with your new baby and how the situation created by the covid19 pandemic affected you and your family tell us about your experience of support during the covid19 pandemic and tell us about your experience of searching for and receiving information about caring for yourself your baby and your family during the covid19 pandemic data analysis team members who completed the analysis were from diverse socially constructed positions including race gender and sexual orientation this supported a diversity of perspectives when interpreting the data we specifically followed the data analysis steps recommended by aston 32 which integrates foundational literature on feminist poststructuralism and discourse analysis 31333436 to guide the feminist poststructural analysis of qualitative data these data analysis steps include identify major issues apply beliefs values and practices write about social and institutional discourses respond to relations of power and add participant subjectivity and agency each of the eight team members read the participant transcripts individually focusing on what each participant had written to describe the individual meaning of their experience we first started by identifying each participants beliefs and values as they related to their experience followed by what they did or practiced in response to that experience for example if a participant described anger at the lack of physical support for breastfeeding due to covid19 related health systems changes we closely reviewed the language of the participant to understand their personal beliefs and values related to physical breastfeeding support we then went on to identify how the beliefs values and practices of social and institutional context informed the participants experience using the words and meanings described by the participant for example participant responses highlighted that there was a socialinstitutional belief that it was not important for postpartum mothers to have access to breastfeeding support resulting is these services being stopped due to covid19 we then went on to identify participants subjective experiences how they responded to the relations of power in the socialinstitutional context and if they exercised agency to practice their beliefs and values related to accessing information and support during the postpartum period the individual personal experiences of participants were the foundation of our analysis which then led to examining similarities and differences in experiences across all 68 participants discourse analysis requires the inclusion of a variety of concepts that cannot be linearly organized in software data therefore we used an iterative back and forth way of discussing meaning until there was consensus 32 we iteratively discussed the identified participant beliefs values and practices the impact of social and institutional context relations of power and participant subjectivity and agency this discussion allowed us to come to a consensus on emerging themes grounded in feminist poststructuralism that best represented participant experiences from their responses this paper presents a secondary analysis of data from a previously published report 37 the analysis presented in this paper is unique from our previous reports in that its focus is specifically on the personal social and institutional construction of mothers experiences of health systems support and social support trustworthiness we maintained trustworthiness through accurate documentation of participant responses and detailed notes 3839 we attained credibility dependability and confirmability by investigator triangulation through regular team meetings to discuss and confirm the ongoing analysis team members used reflexive notes to identify personal observations feelings and biases 38 as part of the feminist poststructural analysis we discussed our own socially constructed positions and their influence on the analysis to enhance credibility and authenticity 32 dependability and confirmability were established through an audit trail that recorded analysis decisions and rationale results participant demographic information is summarized in table 1 all participants were from nova scotia canada all participants identified as mothers and were predominantly white heterosexual women who lived with their partners approximately half of the participants were firsttime mothers we identified three distinct themes that captured participants experiences of isolation during the covid19 pandemic and their health care and social support needs covid19 and the social construction of isolation feeling forgotten and dumped perpetuating the invisibility of mothering and navigating and negotiating conflicting information covid19 and the social construction of isolation as captured under the first theme covid19 and the social construction of isolation participants described how isolation negatively affected their experiences in extreme ways due to public health orders to stay home and not visit with members of other households most participants spoke about how their needs for socialemotional and practical support to care for an infant and themselves were unmet because they were isolated at home connecting with the community was identified as very important in the postpartum period many mothers experienced tension between the expressed need for community and the restrictions in place limiting that community this statement exemplifies the extreme effect that public health orders had on many participants in this study there is no support while text messages and phone calls help its not the same it took me a while to be less angry at the adage that it takes a village to raise a family that village is illegal raising children and families together with others outside ones immediate family was important to this participant as well as others in our study being denied access to their broader communities produced feelings of anger participant 4 s statement highlights the emotive aspect of isolation that can be devastating for families our analysis revealed that the meaning of community was constructed through a discourse that valued and expected families to support and raise each other participant 4 demonstrated how she used her agency to question how the community was being handled by public health if we see the relation of power as constructed between the public health mandate for isolation and the desires of parents for the community then we can see participant 4 challenging the systemic experience of isolation feeling isolated and alone in such an extreme way with a new infant was stressful and highlighted the need to be connected to the larger community to feel supported it has been hard to balance my day to keep him busy and thriving i feel as if i am a bad mum for allowing him independent play time which often involves his books we do not watch or use technology he has become more demanding of my time and is able to open up all the drawerscupboards meeting with other mums and dads means that i can learn new ways to help him grow and develop overwhelmingly participants stated that isolation was detrimental to their health and the health of their infants to break the isolation most participants used virtual technology to connect socially and seek information and support from family during the pandemic however remote communication using phone or video communication programs was not seen as equivalent to inperson connection physical contact and support while several participants used the phone to call family for advice the need for practical help and support in the daytoday tasks of caring for a new infant could not be met through virtual contact several participants spoke about the challenges associated with virtual contact such as issues with scheduling with family members i have very little support sometimes my family facetimes but my husband is at work all day and both of our families live in separate areas i can talk to people on the phone but everyone i know is still working meaning that i feel even more isolated as i have not had a facetoface conversation with anyone aside from my pharmacist since the state of emergency began phone and facetime were the primary tools participants used to connect with family and friends many expressed that while this was helpful it also reminded them of what they were missing they believed that it was imperative that they connect with people inperson motherbaby yoga and swim groups walks in the park play dates library visits and reading sessions and music classes were all viewed as engagement opportunities that were essential to social and emotional health one participant described how her mental health was suffering because of her lack of connections with other mothers i feel the biggest difficulty has been finding social support for my emotional health i had wanted to find a group of local moms prepandemic and had found yoga stroller fit pelvic floor physio music and swim groups that i wanted to try out for bonding with my daughter and expanding my support circle that has been the most difficult hole to fill by far and i feel my mental health is suffering because of missing connection with other firsttime moms many participants spoke about the pressure to be everything for their new baby without the broader community of social support this demonstrates the social discourse that has been constructed that mothers should be everything for their babies and know how to mother or parent naturally 40 this creates pressure and compounds the experience of isolation the assumption that mothers are to be everything for their babies counteracts and minimizes that belief that mothers need to connect with and be supported by the community participant 8 challenges the notion of being everything when she articulates that she believed she could bond with her daughter through meeting with other people this challenges the discourse that bonding is an individually constructed experience and a private matter between mother and child another participant shared an example of the pressure isolation placed on parents the pandemic has limited our social networks and our inperson support network and increased the pressure on us as new parents to provide care support interaction socialization and entertainment for our child and one another we can see that the pandemic exacerbated the normalized discourse of postpartum isolation and the expectation that mothers and parents be alone with their babies participants tried different ways to deal with isolation such as trying to connect with family friends and health care providers by telephone and various online platforms while this new way of connecting was helpful in some ways it was not ideal for most participants feeling forgotten and dumped perpetuating the invisibility of mothering under the second theme feeling forgotten and dumped perpetuating the invisibility of mothering participants emphasized the effects of the covid19 health system response on the postpartum care of mothers and infants while some believed that their health care needs were met by the health system most emphasized how changes in service delivery due to the pandemic response did not meet their social emotional or physical needs participants described essential postpartum and newborn services being eliminated completely or reduced to virtual care because of public health orders to minimize physical contact this left most participants feeling they had to navigate alone without routine care and were left to decide what was physically and emotionally normal for them and their infant many participants specifically spoke about feeling forgotten by the health system i also feel as if moms are being treated as second class citizens as they no longer offer 6 weeks postpartum checkups meaning that we are left to decide if things seem normal or not after giving birth my 6week postpartum appointment became over the phone i had a seconddegree tear and my stitches had opened once returning home since i had a phone appointment i had nobody check and tell me if i was healing properly some participants felt that this shift to virtual care met their information and support needs and viewed virtual care as a way of reducing their risk of covid19 exposure however most emphasized that virtual care was not meeting their needs and described how the gaps created by virtual care were compromising both their health and the health of their infants the relationship between mothers and their health care providers was significantly altered due to mandated isolation mothers still expected their health care providers to be experts who would be able to let them know if things were normal and if they were healing properly however connecting virtually did not support this expected relationship the gap in care was particularly evident in relation to breastfeeding support our daughter had a tongue tie and we were initially connected to public health lactation consultants and the collaborative breastfeeding clinic we had one meeting with public health before they reassigned our nurse to the covid team and we were dumped the breastfeeding clinic cut her tongue tie but did a phone follow up instead of in person due to covid and dumped us even though we were still having feeding issues the lactation consultants at the hospital also closed our file early due to covid ive felt very let down by the health care system feeling like a secondclass citizen let down or dumped clearly demonstrates that participants felt forgotten and that negotiating relations of power associated with the shift to virtual care was extremely difficult for them participants challenged virtual care by expressing their belief that it was unacceptable to be denied help from their health care providers and to be expected to deal with postpartum issues on their own navigating and negotiating conflicting information as described under the third theme navigating and negotiating conflicting information there was a lack of information and conflicting recommendations and advice regarding covid19 and its potential effects on infant health maternal health breastfeeding and the safety of childcare participants identified continual staffing changes associated with the health system response to covid19 as contributing to conflicting information and confusion about where to go for information it was clear that participants in our study had a very difficult and often stressful time searching for reliable information and advice they were in a position of questioning the health care system and trying to negotiate the constant changes and shifting power due to covid19 while some participants could not confidently choose between conflicting advice others spoke about how they demonstrated agency to critically evaluate information from health care providers and other sources lack of access to health care providers family friends and other parents to discuss and critique different information made conflicting recommendations particularly frustrating and problematic it was a hassle trying to figure out who would do my daughters 2 months needles injections as the public health nurse told me she did not need them and that she would be protected by herd immunity knowing this is not appropriate information to give people we found someone to immunize her this participant did not trust the health professional advice they received regarding immunizations so they searched for and appraised information on their own most participants attempted to access information and support from health care providers however many participants also sought and accessed information through nonprofessional online sources some participants perceived google as a valuable resource whereas others perceived knowledge accessed in this way as variable stressful extreme or not relevant most mothers found it was an ongoing challenge to search for information and decide what information they would trust i think the biggest struggle at the moment is finding information related to the risk of sending our son to daycare to me it seems preposterous that it is too dangerous for me to go into the office to work but it will be safe to send my 12monthold son to daycare which is known for being high risk for sickness during noncovid19 times this statement highlights the struggle that many participants experienced between their own personal knowing and available knowledge related to the health of their baby they sought validation and reassurance regarding systemslevel decisions being made that impacted their own and their infants life discussion our findings provide insights into the postpartum experiences of canadian mothers during the covid19 pandemic that can inform evidencebased support and services participants emphasized the importance of community and social support during the postpartum period and described that inperson connection was necessary but also unavailable due to the pandemic this finding is consistent with other research where participants identified that a lack of inperson support in the postpartum period from family friends and health care providers challenged their physical social and emotional wellbeing 1341 our analysis shows that the meaning of community was constructed by most participants through values and beliefs that families raise each other as part of a village of support participants also identified the competing social and institutional discourse that mothers should be able to cope naturally with a baby on their own social isolation may be seen as a normal and a good thing for mothers and infants to bond together 40 however previous researchers have shown that the postpartum period is an isolating time for new mothers 134142 and mothers do not feel psychologically and practically supported in the postpartum period 13 participants in our study echoed these experiences highlighting how the social restrictions and lack of health care provider availability that resulted from the covid19 pandemic increased their experiences of isolation loneliness and lack of support feeling like they had not been given priority treatment and using terms like secondclass citizen participant responses highlight how to covid19 pandemic exacerbated the invisibility of postpartum care and mothering support for mothers and parents has been constructed through different discourses a health discourse of support primarily focuses on physical and psychological support constructed through practices of meeting with health care professionals 43 and is based on a relationship of health care provider as the expert and the mother as the client or consumer a community discourse of support focuses more on psychological and emotional support through practices of meeting with other mothersparents family and friends 161719 community discourses of support are often constructed as less important than health care provider support that is focused on physical outcomes our participants believed that social emotional and physical support from family and friends as well as health care professionals was crucial to their own and their familys wellbeing demonstrating the importance of both discourses in a recent metasynthesis of 36 qualitative studies across 15 countries finlayson et al 14 identified practical and emotional support from partners families and elders information advice and support from health care providers and information support and reassurance from other mothers as highly important to mothers in the postnatal period previous work has shown that mothers particularly value and trust the advice and support they gain from inperson interactions with other mothers who have infants of a similar age 1617 participants in our current study described how the covid19 related restrictions diminished social networks and created situations of extreme isolation that prevented them from engaging with other mothers and infants this brings to light how a mothering discourse perpetuates the undervalued complexities of raising an infant participants described inperson interactions with care providers as essential participants acknowledged that while virtual care was helpful at times it did not meet all physical emotional and informational care needs furthermore inconsistent information related to infant care and health in the context of the covid19 pandemic from health care providers and online sources was a source of stress the construction of knowledge related to the postpartum period and mothering can take on many forms through different discourses medical health community or grassroots are some of the discourses that continue to be perpetuated there is still an expectation that postpartum information can and should be obtained from health care experts 4344 many participants in our study identified cessation of services or lack of access to inperson appointments with health care providers as a let down and felt that they were forgotten to navigate caring for an infant on their own this highlights the value mothers place on consulting with experts to access consistent information to meet their physical needs in the postpartum period primarily related to their physical care infant development immunizations and breastfeeding and infant nutrition 1314 however the participants in our study also challenged the health care provider as expert discourse when presented with conflicting information and exercised their agency to access the information they needed to feel confident in their parenting decisions while this finding is consistent with our prior research 161744 challenges with the negotiation of knowledge were exacerbated by having a new layer of information related to covid19 and its effect on maternal and infant health that was either not available or presented conflicting points of view participants in our study described having to rely even more on their own personal knowing and critique of information limitations while we broadly recruited participants through social media platforms our sample was largely homogenous and made up of white heterosexual femaleidentifying mothers with high employment incomes from nova scotia canada our findings may not reflect the experiences of diverse mothers including those identifying as members of historically underrepresented groups families living with lower employment incomes fathers those who did not have access to social media or online technology to complete the survey or those living outside of nova scotia canada purposive sampling of diverse participants is needed to capture those experiences we did not characterize the clinical details of the sample therefore it is not possible to draw conclusions regarding the influence of these factors on the experiences of the participants conclusions our research highlights the personal experiences of mothers following childbirth surrounding the social and health systems response to the covid19 pandemic social and health care provider interactions were crucial to the experiences of mothers and their infants governments and health systems must recognize the physical and psychological needs of mothers with infants during responses to public health crises opportunity for peer and health care provider interaction and support must be sustained during times of isolation to support health and wellbeing continued research to develop care approaches to best meet the social and health care needs of mothers raising their infants in isolation is necessary to support positive outcomes data availability statement data are unavailable due to ethical restrictions

social support and health services are crucial for mothers and families during their infants first year the aim of this study was to explore the effect of selfisolation imposed by the covid19 pandemic on mothers access to social and health care systems support during their infants first year we utilized a qualitative design using feminist poststructuralism and discourse analysis selfidentifying mothers n 68 of infants aged 0 to 12 months during the covid19 pandemic in nova scotia canada completed an online qualitative survey we identified three themes 1 covid19 and the social construction of isolation 2 feeling forgotten and dumped perpetuating the invisibility of mothering and 3 navigating and negotiating conflicting information participants emphasized a need for support and the associated lack of support resulting from mandatory isolation during the covid19 pandemic they did not see remote communication as equivalent to inperson connection participants described the need to navigate alone without adequate access to inperson postpartum and infant services participants identified conflicting information related to covid19 as a challenge social interactions and interactions with health care providers are crucial to the health and experiences of mothers and their infants during the first year after birth and must be sustained during times of isolation

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in the uk major incidents are defined as an event or situation with a range of serious consequences that require special arrangements to be implemented by one or more emergency responder agency 1 they lead to a range of mental health outcomes that extend months and sometimes many years 2 distress during and after incidents is ubiquitous but not necessarily a function of psychopathology including mental illness 3 4 5 the nature of distress a term that requires greater clarity is distress there are three common approaches an epidemiological approach is based on literature that refers to distress being composed of subthreshold symptoms of anxiety depression or posttraumatic stress disorder 6 a typological approach uses the term in relation to emergencies to depict people who have a range of experiences that are anticipated and usually broader than symptoms of common mental disorders some accounts organise these experiences into emotional cognitive social and physical domains 7 a third approach is based on the experiences reported by people who say that they have been or are subjectively distressed 8 our definition recognises that people are likely to feel stressed in emergencies their experiences are described as distress when their stress is accompanied by emotions behaviours thoughts and physical sensations that are upsetting or affect their relationships and functioning distress is not a diagnosis but may accompany a disorder trajectories of distress and recovery after major incidents there are many models of the risk of mental health disorder in the aftermath of major incidents 9 10 11 however relatively little is known about the spectrum and course of distress apart from the broad categories or trajectories of response 12 research has been dominated by biomedical models addressing epidemiological issues and identification and treatment of psychiatric disorders there has been less focus on the majority of people who experience distress that does not meet the threshold for specialist services 13 there is a need to better understand their experiences using measures of distress that are less focused on symptoms of disorders and more sensitive to the broader range of experiences primary and secondary stressors the psychosocial effects of extreme events can be influenced by a complex combination of primary and secondary stressors primary stressors are factors inherent in particular major incidents disasters and emergencies and arise directly from them secondary stressors are defined as social factors and peoples life circumstances that exist before and affect people during the major incident and or societal and organisational responses to an incident or emergency 14 examples include breakdown of family relationships lack of support in peoples workplaces concerns about access to appropriate healthcare and overwhelming workloads secondary stressors affect peoples wellbeing and mental health in ways that exacerbate the direct effects of major incidents 1415 they are potentially tractable and should be included in psychosocial care programmes to mitigate distress and mental health disorders however our current understanding of the role of secondary stressors in the context of terrorist attacks has been limited social cure processes disasters happen to people collectively one factor that can mitigate both primary and secondary stressors are new group relationships and any associated social support social support can contribute to survivors wellbeing 1617 and reduce psychiatric symptoms 18 19 20 the support that people receive from their families friends colleagues organisations and communities has a profound effect on the meaning people derive from events their feelings of control their agency and their capacity to deal with adversity 1617 offers of support may be experienced differently depending on who they come from 21 with certain forms of social support experienced as unhelpful by survivors 2223 recent studies of a variety of emergencies have found that survivors reported particular benefit from support from people who shared the experience of the emergency with them 24 25 26 they see these people as understanding their distress and being willing to listen in our qualitative study we found that many survivors felt constrained from sharing their feelings with friends and families if survivors perceived them as unable to understand their experiences 13 they also described various forms of helpful social support including social validation which was a feature of support provided by others access to groups based on shared experience is an important factor for many people in their coping and recovery and a possible springboard to personal growth 27 these common experiences can create a new shared social identity based on the category of people involved in the incident 28 sharing social identity motivates people to give support to others and expect support from them shared social identity and perceived support also increase the sense of group efficacy defined as the perceived ability to coordinate and respond collectively to the disaster 2829 this approach examining social identity as a mechanism for wellbeing is known as the social cure 29 our study the study reported here is part of the twophase mixedmethods exploratory and coproductive research programme social influences on recovery enquiry phase 1 involved qualitative analysis of semistructured interviews with 18 survivors of the manchester arena attack to characterise their experiences and opinions on the psychosocial care that affected their recovery 1327 informed by findings from phase 1 phase 2 is an exploratory quantitative analysis that complements our earlier qualitative study and tests whether our interviewees experiences were replicated in a larger sample our semistructured interviews and the questions in the online survey were developed with survivors we used learning points from analysis of the qualitative interviews to generate questions for our online survey thus we constructed bespoke measures grounded in the experiences of our interviewees we sought to answer three questions first what experiences of distress did each participant report and how did this change over time based on our qualitative findings 13 we expected distress to be universal and enduring for the majority with people who had milder reactions being more likely to show improvement over time second how might secondary stressors have influenced participants psychosocial recoveries based on our previous study 13 we anticipated participants experiences of secondary stressors would correlate with heightened distress and low wellbeing we also compared the impact of different types of secondary stressor on participants distress trajectories finally what part have social cure processes in particular social identity and use of social support played in the relationships between distress and participants recovery trajectories based on our qualitative study and previous research 2728 we expected support from families friends and people who were at manchester arena to be perceived as more helpful than support from other sources we anticipated that support measures would be associated negatively with distress and positively with current mental wellbeing this paper presents the findings from our bespoke survey and from a longitudinal analysis of validated questionnaires completed for the manchester resilience hub the hub was established following the arena bombing in 2017 as a national health service remote consultation service to help people from across the uk who were experiencing problems resulting from the incident it provided a central point for psychosocial support mental health advice and an online monitoring programme to identify people who might require specialist mental health or other services 30 this paper develops our previous findings by examining further the interrelationships between social support secondary stressors postevent distress and mental health outcomes among physically uninjured survivors of the arena attack we compared two different pathways by which social identification could operate to reduce distress and facilitate recovery in model 1 social identity is the basis of perceived support and hence efficacy 1931 in model 2 perceived support is the basis for seeing others as part of their ingroup and identifying with them 27 in both models efficacy is expected to be strongly associated with wellbeing we report testing of how these models apply to our data from a sample of survivors assessed through the significance of indirect pathways method design the present study is a quantitative analysis of two datasets provided by the same participants the first dataset is a crosssectional online survey of a convenience sample of survivors of the manchester arena attack completed in january 2021 this includes a measure of participants retrospective experiences of distress in the 3 months after the event using an unvalidated scale that is based on analysis of the subjective accounts of survivors who took part in our earlier qualitative study 13 it also includes a validated mental wellbeing scale this measures participants mental health in terms of the broad categories of psychological functioning life satisfaction and ability to develop and maintain mutually benefiting relationships administered at a time point nearly 4 years after the event the second dataset the longitudinal element of our study is the same participants contemporaneous scores on selfreport mental health questionnaires collected prospectively online from 3 months to 3 years postincident we use the results of validated mental health measures to define the levels of distress experienced by participants over the course of 3 years following the attack the differing yet complementary perspectives and the crosssectional and longitudinal analyses enabled exploration of participants distress trajectories and how secondary stressors and social cure processes might have affected participants coping and recovery the sample the study was conducted with registrants of the manchester resilience hub they were survivors of the arena attack who contacted the service and completed the mental health questionnaires used at the hub within a year of the attack the hub had registered over 3000 people representing approximately 16 of people who were physically present at the arena during the attack 32 the participants who completed the sire online survey were recruited from a convenience sample of researchwilling registrants eleven of the survey sample had also participated in the phase 1 qualitative interview study eligibility criteria eligible participants were identified through the hub database and were people who attended and were directly affected by the arena event but were not physically injured completed the hubs measures of mental health at the 3 andor 6 month postevent time points were aged ≥18 years on registration with the hub and had given consent to be contacted about participation in research measures crosssectional survey measures the majority of our survey questions are unvalidated items based on the subjective experiences of the participants in our previous interview study our rationale was to substantiate and amplify our earlier findings we did not intend to create and standardise a new scale for further research or clinical use a full copy of the questionnaire comprising 103 items and items not included in the analyses presented here are given in the supplementary material available at measures of wellbeing and distress we included a single item measuring stress and distress in the month before the incident and asked participants to choose which of the options best described their experiences we measured wellbeing with the wemwbs the wemwbs is a 14item psychometrically robust measure of current mental wellbeing in the general population validated in a number of populations including clinical and ethnic minority samples 3334 it covers feeling and functioning aspects of mental wellbeing which it represents as the positive end of a continuum the scale is 1 to 5 to measure postevent distress we constructed 29 items aimed to give a measure of participants experiences in the first 3 months after the event the items were based on the experiences of distress reported by the participants in our earlier interview study 13 all of the questions were scored from 1 to 5 to measure secondary stressors we constructed 18 items drawn from the findings from the qualitative phase of our study to measure difficult or stressful things that sometimes happen to people before during and after major events 13 participants were asked to rate how frequently since the event they had experienced stress with each item questions were scored from 1 to 5 social cure variables to assess identification with others who shared the same experience at the arena attack we used three items adapted from the items in leach et al 35 to assess participants identification with other people with direct experience of the arena attack the validity and reliability of these items have been established in a broad range of social groups 36 based on established measures used in previous research studies 20 we developed three items to measure personal and group efficacy in the domain of coping after the attack we also included one item measuring efficacy in accessing services to assess perceived social support we constructed 21 items that covered sources and types of support that were based on the experiences of social support reported by the participants in our earlier interview study 27 they included nine items referring to perceived support from others who were at the arena attack three items referring to perceived support from family and friends who were not at the arena attack three items referring to perceived support from people at ones workplace and one item referring to perceived support from professionals longitudinal hub measures survivors completed four questionnaires online when registering with the hub three measure symptoms of mental health disorders 37 patient health questionnaire9 38 and generalised anxiety disorder7 39 the fourth the work and social adjustment scale measures functional impairment 40 these measures are validated and have established clinical cutoff points the hub identified clinical priority with this online tool supplemented by telephone contact from a clinician if indicated the initial assessment took place 3 months after the attack and survivors were invited to repeat the online measures at regular intervals thereafter procedure eligible participants for the online survey were invited to participate by email and supplied with the patient information sheet the survey data were collected online with snap version 11 for windows a gdprcompliant cloudbased platform the survey items were scored on likert scales to measure how initial experience of distress and social and contextual factors have affected mental health coping and recovery participants longitudinal scores on the triage measures were obtained from the hub database with their consent consent and ethical approval participants were given the legally required data protection and participant information in a retainable form the online questionnaire included a final page containing a submit button prefaced by a statement reminding each participant that clicking the final button would constitute that participant giving informed consent in full knowledge of the data protection and participant information provided participants were able to withdraw from the survey without explanation at any point ethical approval was provided by the uks integrated research application system process data analysis the results of the hubs four measures were used to provide an overall categorical rating of mild moderate and severe responses for each participant at first completion and over the course of the we examined the descriptive statistics for the questions in the crosssectional survey for differences between the three response groups using parametric and nonparametric tests as appropriate with participants consent these data were also linked with clinical information held in health records at the hub thus we examined the extent to which factors measured in our survey predicted participants coping and recovering including the extent to which the effects of social support are mediated by shared experience and social identity a postevent distress score was derived for each participant by calculating the mean of all of their scores on the 29 questions intended to measure postevent distress other variables were constructed by calculating their mean scores on the secondary stressor and social cure items within the survey each participants wemwbs score was derived by summing all of the items within the scale giving a potential range of 1470 it provides a measure of participants mental health at the time when they completed the survey in late 2020 and early 2021 we carried out regression analysis analysis of variance mediation analysis and path analysis to generate the inferential statistics used to address the study questions results demographics of the 262 people who met our eligibility criteria 84 responded to the survey we were unable to use the longitudinal data from all 262 people because we did not have permission to use clinical data from all but the 84 people who did consent the supplementary material includes a demographic breakdown of our survey respondents there were no significant differences in gender between the survey respondents and all hub registrants the age profile of our survey respondents was skewed toward older age compared with all hub registrants the majority of respondents described themselves as white british which closely corresponds with ethnicity data recorded on the hub database a total of 47 were from northwest england which is representative of all hub registrants what were participants experiences and trajectories of distress and recovery over time experiences of distress we examined all of the postevent distress questions and differences between the mean for each item and the overall mean for all of the items combined feeling unusually alert or on my guard and shocked were the highest scoring items followed by worries about the risk of another terrorist attack and upsetting thoughts or images about the event the lowest scoring items were being unsure about where i was or about what was the date and losing skills that i had before the event current mental wellbeing the wemwbs mean score for our sample is 424 with a median of 43 table 1 shows the descriptive statistics of the survey respondents on wemwbs compared with the health survey for england 2011 data 33 the mental wellbeing of our participants was lower than the general population with a mean difference of 93 a total of 46 of our sample scored below the 15th centile postevent distress and current mental wellbeing the relationship between current mental wellbeing and our participants reports of postevent distress was examined with the pearson correlation coefficient the overall association between wemwbs scores and the combined score for all of the post event distress items was low only four items had both significant association and mildtomoderate effect sizes question 33 i wanted to be by myself most of the time question 34 i was irritable without good reason and took it out on other people or things question 35 i had serious disagreements or arguments with other people that were unusual for me and question 22 i had problems remembering things exploratory factor analysis of postevent distress items we conducted a principal axis factor analysis on the 29 postevent distress items to explore the extent to which they made up different factors five factors had eigenvalues over kaisers criterion of 1 and together explained 64 of the variance in postevent distress scores however the first factor alone explained 51 of the variance and had by far the largest eigenvalue the scree plot also indicated only one factor the factor loadings of the postevent distress items after rotation are shown in the pattern matrix factor 1 contains five items which appear to measure social withdrawalphysical symptoms factor 2 contains five items that appear to measure fear of recurrence factor 3 contains seven items that index impaired everyday functioning factors 4 and 5 each contain five items which appear to measure changes in affect and intense feelings respectively regression analysis we examined the extent to which the five postevent distress factors predicted wemwbs scores they explained 16 of the variance in wemwbs scores the social withdrawal physical symptoms factor was not predictive of mental wellbeing at 3 years 8 months postincident impaired everyday functioning and change in affect were predictive factors the betacoefficients indicate that the magnitude of effect of each factor varied from small to moderate longitudinal hub measures response category at initial assessment based on the hub algorithm participants scores on the hub measures at 3 months or 6 months were categorised as mild moderate or severe responses comparison of initial assessment data for all hub registrants with the data for survey responders showed that there were differences between the two groups on two of the hubs measures more people were categorised with severe reactions in the survey group changes in hub scores over time longitudinal analysis of the hub scores of our survey respondents showed that there were decreases in their gad7 and tsq scores over 3 years however the betavalues and confidence intervals associated with these changes indicate small effect sizes the phq9 and wsas scores did not decrease over 3 years linear regression analysis showed that there were differences albeit small effect sizes between the mild moderate and severe distress response groups in the trajectory of scores on the hub measures over 3 years the mild response group showed decreases in gad7 and tsq scores from the 12month time point the moderate response group showed reductions in phq9 and tsq scores from the 18month time point in contrast the severe response group did not show any reduction in scores on any of the four hub measures none of the three response groups showed any improvement in wsas scores over time of note the tsq was the only hub measure at initial assessment that did not correlate with final distress response categorisation changes in each participants response category over time we compared the hub initial and final response categories to give an indication of respondents improvement or deterioration over time twentysix of the 84 survey respondents did not have hub scores at either 30 or 36 months therefore this analysis is based on 58 participants table 4 shows the number of participants who changed category between the initial and the final assessment overall 13 respondents improved 41 stayed the same and four deteriorated 22 of the 58 respondents were still experiencing moderate or severe distress at 3036 months wemwbs and postevent distress scores and their correlation with hub scores supplementary table 6 shows the correlations between the wemwbs and postevent distress scores with the hub scores at 3 6 and 36 months after the incident there were high correlations between some of the initial hub assessment measures and wemwbs this was most significant for the wsas followed by the phq9 the gad7 was significant at 3 months but not at 6 months the tsq scores at 3 and 6 months were not associated with participants mental wellbeing after 3 years 8 months of note the contemporaneous hub scores at initial assessment have high correlations with our retrospective measure of postevent distress we examined all of the secondary stressor items for differences between the mean for each one and the overall mean for all of the items combined the most commonly reported stressors were exposure to negative reports in the news media new or continuing mental health problems and social media causing a moderate amount or a great deal of stress to 62 60 and 54 of our respondents respectively the lowest scoring and less frequently reported stressors were lack of access to physical healthcare lack of education opportunities or facilities and loss or lack of employment secondary stressors and current mental wellbeing the relationship between current mental wellbeing and the secondary stressor items was examined with the pearson correlation coefficient the overall correlation between wemwbs score and the combined score for all of the secondary stressor items was moderate the only secondary stressors with significant associations and moderate effect sizes were disruption to relationships with friends disruption to relationships with my family and new or continuing mental health problems exploratory factor analysis of secondary stressor items we conducted a principal axis factor analysis on the 18 stressors to explore the extent to which the secondary stressor items clustered five factors had eigenvalues over kaisers criterion of 1 and in combination explained 65 of the variance the scree plot did not clearly suggest five and indicated two the items that cluster on the same factor suggest that factor 1 represents family and friends stressors factor 2 represents work stressors factor 3 represents compensation stressors factor 4 represents service stressors and factor 5 represents physical health stressors family and friends was the only secondary stressor factor that had a significant correlation with wemwbs score the magnitude of effect was moderate multiple regression analysis the five secondary stressor factors were put into a regression equation with wemwbs score as the dependent variable the secondary stressors together explain approximately 175 of the variance of wemwbs score but only one emerges as significant the family and friends factor accounts for the majority of the association with a moderate effect size the other factors were not predictive of wemwbs score longitudinal hub scores and secondary stressors oneway anova was carried out to compare the overall mean of participants secondary stressor scores across the three different response categories based on the hub measures participants mean scores on the secondary stressor items were significantly correlated with response category at both initial and final assessment post hoc comparison using tukeys honestly significant difference to correct for type 1 errors showed that there were higher scores for secondary stressors for people in the moderate and severe response groups compared with the mild response group at both the initial and final assessment hence secondary stressors were not only associated with the relative severity of peoples initial reactions but also with the enduring nature of those reactions what part have social cure processes played in participants recoveries experience of social support we examined all of the questions constituting the social cure variables and their association with postevent distress secondary stressors distress trajectory and current mental wellbeing the perceived social support variable comprises items from three different sources others who were at the arena attack family and friends who were not at the arena attack and peoples workplaces thus in total five social cure items were subject to analysis identification with others at the arena efficacy support from people at the arena support from family and friends not at the arena and support from people at ones workplace comparison of sources of social support repeated measures anova was carried out to compare participants responses across the three different sources of support participants agreement with the statements was significantly associated with the type of support 903 p 0001 ηp 2 011 post hoc tests show that there were significantly higher scores for arena support than for support from family and friends not at the arena and support from ones workplace however there was no difference between scores for support from family and friends not at the arena and support from ones workplace to test that the pattern of results that emerged from the analysis was not a result of differences in how the items were worded the same analysis was carried out using just the phrase showed a lot of understanding of what ive been through which was common to three questions in the survey this procedure produced the same significant overall difference as for the full scales 929 p 0001 ηp 2 011 and the same pattern in the post hoc tests longitudinal hub scores and social support we compared the mean scores of the hub respondents categorised as mild moderate and severe at 3or 6month and 30or 36month assessment on the five social cure variables oneway anova showed that there were significant differences between the response groups on two of the support factors family and friends not at the arena and efficacy post hoc tests showed that there were significantly lower scores in the severe group as compared with the other groups at both initial and final assessment time points implying that lower scores on these variables may be associated with chronic trajectories of distress correlations table 6 shows the associations of the social cure variables with postevent distress secondary stressors and current mental wellbeing current mental health was most associated with efficacy social identity and support from family and friends not at the arena as expected social identity was associated with arena support efficacy and postevent distress efficacy was associated with arena support support from family and friends not at the arena postevent distress and secondary stressors also as expected support from family and friends not at the arena was negatively associated with postevent distress and secondary stressors arena support was not associated with postevent distress or current mental wellbeing secondary stressors and support from ones workplace were not associated with any other measures mediation models results are reported for the two proposed mediation model structures controlling for age and secondary stressors for each model we report the indirect effects for model 1 we used process version 33 for windows to test the pathway from social identity to current mental wellbeing via arena support and then efficacy 41 results based on 10 000 bootstrapped samples indicated no indirect effect 0742 to 0851 age was a nonsignificant covariate and secondary stressors were a significant covariate for model 2 using the same analysis we tested the pathway from arena support to current mental wellbeing via social identity and then efficacy figure 1 shows a nonsignificant pathway between arena support and efficacy and this is the key difference between the two models results based on 10 000 bootstrapped samples indicated that there was a significant indirect effect therefore this is the preferred model secondary stressors were a significant covariate age was again a nonsignificant covariate both models were considered to be just identified meaning the fit is considered perfect to the observed correlation matrix and so goodnessoffit measures were not appropriate discussion the sample our sample is of predominantly female participants that might appear as a bias but it was representative of the gender imbalance of the people who attended the arena event therefore their experiences may reflect the much larger population of people affected by the incident however our findings with this female dominated sample may not be typical of other events with more diverse populations experiences of distress consistent with our earlier interview study 13 excessive arousal and vigilance at social gatherings and in public places fear of recurrence of the event and upsetting thoughts or images of the event were the most reported experiences of distress in this larger survey in the first 3 months following the incident in our earlier study we also found evidence suggesting that certain initial psychosocial responses such as social withdrawal and changes in mood were associated with more severe and enduring distress this association has also been reported recently in relation to terrorist attacks 42 43 44 and natural hazards 45 suggesting that certain early experiences might serve as markers of the risk of longerterm distress we found that specific postevent responses such as social withdrawal irritability and memory difficulties were the items most associated with lower wemwbs scores based on our exploratory factor analysis social withdrawalphysical symptoms appears to be a genuine latent construct of postevent distress in our sample however regression analysis showed that the social withdrawalphysical symptoms factor was not predictive of mental wellbeing 3 years postevent impaired everyday functioning and change in affect were predictive of current wellbeing with moderate effect sizes however they only accounted for a small amount of the variance in postevent distress therefore it is unclear whether they represent legitimate constructs of postevent distress with any predictive value trajectories of distress and recovery analysis of the crosssectional survey and longitudinal hub data has provided notable findings on the course and patterns of distress in our cohort of survivors comparison with wemwbs population norms showed that the mental wellbeing of our sample was significantly lower than the general population the event continued to have an impact on survivors mental wellbeing more than 3 years later our participants had a mean score more than 9 points below the uk national average differences of 3 points or more are viewed as clinically important in outcome studies 46 studies comparing wemwbs scores with a validated measure of depression indicate that 42 of our sample of survivors could be at high risk of major depression and 60 should be considered in high risk of psychological distress and increased risk of depression 47 longitudinal analysis of the hub data also provides evidence of enduring impairment there was a significant fall in the gad7 and tsq mean scores but no significant changes in the phq9 or wsas scores over 3 years scores in the severe group did not reduce significantly over time on any of the hub measures in addition 69 of people with a moderate or severe initial reaction were still categorised as moderate or severe on hub metrics 3 years after the arena attack thus slow recovery and chronicity are common trajectories for the moderate and severe response groups in our sample these findings are consistent with the typical broad pattern of psychosocial responses or trajectories reported elsewhere in the literature 48 49 50 and provide evidence that peoples responses to major incidents fall into three main groups shortterm distress more persistent distress and slower recovery and high stress and deteriorating responses previous work on the impact of major incidents indicates that the intensity of initial distress is strongly associated with enduring and debilitating distress 44 some studies suggest that distress reaches a peak in the year following the event and then slowly improves with recovery ranging from several months to 2 years 5152 however a number of longterm studies report persistent distress and enduring psychosocial repercussions for some people over many years 2253 many of our survivors who experienced mild and moderate responses were still experiencing some degree of distress and impaired functioning 3 years after the event thus the existing literature might underestimate the number of people who take a long time to recover the impact of secondary stressors secondary stressors have the potential to exacerbate distress during and following major incidents 1415 however there is a dearth of research identifying which secondary stressors are particularly associated with mass terrorist events and how they can be targeted by more effective and timely psychosocial interventions our findings advance understanding of secondary stressors and elucidate the stressors that affected coping and recovering in our respondents our analysis showed that disruption to relationships with family and friends has a significant association with our survivors current mental wellbeing this amplifies the findings from our earlier interview study 13 we speculate that the quality of relationships may be a salient influence on coping and rate of recovery following terrorist attacks we suggest that enquiring about the quality of relationships should be central in assessing risk and need the longitudinal hub data also showed that there may be evidence of a linear relationship between secondary stressors and longerterm outcome which suggests that secondary stressors might be associated with the enduring risk of mental health disorders however we note that all of the factors arising from analysis of secondary stressors were significantly correlated with postevent distress this could indicate a bidirectional relationship between postevent distress and secondary stressors and complicates any simple conclusions about a causative interpretation of relationship between secondary stressors and longerterm outcomes social cure processes in line with previous research our participants showed high levels of identification with others who had been at the arena 27 we found that our participants showed greater appreciation or perceived greater effects of support from other people who had been at the arena than support from work colleagues or family and friends who had not been at the arena this finding corroborates our interview study finding that people who share the common experience of a disaster are perceived as more able to understand participants feelings and participants feel more able to disclose to them 27 only the social support variable concerning family members and friends not at the arena was shown to relate directly to current mental wellbeing and postevent distress suggesting that support from families might reduce distress both immediately and in the longer term we tested two social cure models and found that there was greater statistical support for a model in which perceived support from other people present at the arena leads to efficacy and current mental health via shared identity 28 than a model in which shared identity leads to efficacy and current mental health via social support 20 perhaps in the context of a recovery period extended over several years experiencing support from others at the arena was crucial to people forming and sustaining an identity defined by the event typically disaster communities and their associated identities are short lived 1655 conscious action is needed to keep them alive and sustain their benefits 56 although we expected support from other people at the arena to be directly associated with reduced distress we did not find that here however we did find a relationship of support from others at the arena with social identity and efficacy in turn efficacy was strongly negatively associated with postevent distress chronic trajectories of distress on the hub metrics and current mental wellbeing in line with previous research 29 importantly as our qualitative findings suggest 27 it seems that the beneficial effects of identifying with and receiving support from other people at the arena is indirect with each affecting beliefs about ones abilities to cope which had a direct effect on current mental wellbeing measurement issues hub questionnaires participants initial tsq scores did not correlate with their final distress categories this suggests that the tsq was the weakest predictor of longterm recovery trajectory of all of the hub metrics and is consistent with evidence in the literature of the low specificity and sensitivity of the tsq 57 the wsas and phq9 were better predictors of mental wellbeing at 3 years compared with the tsq and gad7 the wemwbs there were very high correlations between the final hub metrics and wemwbs scores wemwbs was not designed as an instrument to detect mental illness but very low scores may indicate need for clinical examination the wemwbs can measure a wider range of distress and everyday functioning than metrics from other measures that are intended to detect psychopathology this suggests that it may be appropriate to utilise a measure of mental wellbeing such as the wemwbs in early assessment and intervention programmes after major incidents limitations and strengths our study is an exploratory analysis we acknowledge its limitations and recommend caution when interpreting the results sample size and bias may limit the generalisability of our findings and the power of the results reported herein particularly in the small group comparisons comparison of initial assessment data for all hub registrants completing 3 andor 6 month assessments with our survey responders showed that there were statistically significant differences between the two groups on two of the hubs measures with more people categorised with severe initial reactions in our survey group the age profile of our survey respondents was skewed toward older age compared with all hub registrants our respondents were recruited from a subset of 262 survivors who registered with the hub in the aftermath of the arena attack and had expressed an interest in participating in research we cannot assert that our respondents experiences are representative of all survivors of the event we think that the way in which we recruited our sample made it more likely that fewer of our participants experienced shortterm distress because our sample was composed of people whose distress was of sufficient duration andor severity to take them to the hub the items in our online survey except the wemwbs questionnaire and the social identity measures were not previously validated this might have affected the quality of the data in terms of comparability and credibility the selfreport and retrospective nature of our survey data collection also brings limitations in that the data are not supported by clinical interviews to validate our respondents experiences of distress secondary stressors or social support a strength of our study is that we were able to draw on longitudinal data collected at regular intervals over 3 years and combine it with the selfreport data to mitigate the potential biases an asset of our online survey is that much of its content was based on learning from participants experiences and opinions gained from an earlier qualitative analysis of semistructured interviews with a purposive sample of survivors of the arena attack the qualitative study in the first phase informed and complements the quantitative study reported here a benefit of this coproductive mixed methodology is that it lends itself to more contextspecific analysis of the impact of major incidents it facilitates designing bespoke psychosocial interventions tailored to the specific risks and needs of various incidents as opposed to a onesizefitsall approach previously we outlined three approaches used to define distress epidemiological typological and experiential our approach to understanding distress has straddled these differing perspectives by drawing on a validated measure of current mental wellbeing the longitudinal clinical data from the hub and our participants subjective reports of their postevent distress we believe that these complementary viewpoints generate congruent findings in relation to distress trajectories secondary stressors and social cure processes practical implications the importance of psychosocial care distress was extremely common and enduring for most of our participants including people who were mildly affected but they did not reach the threshold for mental health disorders or specialist care they represent a large group of people whose suffering warranted validation and many of them desired access to psychosocial care this requires agencies to act together to broaden the scope of approaches to recovery to include monitoring distress associated experiences and effects on functioning clinical interviews are important in deciding the severity of peoples responses and the nature of interventions offered assessing and monitoring people in need measures identifying symptoms of mental disorders have inherent limitations in specificity and sensitivity and they can lead to inappropriate premature pathways to specialist mental healthcare for some people or overlook the large group of people who are distressed and may require psychosocial care our view is that overreliance on instruments that measure peoples distress from one perspective has inherent limitations our study combined wider perspectives on distress with measures of disorder measures of broader categories of functioning and subjective accounts of the experience of distress our experience highlights the importance of considering all perspectives when assessing survivors needs for psychosocial care following major incidents we advocate brief narrative assessment and regular monitoring to identify people who may need more personalised psychosocial care in the early stages this could be supplemented by psychosocial tools that assess mental wellbeing overall functioning and coping abilities the support available within each persons social context and particularly their closest relationships and any hindrances to accessing social support 58 59 60 61 strengthening the contributions of families friends and significant others people need acknowledgement and emotional and practical support from their close families friends and colleagues however we cannot assume that this happens naturally sire has shown that although family and friends are very important sources of support their attempts at support can also be unhelpful 27 poorquality support can exacerbate distress and prolong recovery hence services should focus on helping to mobilise support from each persons network and offer psychosocial interventions with families to enable members to seek social support and validation facilitate intrafamilial communication processes and increase families understanding of survivors experiences activities that can have positive effects include bringing together people with shared experiences they can be facilitated by enabling survivors to contact other people who have been affected or have had similar experiences these contacts can also be organised in selfhelp groups peer support offered by people who have shared experiences provides mutual support and can be a catalyst for social validation information exchange and develop social identification outreach services can also facilitate workshops and visits to create spaces wherein people can talk about their experiences and come together and these formal group meetings can lead to informal meetings attending to the impact of secondary stressors although exposure to primary stressors may increase distress in the short term the longterm course of distress may depend on persistent exposure to secondary stressors they are tractable and recognising them should be included in psychosocial care programmes to mitigate the longterm course of distress and restore functioning thus the social model of secondary stressors enables a holistic approach to conceptualising and intervening to remedy many of the longerterm and widespread negative psychosocial effects of major incidents 514 in conclusion our exploratory study raises issues that require further debate we recommend longitudinal research using larger sample sizes to confirm or refute our findings nonetheless our main conclusions are that distress is enduring for many people even those with relatively mild impairments who do not need formal assessment and specialist healthcare also secondary stressors are associated with enduring distress and possible mental health disorder and should be central in assessing risk and need following major incidents the quality of close relationships is pivotal to longterm outcome finally constructive support from families friends and people with shared experiences at the event are key to social cure processes that promote recovery planners and practitioners should take these processes into account when they design services for future incidents data availability the authors confirm that the data supporting the findings of this study are available within the article and the supplementary materials or from the corresponding author js upon reasonable request declaration of interest rw is a deputy editor of bjpsych open he played no part in the journals review and editorial processes for this paper js pc pf and ab were involved with the work of the nhs manchester resilience hub all other authors have no conflicts to declare

terrorist incidents lead to a range of mental health outcomes for people affected sometimes extending years after the event secondary stressors can exacerbate them and social support can provide mitigation and aid recovery there is a need to better understand distress and mitigating factors among survivors of the manchester arena attack in 2017we explored three questions first what experiences of distress did participants report second how might secondary stressors have influenced participants psychosocial recoveries third what part has social support played in the relationships between distress and participants recovery trajectorieswe conducted a crosssectional online survey of a convenience sample of survivors of the manchester arena bombing n 84 in january 2021 3 years 8 months postincident and a longitudinal study of the same participants scores on mental health measures over 3 years from september 2017survivors mental wellbeing scores in early 2021 were significantly lower than general population norms longitudinal followup provided evidence of enduring distress secondary stressors specifically disruptions to close relationships were associated with greater postevent distress and slower recovery we found an indirect relationship between identifying with and receiving support from others present at the event and mental wellbeing 3 years laterthe arena attack has had an enduring impact on mental health even in survivors who had a mild response to the event the quality of close relationships is pivotal to longterm outcome constructive support from family and friends and people with shared experiences are key to social cure processes that facilitate coping and recovery

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introduction an informal economy or grey economy which plays an important role for employment creation income generation and poverty reduction in many developed as well as developing countries like india informal sector is an unorganized sector consists of all unincorporated private enterprises owned by individuals or households engaged in the sale and production of goods and services operated on a proprietary or partnership basis and with less than ten total works unorganized workers consist of those working in the unorganized sector or household excluding regular workers with social security benefits provided by the employers and the workers in the formal sector without any employment and social security benefits provided by the employers is known as informal employment the first indian national commission on labour under the chairperson of justice gajendragadkar has defined the unorganized sector as that part of the workforce who have not been able to organize in pursuit of a common objective because of constraints such as casual nature of employment ignorance and illiteracy among informal laborers the informal employment is against the global standards endorsed by the 15th icls employment in the creation of goods or services with the main goal of giving the people involved employment and incomes unincorporated businesses that are part of the informal sector are not set up as separate legal entities from their proprietors they are owned by one household member numerous members of the same household or members of various households they typically have little or no separation between labour and capital as inputs of production operate on a small scale and have minimal levels of organization compared to the organized or official sector employers in the informal sector typically have lower pay lower skill levels and fewer access to financing and social safety nets they frequently work and live in cramped spaces and they only ever use cash for transactions which encourages the spread of a number of hazardous diseases in developing and expanding economies like india the impoverished frequently rely on illegal economic activities for their means of subsistence in india the informal economy produces close to 50 of the countrys gdp on average while more than 90 of all workers are employed in the informal sector workers select informal employment for a variety of reasons depending on indias circumstances and worker characteristics informal workers can be found in a variety of smallto mediumsized businesses unorganizedorganized firms and adjacent industries as day labourers significance of the study the informal economy which includes the informal sector in large part can be modified slightly to accommodate disorganized manufacturing over the past two decades indias economy has expanded quickly but more than 90 of the countrys labour has remained unemployed contributing around 50 of gdp data from the periodic labor force survey show that 75 of informal workers are independent contractors and that normal wage workers make less money on average than regular salaried employees while the proportion of formal workers in india is 97 there will only be 475 million of them by 2022 poor capital intensity low productivity the prevalence of family labour and simplicity of entry are some characteristics of the informal sector the most significant aspect is the employment chances created by indias informal sector which helps to alleviate the pressure of specific issues like unemployment and poverty by heavily utilizing local resources and timehonored conventional ways that only satisfy local needs background of the study many studies and articles have expressed various serious concern about the deterioration in the employment scene in the country in past years role of informal sector in employment generation in india has explained without support of the government this sector is generating a huge employees in different sector of the economy it is based on the findings that if government will interfere then the condition of the informal employee will be better for economic growth this paper find out that the veracity of assertions such as decline in workertopopulation ratio in recent years increase in unemployment withdrawal of women from workforce and deterioration in the overall employment scenario in india workforce changes and employment a niti aayog discussion paper this paper has concluded that structural changes in output and employment as growth rate in the output of the nonagriculture sector did not generate commensurate employment because of job security assured salary and other pay and prestige associated with it preference towards government jobs has increased tremendously rural nonfarm employment and rural transformation in india this paper examines that though there is growing share of rural nonfarm employment still agriculture is the major employer of the rural workforce objectives of the study ➢ to study the role of informal sector for employment generation ➢ to study the current scenario of informal employment in india ➢ to study various challenges and difficulties faced by informal employment in india method and data sources the present study is based on secondary data only data are collected from periodic labour force survey survey reports ministry of labour employment government of india international lab our organization national sample survey organization central statistical organization economic survey of india etc the accessible secondary data is intensively used for this research study figure 1 informality concept informality as a concept combined both informality of enterprises and informality of employment as informal sector conceptual framework of informal employment contrary to the idea of the informal sector which sees jobs as observation units instead of production units the idea of informal employment sees jobs as observation units regarding own account workers and employers the jobs status as an informal employment arrangement is determined by the enterprises participation in the informal economy ownaccount personnel managing a freelance business are therefore seen as being in a freelance position source prepared by using plfs report the distribution of employment in indias unorganised sector from 201718 to 202021 is shown in the table above this table shows the percentage of male and female workers in indias unorganised sector every year a greater proportion of men than women are employed informal sector enterprises according to the 15th icls conceptual framework unincorporated enterprises owned by households are largely considered as informal sector enterprises according to plfs proprietary and partnership enterprises are considered as informal sector enterprises in bellow table share of workers in informal sector among workers in usual status in nonagriculture sector is presented table 15 percentage of workers in nonagriculture sector source annual report of plfs in the above table we can see category of workers specially male and female percentage of workers engaged in both rural and urban areas also we can see the percentage of rural and urban mix for both male and female workers engaged in nonagricultural sector from the period 201718 to 202021 among the above given period in the table we can see male workers percentage is highest 809 in rural area in 202021 year lowest in 201718 that is 744 male workers percentage is also highest 685 in 202021 in urban area lowest in 201819 that is 658 only in female workers category it was highest 594 in 201920 in rural area the share of female worker was lowest in 201819 and 202021 both 585 in rural area in urban area share of female worker is highest in 202021 with 547 and lowest in 201819 with just 502 in rural urban the male workers percentage is lowest in 201718 with 71 and highest in 202021 year with 753 ❖ there are no social security programmes in place to address risks and guarantee the continuation of minimal standards of living during emergencies like unemployment or medical problems ❖ compared to men women are more exposed to informality and frequently find themselves in precarious circumstances productivity the msmes and home enterprises that make up the informal sector are often smaller than companies like tata the benefits of economies of scale are inaccessible to them inability to raise tax revenue since the informal economys companies are not directly regulated they typically evade one or more taxes by concealing their revenues and outgoings from the legal system the government faces a dilemma because a sizable portion of the economy is still untaxed lack of control and surveillance the government continues to not oversee the informal sector furthermore the government finds it challenging to formulate policies regarding the informal sector in particular and the entire economy in general due to the lack of official statistics that accurately reflect the state of the economy lowquality products despite the fact that more than 75 of indians work in the informal sector very little value is added by each person this indicates that a significant amount of our human resource is being wasted initiatives ▪ in order to help the poor who make up the majority of the unorganised sector programmes like the nehru rozgar yojana mgnrega and the swarna jayanti shahri rozgar yojana were introduced ▪ atmanirbhar bharat abhiyan ▪ deendayal antyodaya yojana national urban livelihoods mission ▪ pm garib kalyan ann yojana ▪ one nation one ration card ▪ pradhan mantri kisan samman nidhi ▪ world bank support to indias informal working class conclusion the characteristics of the firm rather than the traits of the person are what define workers in the informal sector the concept of a informal worker places more emphasis on the personality of the employee than on their employer people with and without education can find opportunities in the informal sector in all regions of emerging nations this is not a remedy for the current economic downturn or crisis to support their families and take care of their childrens education everyone needs a certain amount of basic income because this sector contributes more than the official sector the government should pay close attention to it

according to the code on social security 2020 an unorganized worker is one who works from home employees in the organized sector who are not protected by the industrial disputes act of 1947 or chapters iii to vii of the code such as employees provident fund employees state insurance corporation gratuity maternity benefit or employees compensation may be selfemployed or wage workers in the unorganized sector in india around half of the gross domestic product gdp of the country and more than 90 of the total workforce have remained informally employed in informal sector since india got independence this informal economy have played an important role for socio economic development process especially in agriculture and allied activities informal employment contributes more than 95 of total workforces in indian agricultural sector this paper presents various issues and challenges faced by informal workers in india and discuss about it remedies also in this paper we have discussed about the current scenario and condition of informal workers force in india india needs to have employmentintensive growth in the future if it is to properly resolve the demographic dividend conundrum

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background the demand for abortion and post abortion care continues to be an issue in both economic and political spheres in most african countries abortion remains both unauthorized and unsafe which is why it is the leading cause of maternal deaths accounting for a global average of 13 of fatalities related to pregnancy 1 studies have shown that the majority of women who undergo unsafe abortion are young and unmarried poorly educated and of low socioeconomic status 2 an estimated 244 million adolescents resort to abortion worldwide annually 3 the world health organization estimates of unsafe abortion reveal that it is only in the african region that population between 15 and 24 years account for more than 50 of all abortion related mortalities 4 poverty is considered a key determinant which affects womens decision making about unintended pregnancy as well as their access to safe post abortion care many women choose to terminate a pregnancy because of economic hardship and their inability to support a child 5 nigeria is on the verge of not meeting the millennium development goals on maternal health a due to a high maternal mortality ratio in the country estimated to be 630 maternal deaths per 100000 live births recent evidence has shown that a major factor in this trend is the high incidence of abortion in the country 6 despite the fact that abortion is considered illegal in nigeria it is still widespread the 2003 nigeria demographic and health survey estimated that 12 of pregnancies in nigeria end in abortion 7 a 12 year review of women who had undergone induced abortion in ileife in nigeria showed that 30 of the cases of mortality were aged between 1520 years and 37 were students 8 in most parts of the world abortion has declined probably due to the fact that more women are using contraceptives nigeria currently has a high fertility rate coupled with low family planning practice as well as relatively poor access to healthcare family planning usage is estimated to be around 15 per cent in nigeria 9 the high unmet needs b for contraception lead to high number of unwanted pregnancies hence the demand for abortion the 2008 ndhs revealed that about 20 of married women have an unmet need for family planning which comprises 15 for spacing and 5 for limiting henshaw 10 found that an estimated 19 million are spent annually in nigeria in treating unsafe abortion complications and that it would cost only 48 million to prevent those unintended pregnancies a costbenefit ratio of four to one further official statistics do not include privately performed abortions only a small proportion of which are detected when women with obstetrical complications due to unprofessional procedures apply to hospitals 11 in nigeria unsafe abortion has been described as a major issue especially where 80 percent of patients admitted to hospitals with unsafe abortionrelated complications are adolescent girls 12 a host of complications are associated with unsafe abortion and studies have shown morbidity as high as 40 13 methods employed in procuring abortion range from ingestion of toxic substances alcohol mixed with potash or analgesic overdose to surgically induced methods by a variety of untrained individuals 14 in nigeria abortion is permitted only in instances where it is necessary to save the life of the woman and an estimated 610000 of such abortions are performed each year 15 many of these are performed unsafely and evidence from hospitalbased studies in the country have revealed that 25 abortions occur per thousand women in the reproductive age group 16 a host of complications are associated with unsafe abortions including haemorrhage infection uterine perforation genital laceration tetanus and infertility empirical evidence on the demand for abortion and post abortion care has received less attention in the literature available studies have showed various socioeconomic factors that determine the demand for abortion and post abortion care for instance agadjanian 17 showed in the case of mozambique that abortion was prevalent among women under 30 years of age unmarried and still in school also powellgriner and trend 18 found that women are more likely to obtain abortions if they have one or more of the following characteristics residence in metropolitan areas no previous children and completion of high school black and unmarried other studies showed that the cost of travel price of abortion and urbanization had negative effects on abortion demand while religion positively influenced the demand for abortion 19 medoff 20 found average income labour force participation rate and average price of abortion to be positively related to abortion demand madoff 21 also found that abortion ratios and abortion rates of unintended pregnancies were more sensitive to increase in abortion price than when both unintended and intended pregnancies are analyzed together the availability of abortion services was also found by some researchers to be significant in the decision to abort 22 23 24 25 the purpose of this study was to identify the determinants of abortion and post abortion care in the context of nigeria with emphasis on ibadan city such evidence on the magnitude and structure of the demand for abortion is critical for policymakers providers and advocates seeking to mobilize resources to improve the situation methods model specification the model adopted in this study follows king myers and byrnes 26 similar specifications have also been employed in the literature by various researchers 1920 27 28 29 the model was developed from the economic theory of demand the decision to abort was modelled as a function of the full price of abortion and the respondents characteristics this is based on the assumption that abortion is a posterior decision the demand for abortions is modelled in terms of the explicit costs at the time of the abortion decision 28 the abortion choice is thus binary in nature as the effect of variables on the decision to abort is the negative of the decision to keep the pregnancy a probit model is used to estimate the likelihood that a pregnancy will be aborted it is assumed that when pregnant two choices of whether to progress with or terminate the pregnancy are presented to a pregnant woman and one of the alternatives must be chosen it is posited that the maximum utility that a woman receives or expects to receive by making either choice can be expressed as functions of characteristics specific to the individual define the indirect utility received by the already pregnant ith individual choosing alternative a as u ia ¼ x j¼1k β ja x ij þ u iað1þ where a is either choice 0 or 1 j is an index representing 1 through k variables and u ia is a random error term associated with each equation there exists an unobservable random variable of the difference in utilities such that two equations indicated by can be expressed as y i ã ¼ u i1 u i0 ¼ w i þ u i ¼ x j¼1k β j x ij þ u ið2þ where β j β j1 β j0 u i u i1 u i0 and x i1 1 however there exist a limitation to observations on the outcomes of the decisionmaking process where y i ¼ 1if u i1 u i0 oru i w i 0otherwise nð3þ if the disturbance in is assumed to be independently and identically distributed then a probit model can be specified for maximum likelihood estimation of the parameters β j 1 the probability that a woman chooses to abort p i is p i ¼ prob y i ¼ 1 ð þ¼prob u i w i ð þ¼ f w i ð þð4þ where f represents the normal cumulative distribution function empirical models for the purposes of estimation the reduced form equation can be presented as follows ab i ¼ α i þ β 1 ln income i þ β 2 seduc i þ β 3 meduc i þ β 4 feduc i þ β 5 mstat i þ β 6 age i þ β 7 agesq i þ β 8 religiosity i þ ε ið5þ pac i ¼ α i þ β 1 lnincome i þ β 2 seduc i þ β 3 meduc i þ β 4 feduc i þ β 5 mstat i þ β 6 age i þ β 7 agesq i þ β 8 religiosity i þ ε ið6þ equation estimates the socioeconomic variables that influence the demand for abortion the model includes socioeconomic variables such as income age education marital status and religious commitments the second model specified in equation estimates the effects of socioeconomic variables on post abortion care demand a detailed explanation of each of the variables is presented in table 1 data data used for the analysis was sourced from a primary hospitalbased survey of women of reproductive age women between the ages of 1949 years attending antenatal postnatal and women in the outpatient ward were selected using a purposive sampling method adolescents below age 19 were excluded due to the fact that they are considered to be relatively young and sexually inactive according to ndhs 2008 the women completed a selfadministered questionnaire that contained questions regarding the socialdemographic characteristics sexual behavior demand for abortion the cost of abortion and post abortion care the questionnaires were completed by the women this was to allow the women to freely respond to the questionnaire without feeling embarrassed the cooperation of medical officers at these institutions was solicited to assist in the administration of the questionnaires to the women in the sample while the respondents were allowed to complete the questionnaires independently the medical officers provided guidanceassistance when required allowing medical officers to assist respondents was to increase the confidence of respondents in providing such sensitive information as medical officers are more likely to be trusted than ordinary individuals respondents were further assured of confidentiality and the fact that information obtained would be used for research purposes only the medical officers were not given any special training in data collection procedure but were guided on proper filling of the questionnaires a senior doctor assisted in vetting the completed questionnaires 501 questionnaires were planned to be administered but due to time constraint only 384 questionnaires were eventually administered ethical consideration given the nature of the study the sampling and data collection procedure ensured confidentiality in addition the respondents were required to sign informed consent form after the objectives and procedures of the study had been explained to them although there was no immediate gain in terms of incentives for the participants they were made to understand that their participation in the study will contribute towards future policy making and assist in the design of programmes to help females with the problem of unwanted pregnancy the respondents were also informed about the possibility for them to decline to participate in the study in addition to the above procedure the study obtained ethical clearance from the university college hospital research ethics review committee university of ibadan nigeria results descriptive statistics table 2 presents the mean and percentages of the variables included in the study table 2 shows that about 191 out of the 308 respondents demanded for abortion approximately 100 out of the 191 women who demanded abortion also demanded for post abortion care over the period of study about 108 of respondents were employed in private institutions government employees were 92 out of the sample while 25 respondents worked as housewives 83 of the respondents were unemployed the average age of the respondents was 28 years majority of the respondents were single while about 390 were married a relatively smaller percentage of the population was divorced separated and widowed about 184 of the respondents were from the yoruba tribe while 72 and 24 were from the igbo and hausa tribes respectfully all other tribes made up 28 of the total respondents average income across respondents was 56 10948 c nigerian naira while this may be higher than the typical income of a woman in ibadan it may be explained by the large number of women with higher education included in the sample determinants of abortion demand table 3 shows the results from two different models on the socioeconomic determinants of abortion demand the first model includes respondents income education age marital status and parents education while the second model introduces cost of abortion the education variables were automatically dropped when the total cost of abortion was introduced in the second model results from the first model shows that income age marital status and mothers education were significant determinants of abortion demand the relationship suggests that women with higher income were more likely to demand for abortion that is as the level of income increases the probability of demanding for abortion also increases this relationship was significant at 1 with a marginal effect of 01 however in the second model where the total cost of abortion was introduced both income and the cost of abortion were not significant determinants of abortion demand the results also showed from the first model that married women were less likely to demand for abortion relative to women who were not married similarly the age of the respondent showed a positive relationship with the probability of abortion demand in the first model however when cost of abortion was introduced in the model age showed negative and statistically significant relationship with abortion demand both the respondents and fathers education were not significant but the mothers education showed negative and significant relationship with abortion demand women with educated mothers were less likely to demand for abortion with a marginal effect of approximately 015 the respondents religious commitment showed negative and significant relationship at 1 the variable measures religious inclination of respondent and has three categories namely not at all infrequent and frequent engagement in religious activities the results suggest that more religious women were less likely to demand abortion relative to women who were not religious at all this relationship was strongly significant irrespective of whether religious participation was frequent or infrequent determinants of post abortion care table 4 shows that post abortion care demand was only influenced by income age and marital status of the respondent models four and five are distinguished by the introduction of the cost of abortion in model five the results in both models indicate that women with higher income levels were more likely to demand for post abortion care relative to women with lower income levels while respondents age was not significant in model 4 the relationship was significant when cost of abortion was introduced in model 5 the result showed that older women were less likely to demand post abortion care similar to the findings in the demand for abortion model religiosity was a significant determinant of post abortion care relative to those who did not engage in any religious activity women who frequently or infrequently participated in religious activities were less likely to demand post abortion care further the marital status of respondents showed negative and significant relationship with post abortion care demand that is married women were less likely to report for post abortion care relative to unmarried women womens education level and parents education did not show any statistically significant relationship with post abortion care demand total cost of post abortion care did not also show any statistical significance discussion the findings of the study suggest that income of women play an important role in the demand for both abortion and post abortion care this means that women with relatively lower income levels are constrained from going for abortion if they wish to terminate their pregnancies this findings is understandable in the case of ibadan for two reasons first public health care insurance is generally underdeveloped in the ibadan metropolis and nigeria as a whole hence income still plays a crucial part in any form of health care service utilization secondly abortion services are considered illegal in the metropolis like in many other places in nigeria with several risks involved such as the death of patients hemorrhage uterine perforation genital laceration tetanus and infertility hence the cost involved in providing such service is high the constraints posed by income in the demand for abortion and post abortion care may have some positive implications that is fewer women are likely to demand abortion services due to this constraint while this may aid the fight against abortion in the metropolis there is need to ensure that it does not lead to increase in selfinduced abortion cases this situation is much more critical when complications occur and post abortion care is required women who have undergone abortion are safer when they stay under the care of qualified health care professionals for observation and appropriate treatment this finding conforms with that of medoff 20 who found that income of women has a significant positive impact on the demand for abortion services in columbia medoff 20 also highlighted the importance of income in the demand for abortion and post abortion care by showing that women who do not directly pay for abortion related services are more likely to demand for abortion 21 the results also suggest that marital status significantly influence the demand for abortion and post abortion care in both cases married women are less likely to go for abortion or post abortion care this is expected as married women are generally more likely to keep their pregnancies till birth except in cases where medical conditions require that an abortion is performed to save the life of the mother further in cases where married women decide to abort they are more likely to continue to seek for treatment after the abortion to ensure that they do not have complications or when they do they are treated appropriately this finding is similar to the findings of powellgriner 18 that women in the united states of america who are unmarried are more likely to abort their babies than married women note significant at 1 significant at 5 significant at 10 is model without total cost of abortion demand is model with log of total cost of abortion demand robust standard errors are reported in parenthesis the finding on age was expected as younger women were expected to be more likely to abort this is because teenage pregnancy and pregnancy among young women in general are not acceptable in nigerian communities including the ibadan metropolis young women in this condition face several stigmas from society drop out of school and in some cases are rejected by their families to avoid these embarrassments and challenges young women who become pregnant are likely to easily opt for abortion the negative relationship estimated from this study may be mitigated by the increasing public education against abortion among young women in nigeria the purpose of such education by government and other nongovernment organizations is to discourage abortion among young women due to the high risks involved interestingly women education did not show any statistically significant relationship with both abortion and post abortion care demand this contradicts the findings of powellgriner 18 that women who had completed high school were more likely to abort it is worth mentioning that while education and income are usually correlated and both were expected to be significant in determining abortion and post abortion care demand only income was found to be significant this may be explained by the weight given to each of these variables in making the decision to abort the level of income does not only influence the willingness to abort but also the ability to purchase such service education attainment may only to a limited extent influence the willingness to demand abortion services however mothers education was a significant negative determinant of abortion care demand this implies that women whose mothers had some education were less likely to abort relative to women whose mothers had no formal education while a similar relationship was found for fathers education the relationship was not significant the results suggest that mothers have greater influence on the decisions of their daughters than the father the findings also suggest that religiosity of respondents plays an important part in the demand for abortion and post abortion care that is women who frequently or infrequently engage in religious activities are less likely to demand abortion or post abortion care the relationship was expected as most religious denominations in ibadan frown at abortion the moral values taught by religious organizations may also explain the significant negative relationship established surprisingly the cost of abortion and post abortion care did not show any statistical significance even though they positively influenced demand for abortion and post abortion care medoff 20 and deyak and smith 19 found similar relationships in their respective studies conclusion the study sought to estimate a model of the demand for abortion and post abortion care the study used primary data collected from the ibadan metropolis of nigeria and a probit model to determine the factors that influence the demand for abortion and post abortion care the findings suggest that womens income age marital status and mothers education were significant determinants of abortion demand the cost of abortion and womens education did not show any statistical significance similarly womens income age and marital status were significant variables in the demand for post abortion care the findings imply that government policies should be directed towards effective campaign to reduce unwanted pregnancies and unnecessary abortion abortion is not only associated to the poor as the higher income earners were more likely to demand abortion policies should therefore target both the poor and rich in reducing abortion demand and encouraging post abortion care demand as the later could be debilitating further there is need to focus policies to control abortion on both the young and old in society this will be important in reducing the prevalence of abortion as well as reducing abortion related mortalities and disabilities while the findings of this study may be relevant for abortion related policies the extent to which the findings can be generalised may be limited as the scope was restricted to the ibadan metropolis due to financial and time constraints future studies should attempt broadening the scope to cover other states in nigeria endnotes a mdg on maternal health was to reduce maternal mortality by three quarters between 1990 and 2015 b unmet need for family planning or contraception is defined as the percentage of married women who want to space their next birth or stop child bearing entirely but are not using contraception c approximately us 374 at an exchange rate of us 1 ₦150 competing interests the authors declare they have no competing interests

background while induced abortion is considered to be illegal and socially unacceptable in nigeria it is still practiced by many women in the country poor family planning and unsafe abortion practices have daunting effects on maternal health for instance nigeria is on the verge of not meeting the millennium development goals on maternal health due to high maternal mortality ratio estimated to be about 630 maternal deaths per 100000 live births recent evidences have shown that a major factor in this trend is the high incidence of abortion in the country the objective of this paper is therefore to investigate the factors determining the demand for abortion and postabortion care in ibadan city of nigeria methods the study employed data from a hospitalbasedexploratory survey carried out between march to september 2010 closed ended questionnaires were administered to a sample of 384 women of reproductive age from three hospitals within the ibadan metropolis in south west nigeria however only 308 valid responses were received and analysed a probit model was fitted to determine the socioeconomic factors that influence demand for abortion and postabortion care results the results showed that 62 of respondents demanded for abortion while 523 of those that demanded for abortion received postabortion care the findings again showed that income was a significant determinant of abortion and postabortion care demand women with higher income were more likely to demand abortion and postabortion care married women were found to be less likely to demand for abortion and postabortion care older women were significantly less likely to demand for abortion and postabortion care mothers education was only statistically significant in determining abortion demand but not postabortion care demandthe findings suggest that while abortion is illegal in nigeria some women in the ibadan city do abort unwanted pregnancies the consequence of this in the absence of proper postabortion care is daunting there is the need for policymakers to intensify public education against indiscriminate abortion and to reduce unwanted pregnancies in effect there is need for effective alternative family planning methods this is likely to reduce the demand for abortion further with income found as a major constraint post abortion services should be made accessible to both the rich and poor alike so as to prevent unnecessary maternal deaths as a result of abortion related complications

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länder in our analysis we focus on identifying changes in the intensity and spatial pattern of migration flows between 2019 and 2020 we pay attention to differences across age and urbanrural settings to shed some light on the effect of the pandemic on suburbanization we examine the relationship between net internal migration rates and population density using the approach proposed by rees and kupiszewski in the following section we briefly summarize the course of the pandemic in germany and its potential impact on internal migration flows here we focus on changes in the labor and housing markets as well the effects for university students and school leavers in 2020 section three outlines the data and methods and the fourth section describes the empirical results we conclude the paper with a summary and discussion background in germany the number of covid19 infections started to rise steeply in march 2020 with the southern and western states being affected the strongest during the first wave across the country schools and childcare facilities were closed in midmarch and social distancing was strongly recommended on march 23 a farreaching nationwide contact restriction was imposed by government authorities which included the prohibition of small public gatherings as well as the closing of universities restaurants and all nonessential shopping facilities moreover the borders with most neighboring countries were closed the number of infections slowed down in the second half of april so that most measures were relaxed in midmay schools and restaurants reopened in late spring but universities remained closed apart from some local resurgences infection rates remained rather low during summer 2020 however the beginning of a second wave of infections hit germany in late september in the second wave the southern part of eastern germany experienced a sharp rise in infections and mortality to reduce the spread of the virus a second nationwide lockdown was imposed on november 2 including the closure of restaurants entertainment facilities and public recreation centers in addition gatherings in public places were limited to members of two households on december 16 the lockdown was extended to the nationwide closure of schools childcare facilities and nonessential shopping the second lockdown continued to be in place until april 2021 most restrictions were lifted in may 2021 when germany experienced a significant drop in infections and a steady increase in the vaccination rate against covid19 at the time of writing in february 2022 infections with the omicron variant rise sharply while 74 of the population in germany are fully vaccinated against covid19 besides the potential direct impact that the course of the pandemic might have had on moving behavior covid19 might have also had an indirect impact on migration due to its economic implications previous research has demonstrated that movement behavior changes in response to an economic recession thus in their projections bernard et al expect a decline in intercounty migrations flows in australia in 2020 due to the economic decline associated with the pandemic internal migration in germany and the decision to move tend also to be associated with economic shifts for instance in the decades following reunification in 1990 internal migration in germany was dominated by high levels of migration from the economically weaker east to the economically stronger west which resulted in east germany having lost a population of more than 12 million through internal migration since reunification consequently it is worth considering how the covid19induced economic downturn in germany might have impacted on internal migration flows in germany in 2020 the gdp declined by 46 compared to 2019 after a phase of constant growth over the last 10 years moreover the number of employees decreased by around 11 and the unemployment rate rose by 09 percentage points to 59 compared with 2019 existing employment relationships were strongly protected by statesubsidized shorttime work and other measures besides its overall impact on jobs and the economy the pandemic is expected to have a particularly strong impact on life course transitions that mainly take place at young adult ages such as entry into postsecondary education labor market entry and early career development between 2019 and 2020 the number of new hires decreased by around 34 and newly concluded training contracts by around 11 estimations show that the amount of offered apprenticeships declined by around 73 due to the pandemic in 2020 the distribution of employees across economic sectors reveals that the hospitality industry which tends to be popular among students is one of the branches that was affected most strongly by the pandemic a decrease in employment possibilities may have a negative impact on the financial resources of students coupled with rising rental prices in university towns across germany this is likely to affect the decision to leave the parental home or to return back home from the place of study furthermore the greater usage of virtual formats in contrast to onsite teaching at universities as well as very limited possibilities to meet other students and establish new social contactsdue to measures of social distancingmay have reduced the incentive to move to the place of study in fact a recent survey conducted among young adults aged 1834 from five european countries revealed that 46 of the german respondents who were considering leaving the parental home before the onset of the pandemic had postponed their plan and 23 had abandoned it altogether these rates were even higher among young adults from spain italy and the uk overall we would hence expect a decline in the intensity of internal migration flows in germany in 2020 especially among young adults we assume that the pandemic has not only affected the intensity of migration but also the spatial pattern given that young adults tend to move predominantly to urban areas a decline in movements among young adults is likely to result in fewer inflows to urban areas at the same time incentives to migrate away from the urban areas may have increased during the pandemic for several reasons housing costs in the cities remained high and provided an incentive especially for families to move to suburban and rural settings with more affordable housing in addition the lockdown measures against the spread of covid19 have forced people to spend more time at home which posed a challenge especially for those living in urban places with little access to green spaces consequently the pandemic is associated with a growing attractiveness of green space as well as having an own garden the increased desire for detached housing and green spaces is likely to result in a higher number of movements from urban to suburban or more rural areas in sum the reduced movement of younger adults into the cities coupled with the continuing or increased moves of young families out of the cities is likely to have contributed to a strengthening of suburbanization tendencies in 2020 in the following section we examine the impact of the covid19 pandemic on overall migration intensities and their spatial pattern by focusing on changes in internal migration flows between 2019 and 2020 thereby paying attention to differences across age and urbanrural settings development we added the data for the years 20182020 to the time series which was straightforward in the absence of complex boundary changes our data captures all registered changes of residence across municipal boundaries and contains information about the number of moves taking place between i and j for all 401 counties in each year hence our data covers 160400 county pairs over a period of 30 years the counties are nested within 16 federal states for which we also calculated the annual number of moves to trace changes in the intensity of longerdistance moves moreover we differentiate internal migration flows by five age groups data and methods the data is considered as reliable and robust as persons moving within germany are legally required to deregister their old and register their new address at the municipal level we also obtained information on the monthly number of moves between federal states but our data only covers the moment of registration and not the date of the actual move the time lag was especially large when municipal offices were closed for several weeks during the lockdown in spring 2020 the time lag in registration however did not affect the accuracy of the annual migration numbers used in this paper we use the crude migration intensity to determine how the internal migration rate changed over time the cmi indicates the percentage or level of migration defined as the ratio of moves to the population at risk we specify the population at risk in a given county as the midyear population m p cmi 100 to identify changes in the impact of internal migration on the redistribution of population across counties and between urban and rural areas we compute net internal migration rates n d o p 100 i i i i where d i are the total inflows o i is the total outflows and p i is the population of region i to determine how internal migration patterns between rural and urban areas have changed between 2019 and 2020 we aggregate the countylevel data to a regional typology developed by the bbsr that differentiates between the largest cities cities hinterland and rural areas additionally to the bbsr classification we adopt an approach suggested by rees and kupiszewski that uses the population density as a proxy to distinguish between urban and rural areas this approach has the benefits of capturing the urbanrural continuum and being internationally comparable the population density is calculated by dividing the number of inhabitants in a given region i and year j by the area measured in km 2 and then taking the base10 log of population density finally we visualize the changes in the spatial pattern of internal migration between 2019 and 2020 with circular plots of net migration flows results we find that the total number of internal migration flows between counties declined by 5 from 282 million in 2019 to 267 million in 2020 in a similar fashion internal migration flows between federal states decreased by around 6 from 109 million in 2019 to 103 million in 2020 1 hence longer distance moves were even more affected than moves between counties with regard to the seasonal differences between 2019 and 2020 the total number of registered flows between federal states in the prelockdown months january and february 2020 was similar to that observed in early 2019 1 due to the delayed reporting of moves during the covid19 pandemic the internal migration statistic for 2020 can be slightly downbiased in march and april 2020 however migration flows between federal states dropped by more than 25 in comparison to the previous year as described above this decline may be attributed not only to a lower number of moves but also to the pandemicrelated closure of municipal offices during the lockdown in june 2020 the number of moves exceeded the previous years level suggesting a catchup of previously postponed registrations in the months of july september october and december 2020 the total number of moves was lower than in 2019 and in august and november slightly higher or similar to 2019 in figure 1 we depict the cmi of intercounty flows for the period 19912020 we find that the cmi of intercounty flows which indicates the intensity of migration defined as the ratio of moves to the population at risk dropped from 34 points in 2019 to 32 points in 2020 which is the lowest rate since 2011 this drop may appear rather small in comparison to the peak intensity observed in 20152016 when the redistribution of refugees across germany was captured in the statistics as internal migration however when placing the recent drop in intensity in an historical context we find that the intensity of internal migration was remarkably stable in the 1990s and 2000s among german nationals the intensity was also stable in the 2010s whereas internal migration among foreigners increased substantially with the influx of refugees against this background the recent drop in intensity is noteworthy given that the pandemic might have a particularly strong impact on life course transitions that mainly take place at young adult ages such as students entry into postsecondary education labor market entry and early career development we examine whether the drop in the intensity of migration differs by age indeed figure 2 shows that the decline in intercounty migration flows between 2019 and 2020 differs strongly by age group the drop is most pronounced for those aged 1824 years and those aged 2529 years this finding suggests that the migration behavior of educational movers and labor market entrants was most heavily affected by the pandemic children below age 18 those aged 3049 as well as those aged 50 and over also experienced declines in the absolute number of internal migration flows but to a much lower degree of course 2019 could have also been an outlier from the precovid period hence we also compared the intensity for 2020 with the average for the years 20102019 given the bias caused by the redistribution of refugees in the years 2015 and 2016 we omitted these 2 years from our calculation we find that the decline among those aged 1824 years those aged 2529 years and those aged 3049 years are very similar to those observed when simply comparing 2020 to the previous year however the results differ for movements among children below the age of 18 and among those aged 50 or older this indicates that the year 2019 is representative for the prepandemic period when it comes to adults aged 1849 years but not necessarily when it comes to children and the elderly the shifts in the spatial patterns of movements over the last 10 years which we turn to in the following subsection could be a reason for this divergence our results suggest that the covid19 pandemic had an impact on the spatial patterns of migration and on the redistribution of population between urban and rural areas figure 3 shows net internal migration rates for the largest cities cities hinterlands and rural areas in this respect urbanization is characterized by positive internal migration rates for the largest cities and negative rates for rural areas and the hinterland whereas the opposite trend indicates periods of suburbanization germany experienced a period of suburbanization in the years after reunification in 1990 followed by a period of urbanization further evidence for this finding is presented in figure 4 which displays the relationship between log population density and net internal migration rates the estimated regression slopes show a negative relationship for 2019 and 2020 which means the higher a countys population density the more negative its net internal migration rate moreover as indicated by the regression slopes and the 95 confidence intervals this negative association is significantly stronger in 2020 than in 2019 this becomes also evident by the estimated interaction effect thus both the net migration losses for more densely populated counties and the net migration gains for less densely populated counties have become more pronounced consequently the impact of internal migration on the redistribution of population between urban and rural areas has increased since the onset of the pandemic moreover we find that the rise in suburbanization tendencies between 2019 and 2020 was driven by changes in both the inflows and outflows to and from larger cities table 1 provides the inflows outflows their net difference as well as the net internal migration rates for the years 2019 and 2020 by age group and county type we also provide the percentage change of inflows and outflows between 2019 and 2020 which can be found in the last two columns except for the inflow of those above age 50 in rural areas the total number of inflows and outflows decreased between 2019 and 2020 for all age group and county type pairs the overall decline in migration is important to keep in mind when examining the impact of the pandemic on the spatial structure of migration comparing the net internal migration rates for the years 2019 and 2020 shows that the largest cities experienced lower net migration across all age groups and even across young adults whereas the opposite is true for cities and particularly for hinterlands and rural areas moreover table 1 reveals strong declines in the inflows to the largest cities while the outflows showed a substantial decline only for the 18 to 29 year olds in contrast outflows for the families have decreased marginally which demonstrates that they continued to leave the largest cities during the pandemic for less densely populated regions thus the age groups ≤17 and 3049 years experienced the smallest decline in total inflows to rural areas between 2019 and 2020 in contrast the ruralurban movements of those aged 1829 declined strongly between 2019 and 2020 suggesting a postponement of moves for education or jobrelated reasons during the pandemic in concert these changes in agespecific flows mean that suburbanization increased markedly in 2020 given that the pandemic did not spread evenly across germany one might expect that the suburbanization tendencies may differ among regions however figures 5 and6 summary and discussion the aim of this paper was to provide first insights into the impact of the covid19 pandemic on internal migration in germany our descriptive analysis draws on data from the german federal statistical office and the statistical offices of the länder on annual intercounty flows covering the period 1991 to 2020 our results show that the pandemic is associated with a decline in the intensity of migration confirming earlier findings by fielding et al for japan in germany the intensity of intercounty migration declined conversely the pandemic increased the demand for detached housing and the desire to live in a greener environment while the decline in ruralurban movements may well be a tempo effect caused by a postponement of leaving the parental home during the pandemic the new flexibilities of working from home may bring about a new age of suburbanization with all its consequences for infrastructure and service provision thus the pandemic has reinforced the increasing trend towards suburbanization among young families where a shortage of affordable family housing in the cities has been the prime incentive to move besides the financial incentives the pandemic might have brought about new possibilities for moving to less densely settled places beyond the commuting belts that meet personal and has raised questions about the necessity of working in city offices and daily commuting among families with a personal preference for a rural lifestyle the possibility of extensive telecommuting is likely to be translated into the realisation of intentions to move out of cities and into more rural areas hence the pandemic has the potential to result in a longerterm trend of redistribution of population from the cities towards smaller less densely settled places in more rural settings the revival of a phenomenon that has been described as counterurbanization more than 30 years ago would imply the covid19 pandemic to have a longterm impact on internal migration that extends way beyond the direct impact of the pandemic itself but is moderated by the impact of the pandemic on our working life data availability statement the data that support the findings of this study are available on request from the authors orcid nico stawarz conflicts of interest the authors declare no conflicts of interest appendix tables a1 and a2 t a b l e a1 intercounty migrations flows by age and crude migration rate for all moves

the covid19 pandemic has affected economies labor markets health care education and tourism around the globe in unprecedented ways however little research has yet been devoted to the impact that the pandemic might have had on internal migration this study aims to address this gap by determining how the intensity and spatial patterns of internal migration changed between 2019 and 2020 in germany we draw on data from the population register on annual flows between 401 counties we find that the covid19 pandemic was associated with a 5 drop in the intensity of intercounty migration in 2020 compared to the previous year with significant variation across age the pandemic was also associated with an upsurge in net migration losses for the largest cities driven by fewer inflows of young adults and continuing outflows of families

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introduction in recent decades the community corrections system has become a key institution in the social and economic life of poor urban neighborhoods across the united states i the number of americans under community supervision has increased dramatically growing from 13 million in 1982 to 57 million in 2007 before receding slightly to 48 million in 2010 ii despite increasing research in recent years on the connection between skyrocketing rates of incarceration and social inequality there has been relatively little research on how the less mass incarceration poor communities and residential mobility over the last three decades the number of individuals incarcerated in prisons and jails in the united states has risen dramatically from 02 of all us residents in 1980 to 07 of us residents in 2000 whereas in 1975 the population in jails and prisons on any given day was roughly 400000 people by 2003 this number had increased more than fivefold to 21 million people as a result over 600000 prisoners are released each year released prisoners are disadvantaged educationally economically and socially and incarceration has been linked to increasing inequality in the us incarceration is disproportionately experienced by young lowskill africanamerican men and has important consequences for their wellbeing for example declining labor force participation by young black men during the late 1990s when a strong economy pulled other lowskill workers into the labor market has been attributed to incarceration and its effects incarceration also increases the likelihood of experiencing severe heath limitations and mortality rates are particularly high in the weeks following release from prison the steady flow of people into and out of prisons has played a role in increasing inequality in recent decades primarily by reducing opportunities for employment and lowering wages as a consequence of the dramatic rise in incarceration in the united states during the last 30 years many communities are now grappling with the problem of reintegrating former prisoners successful reintegration is challenged by barriers facing former prisoners in housing employment and access to services and by former prisoners disadvantaged positions with regard to education work experience social capital and mental and physical health the challenges of reintegrating former prisoners do not fall on all communities equally poor urban communities bear a disproportionate share of the burden as incarceration rates are particularly high in such communities leading to what some analysts have termed million dollar blocks individual city blocks with such high incarceration rates that the government spends over a million dollars a year incarcerating their residents furthermore some evidence suggests that former prisoners are more likely to return to disadvantaged neighborhoods where resources and services are stretched thin and law enforcement supervision is high as a result the criminal justice system is now as an important an institution for poor communities and their residents as the education system and the labor market understanding and meeting the challenges faced by poor communities requires an understanding of the role of the criminal justice system and its effects on individuals and communities although most research on prisoner reentry has focused on the individuallevel risk factors for recidivism and unemployment some scholars have speculated that the neighborhoods where returning prisoners live may play a critical role in successful reintegration several studies have now shown that returning prisoners who live in more disadvantaged neighborhoods are more likely to recidivate kubrin and stewart found that tractlevel concentrated disadvantage predicted recidivism in one oregon county while mears and colleagues analyzed administrative data for the entire state of florida and found that a countylevel measure of resource deprivation was associated with return to prison for a violent or drugrelated offense hipp petersilia and turner found that neighborhood disadvantage social disorder and access to social services predicted recidivism among parolees in california another important question is whether moving back to the neighborhood where one lived before prison helps or hinders efforts to desist from crime one perspective is that returning home is generally a negative influence on parolees due to the proximity of criminogenic peers and opportunities for returning to crime or substance abuse another view is that the social support and social control provided by existing social networks in ones former neighborhood may be protective in a study of prisoner reentry in new orleans after hurricane katrina kirk showed that former prisoners who returned to their preprison parishes upon their release from prison were more likely to recidivate than those who moved elsewhere in addition to the studies of neighborhood effects on criminal trajectories of returning prisoners there is another stream of research that focuses on the consequences for neighborhoods of losing large numbers of residents to prison andor absorbing many returning prisoners clear refers to such churning between institutional and community supervision as coercive mobility and argues that the residential turnover created by mass incarceration leads to the breakdown of social cohesion in disadvantaged communities as individuals move into and out of poor neighborhoods where residential mobility is already high social networks in the community become sparser trust in neighbors declines and collective action becomes less likely in a study of communities and crime in tallahassee florida clear and colleagues found that neighborhoods receiving returning prisoners at higher rates also had higher crime rates the following year the relationship between neighborhood population loss due to prison admission and subsequent crime was more complex moderate rates of population loss reduced crime but after reaching a critically high level further increases were associated with higher crime rates they argued that the cumulative effect of such churning of people back and forth between prison and the community led to a breakdown in community social networks and ultimately eroded the capacity to control crime through informal social control relatedly hipp and yates found that communities with more former prisoners had higher crime rates and that this effect was moderated by neighborhood social capital and voluntary organizations obstacles to securing stable housing among parolees the problem of housing insecurity among returning prisoners offers a compelling example of how institutional factors can compound socioeconomic disadvantage in an already marginalized group in part the challenge returning prisoners face in finding a place to live is a reflection of their personal economic circumstances including poor work histories and poor credit histories above and beyond these personal circumstances however returning prisoners face an additional set of institutional obstacles that make their housing security especially precarious first many private landlords require applicants to disclose their criminal history and are reluctant to accept applications from those with felony convictions aggravating an already difficult economic situation many parolees also face mounting fees for supervision restitution and child support and their criminal records preclude them from obtaining most types of public assistance public housing and housing subsidies returning prisoners even face obstacles in seeking temporary shelter with friends or family members who live in public housing under the us department of housing and urban developments one strike and youre out policy public housing tenants can be evicted if any other household members or guests are involved in drugs or other criminal activity on or off the premises even without the tenants knowledge making them very reluctant to offer assistance to anyone with a criminal record iii the conditions of parole also impose restrictions on where returning prisoners can live for example sex offenders are usually restricted from moving near schools or daycare centers some parolees are also subject to electronic monitoring in which they wear an ankle bracelet and must live in a house with a working phone that can transmit data to the parole officer in some states parole agents closely supervise parolees living arrangements often through home visits and restrict them from living with others who have felony records as well as any place where there are firearms or drugs on the premises iii in 2002 the us supreme court upheld the constitutionality of such evictions in department of housing and urban development v rucker 535 us 125 despite the great risks for housing instability among returning prisoners there has been relatively little research on their living arrangements and residential moves some studies have used national surveys of state prisoners to examine the housing status prior to their imprisonment one such study found that 12 percent of state prisoners had been homeless at the time of their arrest while another reported that 9 percent had been living on the street or a shelter at some point during the year prior to their arrest in one of the few studies to use postincarceration data on a large sample of returning prisoners metraux and culhane analyzed longitudinal data on all persons released from new york state prisons and paroled to new york city counties between 1995 and 1998 and found that 114 percent entered a new york city homeless shelter within two years of release there have been fewer studies of housing instability and residential mobility among returning prisoners one study using survey data collected on 145 illinois prisoners returning to the city of chicago found that roughly 72 percent of the sample members stayed in the same residence throughout the observation period of the study in a study offering a much less sanguine view of housing security among formerly incarcerated men geller and curtis analyzed housing instability among fathers from the fragile families and child wellbeing sample and found that men who had been incarcerated faced significantly higher odds of being homeless or experiencing some form of housing insecurity within the last year compared to men with no history of incarceration in one of the most comprehensive accounts of parole and prisoner reentry petersilia observed that we know almost nothing about the exact housing arrangements of former prisoners unfortunately this statement remains an accurate reflection of current research even nine years later the current study offers one of the first detailed views of living situations and residential trajectories of a large and representative sample of parolees followed prospectively over a twoyear time period data through a collaborative arrangement with the michigan department of corrections we compiled a unique data set based on detailed administrative records on a cohort of 11064 michigan prisoners who were placed on parole in michigan during 2003 iv over 90 percent of michigans released prisoners are put on parole one of the higher conditional release rates among american states our analyses in this paper are based on a randomly selected sample of 29 percent of this population on which we collected more detailed data on postprison trajectories including the location of all places of residence by coding narrative case notes that parole agents update regularly on each parolee v all of the variables used in our analysis have been extensively cleaned which involved checking for duplicate records multiple people with the same id number and logical inconsistencies across variables as well as detailed reading of the case notes where appropriate to resolve discrepancies across sources our analyses in this paper focus on variation by race sex age and neighborhood poverty our sample is 8 percent female 53 percent black 45 percent white and 2 percent other mostly mexicanamerican address data we defined the first postprison address as the first place where an individual stayed for at least one night and had some community exposure meaning that he or she had unsupervised access to people and places outside of the residence vii parolees are required to report all changes of address for the duration of their parole to their parole officers who in turn are expected to verify this address assess its appropriateness and record it in the mdoc database viii from the case notes we coded dates of all residential moves and periods of unknown residence and absconding as well as the address of each residence and a description of what type of residence it was ix we geocoded all of the addresses and linked them to census tracts and their characteristics from the 2000 census onethird of our sample had at least one unknown residence and about nine percent of the average parolees time was spent in unknown residences the residential histories we analyze in this paper began on the day the parolee was released from prison and ended after a maximum of 24 months or earlier if one of the following events occurred the parolee was returned to prison for either a new conviction or parole violation the parolee was discharged from parole without being returned to prison the parolee died before being discharged or returned to prison none of the above occurred in the first 24 months following release for 37 percent of the sample these individuals were still on parole in the community 24 months after their release from prison although we chose to censor residential histories v to ensure adequate variation in the geographic locations and characteristics of the first neighborhoods to which our sampled cases returned we employed a twostage cluster sampling design with probabilities proportionate to size we successfully identified and geocoded the first residential addresses of all but 25 parolees in the cohort in the first stage we systematically sampled census tracts with probability proportionate to their size in the second stage we sampled individuals within each selected tract with probability inversely proportionate to the tract selection rate when the firstand secondstage selection rates are multiplied together the sampling probability is equal for every individual this approach also ensures that the final sample size of parolees remains the same no matter which tracts were sampled in the first stage some tracts had fewer than the desired withintract sample size of returning parolees in such cases we combined geographically proximate tracts that were in the same county and had similar socioeconomic characteristics until the number of parolees in the combined units equaled or exceeded the expected withintract sample size another issue is that some tracts had a large number of parolees which meant that their first stage probability of being selected exceeded 10 following the method suggested by groves et al we included all such tracts in our sample and directly selected parolees from them at random at the overall sample rate parolees whose addresses were missing or could not be geocoded were sampled separately at the same overall rate we excluded from this analysis eight sampled individuals who absconded from parole immediately after release and were quickly reincarcerated and therefore have no postprison residential information vi sample descriptive statistics are provided in appendix table a1 vii those who were paroled to institutions offering no exposure to the community such as hospitals inpatient treatment centers or county jails were assigned the first subsequent noninstitutional address homeless individuals were assigned the census tract of the shelter or mission where they were staying also about 15 percent of the parolees in our sample were released from prison before their parole date because they were moved to a correctional center where they had community exposure or were placed on electronic monitoring viii failure to keep ones parole agent informed of ones address is a parole violation and parole agents are required to verify residence information provided by parolees so parolees have a strong incentive to provide address information no doubt there are some parolees who do not report their true place of residence and there are some parole agents who are less careful than others in recording this information nonetheless our preliminary research suggests that the addresses in the case notes are surprisingly accurate we are conducting a longitudinal qualitative study of 24 former prisoners who were interviewed once in prison prior to release and at regular interviews for the two years following their release from prison in late 2007 and early 2008 for 18 of the interview subjects we were able to compare selfreported residential histories from our own interviews for the first few months after release with those recorded in mdoc administrative data fourteen of these residential histories matched exactly and the remaining four had one missing address each overall 33 of 37 addresses were correctly recorded by mdoc parole agents missing addresses were either brief stays or short periods of living on the streets and those with missing addresses tended to be more residentially mobile suggesting that the administrative data will understate mobility slightly for some parolees while two of the subjects experienced periods in which they were moving quickly between multiple addresses these periods were very short ix determining exact movein and moveout dates for residences was particularly challenging approximately one quarter of the dates were estimated based on inexact information in the case notes however periods of absconding tend to be well documented in the case notes once a parole agent issues an absconding warrant this signals that the parolee is no longer being supervised by the agent and so the agent cannot be held responsible for the parolees behavior once the person was returned to prison for the current analysis we still observe moves to jail other forms of intermediate sanctions and periods of absconding that occurred before the residential history was censored for one of the above reasons almost 82 percent of those who eventually discharge are still on parole at 24 months while about 53 percent of those who eventually return to prison have already done so by 24 months this means that about 70 percent of those whose residence histories are censored prior to the end of the 24month study period for this paper are censored because they returned to prison this is important to keep in mind in interpreting the results presented below over time the sample becomes more selective of successful parolees as those returned to prison are no longer represented in the data x no prisoner in michigan is released without a planned place to live so living on the streets immediately following release is extremely rare but may be more common later during the parole period few parolees have the financial resources to live alone and few are married so most parolees must either live with parents other family members or romantic partners parolees are forbidden from moving out of state unless they initiate a lengthy bureaucratic procedure and pay a fee moving between counties is allowed but requires prior permission as such a move would require changing parole offices in michigan there is no requirement that the offender must return to the same city or county where she or he was arrested or sentenced we collected data on the preprison addresses of our sample from hard copies of presentence investigation reports in which addresses are usually verified by the mdoc agent preparing the report as well as parole violation reports and parole agent case notes we successfully identified and geocoded preprison addresses for all but 13 percent of the sample xi fortyseven of these addresses or 15 percent were outside of michigan preprison addresses were linked to census tract characteristics for the year in which the individual entered prison xii returning to preprison neighborhoods the first stage of our analysis focuses on the degree to which parolees return to the same neighborhoods where they lived before prison or to neighborhoods similar to their preprison neighborhoods in terms of tract poverty rate in table 1 we examine this question by looking at the geographic distance between parolees preprison addresses and the addresses where they resided immediately upon their release from prison and at each sixmonth interval over the following two years we classified each postrelease residential address based on its geographic distance from the preprison address xiii only 41 percent of parolees ever returned to their preprison neighborhood if we define preprison neighborhood as within half a mile of their preprison address this is an important corrective to the conventional wisdom that many returning offenders are moving back to the x appendix table a2 shows study period length by reason for the eventual end of the observation period xi for some subjects multiple possible preprison addresses were identified in mdoc records we used two methods to choose a single preprison address data used here prioritize identifying preprison addresses with community exposure and with a geocodable address an alternative method which produced almost identical results prioritizes the most recent address these methods resulted in different addresses for only three percent of individuals xii tract characteristics for years between censuses were assigned values created by linear interpolation xiii distance between postrelease and preprison address is undefined if either address is outside of michigan unknown or is an address without community exposure in addition as time passes some subjects become censored due to return to prison or discharge from parole appendix table a3 contains information on undefined distances and their frequencies over time an alternative way of comparing preprison and postrelease addresses is exact address match this comparison is contained in appendix table a4 exact same location where they were living before prison not only are the majority of former prisoners not returning to their preprison neighborhoods many live quite far from their preprison neighborhoods at any given time point over the two year observation period over 56 percent of all parolees in the sample lived more than two miles away from their preprison home and over 38 percent lived more than five miles away moreover the percentage of parolees living within halfamile of their preprison residence declined slightly over time while an increasing percentage lived two to files miles from their preprison address xiv just because relatively few parolees returned to their preprison neighborhoods does not mean that they encountered dramatically different neighborhood contexts after prison compared to those where they lived before prison thus we compared the concentration of poverty classified as low medium and high in each parolees preprison neighborhood to that in their first postprison neighborhood table 2 displays these comparisons separately by the race of the parolee the majority of parolees returned to neighborhoods classified in the same poverty category as those where they lived before prison however there was also considerable variation between preprison and postprison neighborhoods over 40 percent of blacks and over 43 percent of whites lived in a different poverty category before prison than after prison in addition there were striking racial differences in the degree to which parolees experienced continuity in exposure to concentrated poverty before and after prison among black parolees the correspondence between preand postprison neighborhood poverty rates was highest among those who lived in highpoverty neighborhoods before prison we found the opposite pattern among white parolees where the probability of living in a postprison neighborhood with the same poverty rate as the preprison neighborhood was highest for those who lived in lowpoverty neighborhoods before prison the racial disparities are even more striking when we compare the distribution of neighborhood poverty of blacks to whites either before or after prison which shows that 63 percent of blacks lived in highpoverty neighborhoods before prison compared to only 19 percent of whites while 54 percent of blacks moved to highpoverty neighborhoods immediately after their release from prison compared to only 24 percent of whites postprison residential mobility and intermediate sanctions above we examined residential mobility between pre and postprison residences and neighborhoods the next part of our analysis focuses on residential instability among parolees after prison we begin by examining the types of residences where parolees live since temporary or institutional housing is an indicator of residential instability we are also interested in the degree to which parolees reside in intermediate sanction residences mandated by community supervision as these are another potential source of residential instability xiv appendix table a5 examines variation in distance to preprison neighborhoods by demographic groups as measured by the mean and median distance in miles between the address at each time point and the preprison address table 3 presents categories of institutional and noninstitutional residences where parolees live and shows how the distribution of residence types changes with time over 70 percent of subjects moved into a private residence at release but the proportion living in private residences increased only slightly thereafter a smaller but still substantial number of subjects were released to correctional centers operated by mdoc where they have the ability to leave the facility to work look for a job or to visit family but they also have a nightly curfew and are sometimes kept on electronic monitoring our residence typology distinguishes between these correctional centers which are typically but not exclusively used as an intermediate step between prison and living in the community on parole and other custodial centers that are commonly used as intermediate sanctions for probation detention technical rule violation andor reentry programming xv intermediate sanctions are responses by the criminal justice system to proscribed behavior by the parolee that falls short of reincarceration in prison sometimes these behaviors are illegal such as drug use or petty theft and sometimes they are violations of the rules of parole such as alcohol consumption curfew violations failure to report to ones parole officer association with other parolees or contact with crime victims intermediate sanctions are used to punish parolees for minor crimes or rule violations without returning them to prison and they are often intended to stop such behavior from escalating to more serious offenses for example a parolee who fails to report to his parole officer and is suspected of using drugs may be sent to a residential drug treatment program or a technical rule violation center for a week or two in order to detox typically a parolee will not receive such a sanction for a rule violation until heshe has accumulated a number of infractions or displays behaviors consistent with prior crimes only a small fraction of sample members were released to probation detention trv or reentry programming centers but by a year after release 24 were living in such a center another common intermediate sanction is spending time in jail this occurs when a parolee is arrested by the police for a minor crime and either serves a short jail sentence or has the charges dropped before prosecution parolees may also spend a few days in jail as an intermediate sanction at the behest of parole agents the proportion living in jail peaks at almost six percent at oneyear after release other common places for former prisoners to live immediately after prison were hotels and homeless shelters both are typical destinations for parolees who have no private residence where they can return but the proportion of parolees in these places declined over time the homeless category captures people living on the street and is extremely uncommon in our data although it is possible that some of the subjects with unknown residences were homeless unknown to their parole agents transitional housing and treatment programs house parolees under programs operated by private entities typically nonprofits under contract with mdoc treatment programs can also be used as an intermediate sanction by parole officers the category of unknown residence captures instances when the parole agent either does not know where the individual is living or does not record the type of residence associated with the address the frequency of unknown residences increases considerably over time but never exceeds 11 percent of residences we categorize subjects as censored in this table if they had been discharged from parole or returned to prison overall this table documents a relatively high degree of use of institutional housing among former prisoners because such housing is intended to be temporary its frequency is one piece of evidence of a high degree of residential instability in this population xv the subjects who were sent to probation detention centers were simultaneously under parole and probation supervision table 4 shows how exposure to each of these residential settings varies across demographic subgroups displaying both the percentage of sample members who ever resided in each type of residence and the percentage of time they spent in each type during the observation period our focus here is on the prevalence of socalled intermediate sanctions table 4 shows that most parolees experience some type of intermediate sanction while on parole for example almost half of parolees in the sample spent some time in jail while on parole 29 percent spent some time in a treatment program 26 percent in a correctional center and 25 percent in a center for probation detention technical rule violation or reentry programming overall 65 percent of parolees experience at least one of these intermediate sanctions and 53 percent experienced at least one intermediate sanction other than jail moreover intermediate sanctions are common among all subgroups of parolees women are somewhat more likely than men to be sent to treatment and less likely to be sent to detention trv or reentry programming centers because such facilities are gender segregated this difference may simply reflect the availability of sanction options for women in certain geographic areas of the state jail and probation detention trv or reentry programming centers are slightly more common among younger parolees how much time do parolees spend in intermediate sanctions the bottom panel of table 4 shows the percent of time spent in each residence type of the intermediate sanctions the most time is spent in jails parolees on average spend about five percent of their nights in jail or one out of every 20 nights while on parole treatment programs are the second most common followed by detention trv and reentry programming and then by correctional centers these relative rankings are similar across subgroups overall about 12 percent of nights are spent in a residence for an intermediate sanction suggesting that although common stays in sanction residences are relatively short we next turn to another measure of residential instability the number of residential moves per year we ask how residences in intermediate sanction facilities are related to residential mobility among parolees table 5 shows two measures of residential mobility the typical number of moves per year and the cumulative distance moved during the observation period this table also shows the degree to which residential moves are associated with moves into and out of intermediate sanctions the median parolee experiences 26 moves per year or one move every four and a half months this is a very high level of residential mobility a level not seen in most other populations by comparison the conventional threshold for a high degree of residential instability is more than one move per year rates of residential mobility are similar for blacks and whites and for men and women but younger parolees tend to experience more moves than older parolees about onequarter of residential moves are associated with moves into and out of intermediate sanction residences this proportion is slightly higher for blacks and for younger parolees indeed the higher rate of residential moves among parolees age 18 to 25 seems to be almost entirely attributable to intermediate sanction moves excluding intermediate sanction moves equalizes the number of moves across age groups at around two moves per year the cumulative miles measure of residential mobility tells a similar story although there is greater variability in miles moved whites tend to move longer distances than blacks reflecting their greater concentration in the suburbs and rural areas so the proportion of the total distance moved due to sanctions is lower among whites women move further than men overall so the proportion of the total distance moved due to sanctions is lower for women the proportion of distance moved due to intermediate sanctions is also lower for older age groups what are the consequences of intermediate sanctions for the stability of a parolees residence over time we answer this question by examining the rate of return to the presanction address following release from an intermediate sanction facility or center xvi as shown in table 6 parolees return to the previous private residence following intermediate sanctions only threequarters of the time returns are slightly more common among blacks than whites and among men compared to women the rate of return seems to vary somewhat by type of sanction with correctional center sanctions most often leading to returns to the previous private residence and detention trv and reentry programming least often leading to returns these return rates correspond to the typical sanction length with longer sanctions associated with less likelihood of return parolees living in highpoverty neighborhoods before a sanction are least likely to return to the same address after the sanction particularly when those sanctions are treatment programs or jail together the results presented in tables 4 through 6 indicate a considerable amount of residential mobility is generated by intermediate sanctions the implications of returning to a presanction address after the sanction likely depend on the neighborhood where the address is located higherpoverty neighborhoods are expected to present fewer opportunities for employment and greater risks of involvement in drug abuse or crime table 7 examines the presanction and postsanction neighborhoods among individuals who changed addresses following a sanction the top panel presents results for blacks and the bottom panel presents results for whites among both blacks and whites who moved residences after an intermediate sanction there is evidence that postsanction neighborhoods have higher poverty rates than presanction neighborhoods for instance among blacks who were living in a lowpoverty neighborhood before the sanction almost 60 percent moved to highpoverty neighborhoods after the sanction while only 10 percent of blacks originating in highpoverty neighborhoods moved to lowpoverty neighborhoods after the sanction similar though weaker patterns are evident among whites over 30 percent of whites who lived in a lowpoverty neighborhood prior to the sanction moved to a highpoverty neighborhood after the sanction of those who originated in a highpoverty neighborhood only 26 percent moved to a lowpoverty neighborhood after the sanction conclusion the united states is now in an era of mass incarceration with incarceration rates that are unprecedented in our own history and compared to other nations incarceration is disproportionately experienced by poor urban minority men and its effects extend beyond these individuals to their communities rates of incarceration and community supervision are so high in some poor urban neighborhoods that the criminal justice system has become a key institution that structures social and economic life in these communities in this paper we draw on unique data on a cohort of parolees in michigan to offer one of the first detailed portraits of the residential trajectories of returning prisoners we focus on the extent to which former prisoners return to their preprison neighborhoods on the types of neighborhoods and residences where they live and on the role that intermediate sanctions play in generating residential mobility we are aware of no prior study that examines preprison residences and neighborhoods residential histories after xvi we based this analysis on the 4614 cases of intermediate sanctions where a parolee was living at a private address experienced an intermediate sanction and then moved back to a private address in cases where an intermediate sanction was preceded or followed by another intermediate sanction or a period of absconding we used the private residences most proximate in time to the sanction we excluded cases where the parolee was returned to prison following an intermediate sanction without living in a private residence in between the sanction and prison prison the relationship between the two or the role of intermediate sanctions in residential mobility two main sets of findings emerged from this analysis that challenge in some ways conventional wisdom about the living situations and housing instability of returning prisoners and emphasize the ways that both are affected by the institutions of the criminal justice system first our results sharply conflict with what we perceive to be the conventional wisdom regarding the likelihood that former prisoners will return to former neighborhoods after prison in fact less than onethird of parolees in our sample returned to an address within a half mile of their preprison residences after release and by two years after release less than onequarter were living within a half mile of their preprison address the implications of these results for former prisoners are far from clear on the one hand new homes and new communities after prison may mean lack of access to social and economic support that is potentially important for reentry and reintegration on the other hand returning to old places and old faces environments that were potentially criminogenic in the past may increase opportunities for and tendencies toward renewed involvement in substance use and crime the implications of returning home after prison likely vary by the characteristics of that environment moreover high rates of residential mobility mean that future studies need to look beyond the first neighborhood after release in assessing the effects of neighborhood context on the outcomes of former prisoners and further research is required to understand the implications of residential mobility and the predictors of neighborhood and household environments among former prisoners why dont more former prisoners return to their preprison residences or neighborhoods although this question lies beyond the scope of the analysis for this paper we offer some hypotheses based on qualitative interviews we conducted with 24 former prisoners released in southeast michigan in late 2007 and early 2008 first the families and communities from which former prisoners come themselves have higher than average rates of residential mobility during the time a family member is in prison the household may move this is particularly likely when the prisoner provided the main source of household income or owned or rented the familys dwelling second family members may be unwilling to continue to support a former prisoner particularly when he or she has been in and out of prison multiple times or brings substance abuse or other criminal behavior into the household family relationships may fray with frequent contact with the criminal justice system and frequent and prolonged separation due to incarceration particularly for extended kin in such cases treatment programs corrections centers hotels or homeless shelters may be the only postrelease housing options and they are less likely to be in or near preprison neighborhoods third former prisoners preparing for release may not be wellserved by returning to preprison social environments sometimes the former prisoner recognizes this for himself and intentionally stays away from potentially criminogenic environments in other cases parole boards or parole agents may make this determination and require or encourage a new start in a new environment a second major finding concerns the volume of residential mobility among parolees and the degree to which this reflects the experience of parole supervision through intermediate sanctions for example 65 percent of parolees in our sample were moved away from their residence at least once for an intermediate sanction also former prisoners experienced very high rates of residential mobility on average higher than any other population of which we are aware and roughly onequarter to onethird of this mobility was generated by the criminal justice system through intermediate sanctions such as jail treatment programs and residential facilities for parole rule violators moreover a substantial share of parolees who experienced an intermediate sanction did not return to their prior residence after the sanction in short because parolees experience considerable residential mobility associated with intermediate sanctions the effects of the criminal justice system on residential turnover are likely more extensive than previously recognized extending beyond moves to and from prison we are agnostic about the implications of this residential mobility for community wellbeing it could bring further social disorganization to already disadvantaged communities but clears coercive mobility theory particularly the argument that extremely high levels of movement to prison actually increase crime has not been subjected to many empirical tests nor has prior research on coercive mobility considered residential mobility due to intermediate sanctions moreover we note that intermediate sanctions are intended to remove former prisoners temporarily from communities before they progress to more serious crimes they represent both an alternative to the more consequential sanction of returning a parolee to prison and an attempt by parole agents to prevent crime before it happens or before substance use and more minor crimes progress to more serious crimes whether intermediate sanctions benefit or harm either individual or community are open questions the frequency with which they are experienced however suggests that these are potentially important questions for future research moreover because most prisoners are not returning to their former residences many of the parolees who enter disadvantaged neighborhoods do so as newcomers and are therefore less likely to have social resources to buffer the detrimental effects of living in disadvantaged neighborhoods this also means that the coercive mobility that comes from moves to and from prison may be more consequential for social cohesion than previously recognized since it is not always the same individuals who are leaving and then returning to neighborhoods with high rates of incarceration indeed there is something of a paradox when it comes to residential mobility and the neighborhood environments of former prisoners although these individuals experience high rates of residential mobility a small proportion of neighborhoods house the vast majority of former prisoners this is only possible if former prisoners are moving frequently from one disadvantaged neighborhood to another which former prisoners are able to escape highpoverty neighborhoods is an important question for future research one strength of our study is its ability to draw data from multiple cities metro areas and rural areas for an entire state but our analysis is limited to a single state and social and economic conditions as well as criminal justice policies vary considerably from state to state michigan is characterized by high unemployment by declining opportunities for employment in low skill positions and by high rates of racial and economic residential segregation michigan also has few latino or asian residents so we can only analyze racial differences between blacks and whites in terms of criminal justice policies and practices we note that michigans rates of incarceration and parole are close to the national averages michigan also accounts for a nontrivial share of the nations parole population our findings regarding the importance of intermediate sanctions may be particularly sensitive to statespecific resources and policies related to parole supervision particularly parole revocation the rate of return to prison among michigan parolees was 17 percent in 2006 the same as the national average for state parolees yet parole revocation rates are likely subject to countervailing forces for example more stringent supervision may result in higher revocation rates but more stringent supervision coupled with greater use of intermediate sanctions may result in lower parole revocation rates supplementary material refer to web version on pubmed central for supplementary material

poor urban communities experience high rates of incarceration and prisoner reentry this paper examines the residences where former prisoners live after prison focusing on returns to preprison social environments residential mobility and the role of intermediate sanctions drawing on a unique dataset that follows a cohort of michigan parolees released in 2003 over time using administrative records we examine returns to preprison environments both immediately after prison and in the months and years after release we then investigate the role of intermediate sanctions punishments for parole violations that are less severe than returning to prison in residential mobility among parolees our results show low rates of return to former neighborhoods and high rates of residential mobility after prison a significant portion of which is driven by intermediate sanctions resulting from criminal justice system supervision these results suggest that through parole supervision the criminal justice system generates significant residential mobility

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introduction waterpipe also known as hookah shisha arghile narghile hubblebubble and qalyan is a traditional method of tobacco use in which heated tobacco smoke passes through water prior to inhalation 1 in the past two decades wp use has spread beyond its cultural roots in the middle east and southeast asia to become a global epidemic 2 now it is being widely used in europe and north america and is most prevalent in the eastern mediterranean region where regular or occasional use among adults ranges from 33 in egypt to 163 in iran 3 among 1315yearold individuals in 22 arab countries surveyed in 20052011 106 used wp in the past month indicating wp smoking was more prevalent than cigarette smoking 4 many factors such as the introduction of flavored wp tobacco the social nature of wp smoking the thriving café culture the rise of the internet and social media and the lack of wp specific policies and regulations have created optimal conditions for the rise of wp smoking 5 wp smokers inhale greater puff volumes than cigarette smokers leading to larger intake of toxicants including polycyclic hydrocarbons and other carcinogens lungdamaging volatile aldehydes and nicotine 67 growing epidemiological and laboratory evidence links wp to health risks such as lung cancer cardiovascular and pulmonary diseases oral dysplasia infertility and low birth weight 89 in addition wp users are at risk of developing nicotine dependence waterpipe is like a wife qualitative assessment of perspectives on waterpipe smoking dependence satish kedia 1 id nikhil ahuja 2 id fadi hammal 34 id taghrid asfar 456 id thomas eissenberg 47 id wasim maziak 48 id kenneth d ward 14 id and experience dependence symptoms including urges to smoke irritability during abstinence and difficulty quitting 10 wp smokers may also exhibit other dependence symptoms related to highly rewarding features including shared social experience as well as aroma and taste from sweetened and flavored tobacco 11 among a cohort of adolescent wp smokers in lebanon 82 reported that just the sight or smell of wp is enough to make me want to smoke and 78 admitted that it would be very difficult for me to be in a restaurant and not smoke wp 12 survey studies from syria have reported that some wp users particularly heavy users engage in behavioral adaptation to ensure wp access including selecting restaurants or cafes based on wp availability carrying ones own wp apparatus and smoking alone at home 1314 nearly onethird of wp users report wanting to quit and more than half make an unsuccessful quit attempt in any given year 15 16 17 to date most studies about factors associated with wp dependence have been surveyor laboratorybased while valuable quantitative studies do not provide users perspectives on the nature and distinctiveness of wp dependence that can be gained from qualitative research although a few qualitative studies have explored patterns of and reasons for smoking wp 18 19 20 21 22 23 24 none of these have focused specifically on wp smokers perceptions about their experiences of wp dependence furthermore given that wp is smoked at higher rates among people in middle eastern countries than western countries and is considered an expression of cultural identity 31125 it is important to understand wpspecific dependence features among users in these countries the current study contributes greatly to the existing literature on wp by employing qualitative methods to explore adult users perceptions of wp dependence findings will improve our understanding of wp dependence and inform assessment and intervention efforts to address this evolving wp epidemic methods design and participants this study was part of a larger project to develop a wpspecific dependence scale 26 consistent with previous research that used qualitative methods as formative work to develop dependence measurement instruments for cigarette smokers 27 focus groups were used to explore perspectives on dependence among adult wp smokers in aleppo syria those who identified themselves as currently smoking wp at least once a month and not having smoked cigarettes in the past 30 days were included in this study dual wpcigarette smokers were excluded to ensure that perceptions of wp dependence were not adulterated by cigarette smoking participants were recruited using newspaper advertisements flyers and wordofmouth as the first step in developing an interview guide for the focus groups we reviewed theories and frameworks of dependence among cigarette smokers including positive reinforcement 2829 negative reinforcement 3031 social learning and cognitive models 32 33 34 35 36 the health belief model 3738 transtheoretical model 39 40 41 the icd10 42 and dsmivtr dependence criteria 4344 we also evaluated survey data collected by our research team and others about attitudes beliefs and behaviors of wp users that were potentially relevant to dependence 101145 in addition data from our previous surveys and indepth interviews with wp smokers in aleppo syria were used to highlight wp specific themes that are not captured adequately in existing dependence theories 1319 after finalizing the initial list of questions to be covered in the focus groups the research team members discussed each of the items to develop a consensus on the final list two bilingual investigators independently translated questions in arabic and then for validation purpose questions were backtranslated into english by an external professional translator procedure the institutional review boards of the university of memphis and the syrian society against cancer approved the study protocol informed consent was obtained from all participants prior to the start of each focus group session participants completed a selfadministered survey of sociodemographic and tobacco use characteristics for descriptive purposes the number of focus groups was determined using the criteria of data saturation in qualitative methods and additional focus groups were conducted until no new themes emerged in total 15 focus groups involving 64 participants were conducted using a semistructured interview following the social and cultural norms in syria focus groups were conducted separately for men and women each focus group lasted 4560 minutes and was audiotaped data analysis audiotaped interviews were transcribed first in arabic and then were translated into english the transcripts were encoded using the atlasti 52 software for qualitative analysis directed content analysis was utilized in this study 46 in this approach an initial coding scheme is developed based on an existing theoretical or conceptual model and novel emergent codes are used to revise the framework to inform the findings 4647 in the present study the initial coding scheme was guided by constructs of nicotine or tobacco dependence 32 33 34 35 36 one of the coauthors analyzed the data line by line to develop the initial codes these initial codes were then compared and contrasted for their similarities and differences and were categorized based on dependence domains those initial codes that could not be categorized under the existing dependence domains were classified under a new domain at this stage the codes and categories were discussed and reviewed by three other coauthors to ensure rigor during the entire analytical process the transcripts were read several times in order to capture a deeper understanding of wp smokers perceptions about their experience of dependence this manuscript is guided by the consolidated criteria for reporting qualitative research statements 48 results participant characteristics sociodemographic and wp smoking characteristics of the 64 study participants are presented in table 1 age ranged from 18 to 65 years with most participants being under 40 years besides 80 of the participants were male most participants could read and write or had completed secondary education and were either an employee or had a private business most participants had begun smoking wp during their late teens or early 20s and had smoked for at least two years with twothirds smoking daily and onethird less than daily but at least once per month average time spent smoking per week was fairly evenly divided as less than three hours 37 hours and more than 7 hours with about twothirds of the participants smoking primarily at home and onethird mostly in restaurants more than half of the participants wanted to quit and believed they could quit wp anytime with only 19 perceiving quitting to themes and coding data analysis revealed seven dominant dependencerelated themes branching from the various frameworks of dependence and addiction that were referenced in the development of the interview guide thematic categories included smoking larger amounts of tobacco spending excessive amounts of time smoking or gathering wp supplies sensory and socially induced cravings for wp the tendency to maintain a wp habit at any cost an increased tolerance to nicotine the denial of the risks associated with smoking even in the face of physical or psychological issues and difficulty controlling or quitting wp use the thematic categories as well as the extrapolation of subcategories and codes that were developed during the data analysis are displayed in table 2 table 3 summarizes and describes the seven themes along with a relevant example quote from the data smoking larger amounts of tobacco or over a longer period of time dependence on wp was considered multifaceted as the intensity dosage and timing of smoking were viewed by many participants as indices of dependence intense wp smoking in larger amounts multiple heads during a single session and frequent smoking ingenuity was sometimes required when wp supplies were unavailable a young daily smoker said one day the wp glass broke after midnight we wanted to smoke we invented an alternative using a family size bottle of pepsi my mother was astonished she said to that extent you could not stand staying without wp many wp smokers also tried to maintain their smoking habits by ensuring availability of wp in all locations where they spend considerable time craving and a strong desire to use wp elicited by social and sensory cues most smokers reported cravings or strong desire or urge to smoke wp for some smokers craving was associated with certain cues in their surroundings such as being in a restaurant while for others no stimuli was needed to provoke craving for them knowing that they had missed their usual time for smoking was sufficient to other triggers to smoking wp were meal time being on a recreational trip and gathering with friends in a garden or other enjoyable settings one respondent said after each meal i want wp if pleased i need wp im addicted to wp i always light the charcoal while im eating to make sure that when i finish my meal the wp will be ready for most smokers however there were special times allocated for smoking wp when smokers usually felt a strong desire to smoke such as after meals in the evening at night when out for leisure or back home after work many smokers reported that they smoke only at night or in the afternoon others smoked in the morning and most smokers agreed that smoking in the morning especially first thing in the morning is a clear indication of stronger dependence on wp one participant said i believe that the smoker who smokes in the morning is 100 an addict another wpspecific dependence feature to emerge in the data was solitary smoking as an indicator of dependence there was a common perception that the more you smoke alone the more you are dependent and that transitioning from social to solitary smoking indicates that the person is dependent one participant commented the smoker who smokes alone at home is more dependent however i believe that he doesnt enjoy like we who smoke with company maintaining wp smoking at any cost more dependent smokers tend to refuse sharing their wp because it may affect their smoking rhythm burn the head too quickly make them feel nervous interrupt their enjoyment and reduce satisfaction one daily smoker said i do not like anyone to share the wp with me i feel uncomfortable and i prefer to prepare another wp for him even if he wants to take only a few puffs another smoker passionately shared in the past they said the wp is like a wife and you cannot lend your wife to someone the same is for the wp tolerance to nicotine and need to increase wp smoking many participants reported increasing wp smoking to achieve desired effects relatively clear signs of tolerance were expressed by many smokers including increased smoking frequency increased time spent smoking increased number of heads smoked during a single session and changing puff patterns to increase the amount of smoke inhaled as the frequency of wp use increased some smokers purchased extra apparatuses to keep at different locations to ensure access a daily smoker stated i started smoking in restaurants then i got wp at home then i brought one to my sisters home and one to my parentsinlaws home to make sure that the wp is available everywhere around me some smokers reported diminished effect with continued wp smoking and shared that the pleasure and satisfaction associated with smoking wp disappeared over time for some even though the pleasure of smoking wp disappeared with time their habit remained some respondents were convinced that only dependent smokers enjoy smoking the wp and the others are just imitating real smokers a young adult male participant said with time the pleasure reduces and the habit remains in the beginning the wp is associated with the ambiance and gathering with friends but then when the smoker starts smoking alone at home in the sitting room while watching tv this makes me say i cannot understand where is the ambiance and where is the gathering risk denial and continued wp use despite adverse physical health or psychological issues participants continued to use wp despite experiencing health issues caused or exacerbated by tobacco when participants did describe themselves as an addict it often was based on perceived loss of control over their behavior a young woman reported during my pregnancy i tried my best not to smoke daily at home however at least once a week and maybe more i used to go to a restaurant to smoke wp i was smoking during my pregnancy this means im an addict denying or minimizing the healthdamaging effects of wp was common among those who did not want to quit one participant justified the habit by saying you drink coffee and tea and eat vegetables full of hormones and pesticides and the air you breathe is polluted and it is worse than the wp so why should we not smoke you live only once and when it is your time to die you will die regardless of the reason difficulty controlling or quitting wp smoking while a few smokers reported wanting to quit interest in quitting wp was not common i have never thought about quitting and im happy with the wp and i do not want to quit were common responses experiences with quitting or controlling wp use varied although some smokers believed that quitting wp is not difficult many perceived it to be challenging one participant relayed his experience as such i quit the wp one day i went with my friends to a restaurant they convinced me that a few puffs will not be a big deal i took a few puffs then i ordered a wp and when i went home i got my old one out now im a daily smoker again another commented i told you i adore the wp and based on my feelings and nervousness when i could not smoke the wp im telling you it is impossible for me to quit most daily smokers who tried to quit reported experiencing withdrawal symptoms such as headache nervousness irritation anxiety anger trouble concentrating and feeling that something is missing these symptoms made quitting wp seem formidable one wp smoker said you feel like youre lost that something is missing you cannot work and you lose concentration i cannot quit ask me to stop breathing but not to stop smoking wp however not all face these challenges one respondent commented despite being a daily smoker i quit for one month and i did not feel anything i relapsed because i have a lot of free time some of the barriers to quitting mentioned were feeling addicted habit life stressors wide availability of the wp having friends who smoke lack of willpower too much free time and fear of withdrawal symptoms some smokers perceived resisting a temptation or refusing an offer to smoke wp to be difficult this temptation took different forms including visiting a friend who is smoking wp going to a restaurant or being invited by a friend to go out to smoke wp for me the wp is not enjoyable when you smoke alone it requires the gathering or at least a friend many participants found wp to be a habit which they distinguished from an addiction which was due to its widespread availability one participant commented im telling myself it is not a habit but practically i cannot quit and it became a habit no other explanation i dont prefer using addiction it is not a good word wp became part of their routine as expressed by one participant for me smoking wp is a habit like other habits in your life you used to dress to wash your face to brush your teeth and to drink water it is like your body is pushing you discussion survey and laboratory studies indicated that wp smoking can cause dependence 10 the purpose of this study was to extend this growing body of literature using qualitative methodology to assess in greater depth wp smokers perceptions of dependence features in particular we were interested in exploring whether perceived symptoms are similar to known dependence features derived from cigarette smoking and whether any wpspecific features were identified some distinct dependence features were expected due to wps unique use characteristics including its timeconsuming preparation and consumption intermittent use patterns and unique sensory and social cues several themes emerged that were similar to cigarette smoking including positive reinforcement features social and sensory cues intensity and timing of smoking negative reinforcement features urgescravings and difficulty quitting in addition two themes emerged that described distinct features of wp dependence including behavioral priorityadaptation and solitary smoking wps growing popularity is primarily due to several positively reinforcing features which help to maintain its use and are linked to the development of dependence 10 these features include its association with socializing and cultural identity and moodenhancing effects participants reported how wp smoking became a regular sometimes daily habit that was a part of social rituals to the point where smokers perceived that smoking must accompany spending time with family and friends these results among wp smokers confirm survey findings from several populations and age groups 1149 moreover similar features of dependence have also been reported among cigarette smokers who expect smoking to be extremely pleasurable and to help them deal with negative affect and stress 50 51 52 the results of the present study provided a nuanced view about how intensity of wp smoking is related to dependence participants consistently viewed smoking more frequently as well as smoking multiple heads per session as signs of dependence but important exceptions were noted those who smoked every day were not thought to necessarily be dependent as long as smoking was limited to one session or head per day smoking every day was thought to sometimes reflect having free time rather than needing to smoke indeed some participants reported smoking every day without increasing their smoking over time or experiencing other dependence symptoms such as craving or withdrawal likewise participants did not believe length of the smoking session was a reliable indicator of dependence because it may reflect availability of free time these findings are consistent with a survey study that compared wp smoking among young adult university students to adult café customers and found that university students who smoked daily were more likely to perceive themselves to be not hooked than café customers who smoke daily 53 in contrast some studies have also reported length of smoking session as a novel indicator of dependence among wp smokers 554 the results of the current study indicated the importance of carefully assessing smoking patterns in survey studies and clinical cessation encounters a consensus statement about wp use assessment recommends several items to assess intensity of smoking 55 it would be helpful to include items that explicitly capture the usual number of heads smoked per session and how frequently multiple smoking sessions occur in the same day additionally it would be helpful to capture whether smoking occurs in the morning wp smoking in the morning appears to be rare 5657 but viewed as a reliable indicator of dependence participants distinguished between habit and addiction this difference reflected perceptions of psychological vs physical dependence and was related to intensity of smoking those who smoked less frequently were more likely to report that their smoking was a habit or behavioral routine which they enjoyed and did not want to quit in contrast participants who smoked more frequently were often willing to refer to themselves as addicted and believed that they were unable to quit understanding oneself to be addicted often resulted from the realization that one had lost control of the decision to smoke or not such participants could point to specific situations where they smoked despite doing so not being in their longterm best interests such as when suffering from a lung infection during pregnancy or having to go out in the middle of the night to obtain wp supplies regardless of whether participants perceived themselves to be addicted or to merely have a habit interest in quitting was low and quit attempts mostly unsuccessful as has been reported in survey studies 111758 difficulty quitting among occasional smokers most often was attributed to external cues such as seeing others smoke whereas daily smokers often cited internal cues such as withdrawal symptoms as making it difficult to quit certain shared features of tobacco dependence such as cravings and sociocognitive cues can be different for wp due to its specific makeup like timeconsuming preparation and consumption greater size of apparatus that limits mobility during use and use in social contexts 13 consistent with these features wp users in this study often went to great lengths to procure and smoke wp cafésrestaurants were selected based on quality of wp served rather than quality of food or drink smokers spent more money than they could afford on wp and if wp was not available would inconvenience themselves to obtain it some smokers carry their own wp with them or keep a wp at work or at friends homes to ensure easy access wp use also produces unique specific stimuli which are different from cigarette smoking and interact with more general smokingrelated cues 14 furthermore consistent with previous studies 1314 extensively prioritizing or adapting ones behavior was more common among individuals who smoked more often and felt more addicted another unique feature of wp smoking is that users transition from social to individual smoking as they become more dependent participants who perceived themselves to be dependent reported having transitioned from smoking with family and friends to smoking mainly alone at home by themselves and without sharing the wp with others this phenomenon was first observed in a survey study of syrian wp smokers in which the likelihood of smoking alone increased and the likelihood of sharing the same wp with others decreased across frequency of use 13 one of the limitations of this study was using a qualitative focus groupbased method which is construed as relatively unstructured and subjective and represents interpretations of themes by the researchers another limitation was that the participants were selected using purposive convenience sampling from one city in syria thus these perspectives may not be representative of the rest of the country or other geographical areas conclusion this qualitative study confirms and extends findings from survey studies about wp dependence several dependence features are consistent with those commonly reported by cigarette smokers these include positively reinforced features and negatively reinforced features including relief of withdrawal symptoms likewise quitting is difficult for many users and inability to quit is interpreted as having lost control of ones smoking a common marker of dependence 1059 several observed dependence features were specific to wp including transitioning from social smoking to smoking alone and adapting ones behavior to the considerable effort normally required to engage in wp smoking despite inconvenience or cost and often at the expense of other reinforcers such as social interaction these general and specific features of wp dependence obtained from this study will be useful in developing instruments to measure wp dependence in clinical assessment of wp dependence 26 and in developing cessation programs 60 specifically there is a need to modify existing cessation interventions to suit local wp users and local health systems 13 moreover given that dependence is an important barrier to quitting wp investigating the effectiveness of behavioral or pharmacological interventions aimed at reducing wp dependence requires more research and warrants consideration in primary care and other clinical settings conflict of interests thomas eissenberg is a paid consultant in litigation against the tobacco industry and also the electronic cigarette industry he is named on one patent for a device that measures the puffing behavior of electronic cigarette users and on another patent for a smartphone app that determines electronic cigarette device and liquid characteristics other coauthors have declared no conflict of interest ethics approval the institutional review boards of the university of memphis and syrian society against cancer approved the study protocol supplementary files supplementary file 1 topic guide for focus groups with current wp smokers

background waterpipe wp smoking has become a global public health problem in recent decades and growing evidence indicates that it can cause nicotine dependence most evidence on wp dependence to date has been derived from surveyor laboratorybased studies this study employed qualitative methods to explore wp users perceptions of dependence in aleppo syria methods a total of 15 focus groups were conducted with 64 adult wp smokers 51 males and 13 females using a semistructured interview all focus group discussions were audiotaped transcribed and coded using directed content analysis findings several wp dependence features were consistent with those commonly reported by cigarette smokers these included positively reinforced features such as smokings association with social gatherings and cultural connectedness and negatively reinforced features including relief of withdrawal symptoms stress and boredom although interest in quitting was low many users perceived quitting wp to be difficult and an indicator of loss of control over smoking a common marker of dependence several observed dependence features were specific to wp including transitioning from social smoking to smoking alone and adapting ones behavior to the considerable effort normally required to engage in wp smoking despite inconvenience or cost and often at the expense of other reinforcers such as social interactionthe general and specific features of wp dependence need to be considered in developing instruments to measure wp dependence in clinical assessment of wp dependence and in developing cessation programs

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covid19 and deprivation amplification an ecological study of geographical inequalities in mortality in england background socioeconomic and ethnic inequalities in case hospitalisation and mortality rates from have been demonstrated across many countries this emergent but already fairly extensive international literature has found that people of lower socioeconomic status have mortality rates more than double those of higher ses inequalities between different ethnic groups have been particularly high whereby people of black asian and minority ethnic backgrounds have suffered a higher burden of disease and a much higher death rate from covid19 than their white counterparts geographical inequalities in covid19 have also been extensively studied and research in various global contexts has found that the more economically and socially deprived neighbourhoods municipalities and regions have fared worse for example research in the usa found that the most deprived counties suffered up to twice the mortality rates of the least deprived counties in the first wave similarly in england research found that deprivation was highly associated with covid19 cases and that more deprived local authorities started recording covid19 deaths earlier and saw faster increases in their death rates than more affluent areas research into regional inequalities has found that covid death rates were much higher in the three nnorthern regions of england during the first year of the pandemic these geographical inequalities in the covid19 pandemic have been explained through the syndemic pandemic concept a syndemic describes a set of closely intertwined and mutual enhancing health j o u r n a l p r e p r o o f problems that significantly affect the overall health status of a population within the context of a perpetuating configuration of noxious social conditions deprivation which is a measure of the social determinants of health results in multiple interacting and additive adverse risk factors for covid19 mortality bambra et al use this framing to outline five potential pathways leading to unequal pandemics unequal exposure unequal transmission unequal vulnerability unequal susceptibility and unequal treatment however geographical research has examined either neighbourhood municipalityor regionallevel inequalities there has been little exploration of the potential interactions between these different geographical scales in terms of shaping inequalities in the pandemic the concept of deprivation amplification is potentially relevant to thinking about such influences the deprivation amplification theory draws on the wider health geography literature on health and place particularly the contextcompositionrelational debate cummins et al 2007bambra 2016 the compositional view argues that the sociodemographic characteristics of who lives in a place determines its health outcomes the contextual approach highlights that it is what a place is like that matters for the health of its residents compositional and contextual aspects of place interact relationally the characteristics of individuals are influenced by the characteristics of the area with places constituting sociomaterial assemblages of human and nonhuman materialities the literature on health and place has also begun to consider the influence of macrolevel political economic and institutional factors engaging with this debate the deprivation amplification hypothesis asserts that the negative health effects of individuallevel low socioeconomic status are amplified for those living in more deprived areas in the literature this concept has largely been applied to examining whether differential access to resources between local areas impacts on the relationship between low ses and health most notably this work has examined whether individuallevel ses inequalities in physical activity are compounded by arealevel characteristics in this regard the concept of deprivation amplification has been subject to some debate for example some studies have found support for the thesis that individual ses inequalities in physical activity are higher in more deprived areas whilst others have not however beyond the contextual effects literature deprivation amplification has seldom been used to explore interactions between different scales of place for example by examining differences in the health profiles of more deprived neighbourhoods or local authorities within more or lessdeprived regions there are well established and longstanding regional inequalities in health in england in the mid19th century life expectancies in northern cities were four years lower than in southern cities and today there is a twoyear difference in average life expectancy between the nnorthern regions and the rest of england people in the north consistently have higher mortality rates and lower life expectancy than those in the south across all socioeconomic groups all ages and j o u r n a l p r e p r o o f amongst both men and women premature death rates are now 20 higher for those living in the north and since 1965 this amounts to over 15 million northerners dying before their time socioeconomic inequalities in health are also larger in the north englands regional health inequalities are amongst the largest in europe and there is also evidence that they are increasing particularly amongst younger adults life expectancy in deprived southern local authorities is also higher than in similarly deprived northern areas suggesting a process of regional deprivation amplification much of this northsouth health divide arises because the three northern regions are more deprived than the other regions of england no study has investigated deprivation amplification in the context of the covid19 pandemic we set out to test the deprivation amplification hypothesis and examine whether or not covid19 mortality rates by deprivation differ by region in england to do this the study uses middle super output area level covid19 mortality data from england stratified by msoa deprivation and by government office english region specifically it examines whether more deprived msoas in more deprived northern regions suffered greater covid19 mortality rates during the first fourteen months of the pandemic than those in less deprived regions as covid19 is an infectious disease the analysis also uses spatiallag models to examine whether the covid19 mortality rate and level of deprivation in neighbouring msoas had any impact on covid19 mortality rates of each nearby msoa methods we answered the following research questions 1 were there regional inequalities in covid19 mortality rates across the nine regions of england in particular was there a northsouth divide in covid19 mortality rates j o u r n a l p r e p r o o f 2 did more deprived areas do worse across the country or did deprived areas in the north do worse than deprived areas in the south 3 is the level of covid19 mortality in an msoa affected by the covid19 mortality rate and the level of deprivation in neighbouring msoas data to answer the above research questions we combined data at middle super output area level on mortality attributable to covid19 the age structure the ethnicity structure and the level of deprivation super output areas are artificial statistical geographical units created by the office for national statistics to improve and harmonise analysis they are based on the 2011 census there are three types output areas lower super output areas and middle super output areas oas are based on postcodes and the majority of oas contain between 110 and 139 households oas are then used to form lsoas which range from 4001200 households msoas are in turn created by combining between four and six lsoas on average msoas contain a minimum of 5000 and a maximum of 15000 people and a minimum of 2000 and a maximum of 6000 households we used msoas because this is the smallest geographical scale at which covid19 mortality data is publicly available mortality attributable to covid19 were available from the office for national statistics data were recorded as counts of deaths in the 14month period from march 2020 to april 2021 agestandardised mortality rates were not provided at msoalevel and so we constructed the mortality rate per 10000 population by dividing the total count of deaths attributable to covid19 by the 2019 population estimate and multiplying by 10000 the ons classified deaths directly attributable to covid19 if covid19 was the underlying cause of death this classification would exclude j o u r n a l p r e p r o o f some deaths where the underlying cause was not covid19 but covid19 was mentioned on the death certificate as a contributory cause of death data on msoa population estimates were reported by the ons we used the logarithm of the covid19 mortality rate per 10000 population as the raw data were not normally distributed given the association between increasing age and increasing mortality especially for covid19 deaths we additionally obtained information on the age structure from the 2011 census likewise as various studies have shown a strong association between ethnicity and increased risk of covid19 mortality we also included the ethnicity structure we used the office of national statistics five broad census categories white and white british black and black british asian and asian british people with a mixed ethnicity and other for areas from the 2011 census we did this because whilst it is possible to obtain more granular ethnicity data many cells are suppressed due to small numbers of observations in some msoas we therefore used the fivecategory definition of ethnicity so as not to encounter statistical problems associated with missing or censored data in each case the data indicate the percentage of the msoa population that belong to each category we use data from the 2011 census as it is the most complete and does not rely on statistical modelling ethnicity data at msoalevel is not modelled and is only available in census years ethnicity data are available at larger geographies but that is too large for use here as urbanrural differences in mortality are often significant we additionally obtained information of the ruralityurbanicity of each msoa using data from the ons each msoa is assigned j o u r n a l p r e p r o o f to one of eight categories which we condensed to five 1 rural town and fringe 2 rural village and dispersed areas 3 urban cities and towns 4 urban major conurbations and 5 urban minor conurbations for categories 1 3 we combined the main category with the additional in a sparse area as the latter often had very few msoas in however the main results are robust to keeping all eight categories finally deprivation was assessed using the 2019 version of the index of multiple deprivation obtained for each msoa from imd is the most commonly used measure of arealevel deprivation in england it produces a ranking of areas in england based on relative local scores for income employment health education crime access to services and living environment to obtain msoa scores and ranks from data available at lsoa level population weighted average score of lsoas within each msoa were calculated each msoa was then ranked from 1 to 6791 for ease we split deprivation into five quintiles ranging from 1 to 5 analysis we started by summarising the variables for the 6791 msoas in england we additionally summarised the variables according to whether the msoa was in the north of england or the rest of england we present graphs of the average msoa covid19 mortality rate by region we then present a graph showing the covid19 mortality rate by northrest of england and deprivation quintile including confidence intervals the 95 confidence interval is calculated by applying the formula mean±196×se where se is the standard error of the mean j o u r n a l p r e p r o o f to examine if there was a difference in covid19 mortality rates after accounting for possible confounding factors between the north and the rest of england we estimated a multivariate linear regression model 𝑦 𝑚 𝛽𝑁𝑜𝑟𝑡ℎ 𝑚 𝛾𝑿 𝑚 𝛿𝑰𝑴𝑫 𝑚 𝑒 𝑚 in this setup y refers to covid19 mortality rates per 10000 north is a binary indicator equal to one if an msoa is in the north of england and equal to zero if an msoa is in the rest of england x is a vector containing information relating to the of each msoas population in each age band and each ethnicity group as well as information on the urbanrural status of the msoa these variables are included separately and are also interacted with the north dummy variable to allow for interaction effects imd is a series of four indicators relating to each imd quintile again these imd indicator variables are included on their own but are also interacted with the north dummy variable to allow for differential effects of deprivation in the two areas considered the error term e is assumed to be normally distributed and iid this is shown to hold true when we use the logged outcome subscript m refers to msoa m 1 2 … 6791 because we have taken the natural logarithm of the dependent variable and our main exposure is a binary variable we need to interpret the excess northern mortality in percentage terms we do this by applying the formula 100 × where 𝛽 is the parameter on north in tables we present the raw coefficients however we also provide the percentage interpretation for key parameters in the accompanying text j o u r n a l p r e p r o o f however the multivariate linear regression models ignore the possibility of spatialdependencies that might exist between neighbouring msoas we therefore allowed for this possibility to estimating spatial lag models of the form 𝑦 𝑚 𝛽𝑁𝑜𝑟𝑡ℎ 𝑚 𝛾𝑿 𝑚 𝛿𝑰𝑴𝑫 𝑚 𝜌𝑊 𝑚𝑛 𝑦 𝑛 𝝀𝑊 𝑚𝑛 𝑰𝑴𝑫 𝑛 𝑢 𝑚 where 𝑢 𝑚 𝜀𝑊 𝑚𝑛 𝑢 𝑛 𝜇 𝑚 in this spatial model subscript n≠m refers to the neighbouring msoas of msoa m the error term u includes a spatially correlated component and an orthogonal component 𝜇 𝑚 the term 𝜀 models the spatial error autocorrelation structure the coefficients of interest can be consistently estimated using a generalised twostage least squares approach the defining feature of the above model is the square spatial weights matrix w w is specified as a contiguity matrix such that the element in the mn th position w mn takes the value 1 if msoas m and n have a common border and 0 otherwise we specify queens criteria for defining contiguity although the results are robust to rooks criteria the setup above contains three spatial elements first it allows the mortality rates of neighbouring msoas to affect the mortality rate of each msoa captured by the 𝜌𝑊 𝑚𝑛 𝑦 𝑛 term second it allows the level of deprivation in neighbouring msoas to affect the mortality rate of each msoa captured by the 𝜆𝑊 𝑚𝑛 𝐼𝑀𝐷 𝑛 term finally it allows there to be correlated shocks that are experienced by neighbouring msoas captured by the 𝜀𝑊 𝑚𝑛 𝑢 𝑛 component of the error term our spatial model assumes that there exists spatial dependencies this assumption does not only to test whether it is necessary to perform a spatial analysis we calculate morans i 𝐼 𝑁 𝑆 × ∑ ∑ 𝑊 𝑚𝑛 𝑁 𝑛1 𝑁 𝑚1 ∑ 2 𝑁 𝑚1 where n is the number of msoas indexed by m and n y is the outcome from unit m or n and 𝑦 ̅ is the mean of the outcome across all units w is the contiguity matrix as defined above and s is the sum of all possible weights matrices for all m and n the expected value of i under the null hypothesis of no spatial autocorrelation is 𝐸 𝐼 1 𝑁1 the test has been widely used to test for the existence of spatial autocorrelation we further implement the test suggested by hepple for use on regression residuals and the test statistics and outcomes are qualitatively very similar results descriptive statistics for key variables are shown in 2049 per 10000 regional covid19 mortality rates are shown in figure 1 the north west had the highest covid19 mortality rate and the north east had the second highest these are both nearly double the covid19 mortality j o u r n a l p r e p r o o f rate in the south west panel of figure 1 shows the covid19 mortality rate by imd quintile the most deprived 20 of areas had higher crude mortality rates than the least deprived 20 of areas notes the crude regional mortality rate is the populationweighted average of each msoa within that region each msoas mortality rate is defined as the total number of deaths between march 2020 and april 2021 divided by the population estimate from 2019 expressed per10000 population the mortality rates are not agestandardised in addition they are 14month totals not annual approximations j o u r n a l p r e p r o o f notes the crude regional mortality rate is the populationweighted average of each msoa within that region each msoas mortality rate is defined as the total number of deaths between march 2020 and april 2021 divided by the population estimate from 2019 expressed per10000 population the mortality rates are not agestandardised in addition they are j o u r n a l p r e p r o o f 14month totals not annual approximations the north is defined as the north east north west and yorkshire and the humber the rest of england is the remaining six regions of england the 95 confidence interval is calculated by applying the formula mean±196×se where se is the standard error of the mean the north is less ethnically diverse than the rest of england where 913 of the population are white compared to 844 in the rest of england in the north black asian and mixed ethnic groups make up 120 552 and 143 respectively compared to 409 795 and 249 in the rest of england there is more deprivation is the north of england than in the rest of england 34 of the msoas in the north are in the most deprived quintile compared to 14 in the rest of england accordingly 14 of the msoas in the north are in the least derived quintile compared to 22 in the rest of england from figure 2 and table 2 it can be seen msoas in the most deprived quintile in the north had higher crude covid19 mortality rates than msoas in the most deprived quintile in the rest of england and that this difference was statistically significant this is true for quintiles 2 3 and 4 too although msoas in the least deprived quintile in the north had higher covid19 mortality rates than msoas in the least deprived quintile in the rest of england this difference was not statistically significant similar data is presented for all regions in appendix b j o u r n a l p r e p r o o f the rest of england notes the mortality rate is the populationweighted average of each msoa within that part of england within that imd quintile each msoas mortality rate is defined as the total number of deaths between march 2020 and april 2021 divided by the population estimate from 2019 expressed per10000 population the mortality rates are not agestandardised in addition they are 14month totals not annual approximations the 95 confidence interval is calculated by applying the formula mean±196×se where se is the standard error of the mean j o u r n a l p r e p r o o f in column 3 we add in urbanicity in this specification msoas in the north has higher mortality of around 344 urban areas tended to have higher covid19 mortality and there was very little evidence of differential effects of urbanicity between the north and rest of england finally in column we present the full model where we additionally account for deprivation and its interaction with north northern msoas had 231 more deaths per 10000 even after accounting for age ethnicity and deprivation covid19 mortality rates exhibited a monotonic relationship with deprivation the most deprived quintile of msoas experiencing 441 more covid19 deaths per 10000 population that the least deprived msoas msoas in quintiles one to four in the north had similar mortality to the equivalently deprived msoas in the rest of england however msoas in the most deprived quintile in the north had an additional 145 higher mortality than the most deprived msoas in the rest of england after accounting for the age and ethnicity structure of msoas deprived msoas in the north still have higher average covid19 mortality than in the rest of england the most deprived msoas in the north had a conditional mean of 2601 deaths per 10000 compared to 2298 deaths per 10000 in deprived msoas in the rest of england to test for the existence of spatial correlation in the regression residual from the simple linear model we implemented the stata command to calculate morans i under the nullhypothesis there is no spatial correlation in the residualserror terms the test statistic is distributed as 𝜒 2 the test statistic is 130260 hence morans i strongly rejects the nullhypothesis of homoscedastic error terms and strongly indicates that there is substantial spatial correlation in the error terms indicating the spatial model is preferred respectively these provide further graphical evidence that deprivation and higher mortality rates are more concentrated in the north and there are strong spatial clusters where hot spots of high deprivation and high mortality rates are geographically clustered j o u r n a l p r e p r o o f the conditional means are estimated using the regression output in table 3 column and accounts for the age and ethnicity composition of each msoa as well as urbanity and deprivation including interactions with the north the vertical lines are 95 confidence intervals obtained in the traditional way j o u r n a l p r e p r o o f table 4 reports the coefficients from the model that explicitly allows for the spatial lag terms here we present both the estimated coefficient as well as the average direct effect the average indirect effect and the average total effect the full spatial model confirms that msoas in the north were more likely to have higher covid19 mortality rates and the size of the difference is larger than that reported in the linear model of table 3 here the north experienced 495 more deaths than the rest of the country there again exists a monotonic relationship in the coefficients of deprivation however when we break this down into average direct and average indirect effects it appears that this is being driven by the average direct effect especially for msoas in quintiles 2 and 3 however there is strong evidence of both direct and indirect effects in the most deprived quintile in the most deprived quintile the direct effect is an additional 406 deaths per10000 and the indirect effect is an additional 88 more deaths per10000 resulting in an overall total effect of 529 more deaths per 10000 the spatial lags on the dependent variable and the error term are strongly statistically significant adding further justification to the use of spatial models the spatial lags on the imd terms are not interpretable in their current form and hence we compare direct and indirect effects the spatial lag on the outcome indicates that one additional death per 10000 population in a neighbouring areas leads to 73 higher mortality rate in the area under consideration j o u r n a l p r e p r o o f notes a the additional variables relate to the percentage of the msoa population in prespecified age bands and the percentage of the msoa population classified into five broad ethnicity groups as well as five categories or urbanicity b the definition of average effect for the spatial model is provided in appendix a c we cannot compute the direct indirect and total effect here as some msoas are on the boundary of the north and hence some neighbouring msoas are in the north and some are in the rest of england in this case they parameters cannot be estimated d we also include spatial lags of the key imd terms as well as their interaction with north but we omit them here for reasons of brevity they are all statistically insignificant at p 005 j o u r n a l p r e p r o o f discussion we found strong evidence of the unequal effects of the pandemic on average regions in the north of england were much more likely to have higher covid19 mortality rates we also showed that more deprived areas were considerably likely to have higher mortality than less deprived areas crucially we have found that there were regional differences in the effects of deprivation on average deprived areas in the north fared worse than equally deprived areas in the rest of england our results also show that the higher covid19 mortality rates in the north persisted after adjusting for other possible confounding factors there was strong evidence of spatial clusters of increased mortality and hence models that could account for this were preferred the covid19 mortality rate of neighbouring areas had an effect on the mortality in each surrounding area as did the level of deprivation in neighbouring areas given that deprivation is more prevalent in the north this could in part explain the higher covid19 mortality rates there this is the first application of the deprivation amplification concept to the covid19 pandemic and our results suggest that there is potentially a deprivation amplification effect in regards to geographical inequalities in covid19 mortality rates this takes two forms firstly deprived areas in the more deprived northern regions had higher mortality rates than equally deprived areas in the less deprived regions in the rest of england and secondly some of the excess covid19 deaths in deprived areas in the north are associated with the deprivation rates of neighbouring areas together this suggests empirically that it is not just the immediate neighbourhood context that matters for population health outcomes but also the wider regional and neighbouring contexts this is a key aspect of deprivation amplification theory and so our results support the further use of this concept in health geography research as noted in the introduction the broader relationship between deprivation and covid19 mortality has been previously explained through the syndemic pandemic concept this has suggested that deprivation results in multiple interacting and additive adverse risk factors for covid19 mortality acting through five pathways our results suggest that the deprivation amplification concept can also be added to our theory toolbox for understanding deprivation and covid19 it suggests that these syndemic pathways can be exacerbated in areas of higher deprivation if they are embedded within a wider context of local and regional deprivation this is the first application of the amplification deprivation concept to examine the influence of different geographical scales of deprivation on health previous use of the concept has focused on the influence of local area deprivation on the relationship between individuallevel ses and health outcomes as such our results have implications not just for how we understand geographical inequalities in covid19 and the relationship between deprivation and mortality but also for how we assess the value of the deprivation amplification concept within the broader health geography literature in keeping with previous theoretical work our empirical results here suggest that issues of scale needed to be embedded into our understanding of what constitutes contextual influences on health specifically our work suggests that the deprivation amplification concept can be expanded for wider analytical use within health geography it has utility beyond just examining the interaction of individuals and local areas to assessing the interaction of different spatial scales of deprivation on the health outcomes of local places our study thereby adds to the wider health geography literature debates on the relationship between health and place by suggesting that it is not just the immediate neighbourhood that constitutes contextual influences on population health but the wider regional and neighbouring local context j o u r n a l p r e p r o o f our results showed that it is not only the level of deprivation in the specific area that is important for explaining that areas covid19 mortality but also the levels of deprivation in neighbouring areas it is therefore important to use statistical models that explicitly allow these spatial spill over effects to be modelled and quantified as well as indirect effects operating through the deprivation of neighbouring areas there were strong direct effects given the highly infectious nature of covid19 it is important to allow for the outcomes of geographically proximal areas to have effects on the outcomes of the areas they border strengths and limitations our analyses use information on all msoas within england and hence has national coverage we were able to merge in information on important factors that have been shown to be strongly predictive of covid19 outcomes additionally we were able to assess the deprivation amplification hypothesis by obtaining detailed information on the relative position of each msoa nationally and assigning to quintiles the statistical models used allowed us to account for and quantify direct and indirect effects between neighbouring areas our study also used a theoryguided approach however our study is subject to some important limitations firstly using covid19specific mortality as opposed to a measure of excess mortality could have biased underestimated our estimates of the effect of area deprivation on deaths secondly we used mortality data from msoas in england this was because this was the smallest spatial scale data that was publicly available for covid19 mortality rates when we conducted our analyses however analysis of smallerlevel geographies would allow a more precise estimation of the extent of arealevel inequalities in covid19 mortality the regional focus of our analysis also has limitations as for example the north is less ethnically diverse than the rest of england on average although this does not apply to certain parts of the north such as greater manchester which is more diverse or in contrast parts of the south such as cornwall which are less ethnically diverse further our analysis examines the whole 14month period for which covid19 mortality data by msoa is available we have not thereby examined any temporal differences by region that may have occurred j o u r n a l p r e p r o o f during the different phases of the pandemic finally whilst we have identified relationships at the area level we cannot of course assume that our findings hold true at the individual level to do so would be to risk the ecological fallacy since relationships identified for areas cannot be assumed to apply to individuals conclusion this study has used the concept of deprivation amplification to explore the relationship between deprivation scale and covid19 mortality rates we found that the more deprived northern regions and the more deprived msoas across the country had higher covid19 mortality rates we also found that deprived msoas in the more deprived northern regions suffered even greater covid19 mortality rates we also found strong evidence of spatial clustering and spillovers we argue that this is evidence of deprivation amplification within the covid19 pandemic our findings reinforce discussions on the syndemic nature of inequalities in the covid19 pandemic whilst also advancing the health and place literature by suggesting that the deprivation amplification concept has wider utility in the health geography literature than has previously been explored j o u r n a l p r e p r o o f

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background violence is an important community health problem that can be encountered in every area of human life and is gradually increasing in the world 12 women and children are exposed to the greatest violence in turkey as in in all other societies 3 violence against women can be defined as all acts of genderbased behavior that is likely to result in psychical sexual and psychological harm or suffering to women or causes to coercion or arbitrary deprivation of liberty whether occurring in public or in private life 4 violence against women are often categorized as emotional physical psychological economic and sexual violence 5 physical violence is a means of intimidation suppression and sanction of the brute force sexual violence is the use of sexuality as a way of threat oppression and control psychological violence or verbal abuse is the suppression punishment and control of women with ones behavior speech economic violence is defined as the use of economic resources and money as sanction and treat over women 6 it is notified that 30 of women in the entire world and 37 of women in the east mediterranean region including our country are exposed to physical andor sexual violence by their husbands or partners in any period of their lives 2 the reports of general principles of european union agency for fundamental rights showed that the amount of spousal abuse in the countries of european community ranged from 13 to 32 in 2014 7 according to the research about violence against women resulted in 2014 in the countries of eu one of each three women are exposed to physical or sexual violence from the age of 15 only 14 of the domestic violence cases is reported one of 10 women above the age of 15 is exposed to sexual violence two of five women remarked that they were exposed to psychological violence by their ex husbands life partners 7 in turkey the government has started to take precautions and important steps for combating violence against women and international developments have accelerated relevant studies in accordance with international conventions being signed in turkey the provisions tolerating discrimination and violence against women in the civil code and the turkish penal code have been considerably cleaned up and replaced by provisions aimed at establishing equality 38 as a recent development the law on the protection of the family and prevention of violence against women was passed on 20 march 2012 and domestic violence against women began to be considered a crime 9 one of the most discussed diaries in turkey is violence against women beyond any doubt besides its disgusting appearances with the cases such as murders violence against women also attracts attention with the rates propounded with the researches according to the results of research on domestic violence against women in turkey 2009 39 of women in turkey are exposed to physical violence 15 of them are exposed to sexual violence and 44 of them are exposed to emotional violence according to the results of research on domestic violence against women in turkey 2015 36 of the women in turkey are exposed to physical violence in other words about 4 of each 10 women are exposed to violence by their husbands or life partners 12 of the women are exposed to sexual violence and 44 of them are exposed to emotional violence in the same report 1011 in similar studies conducted in turkey womens exposure to violence is detected at the rate of emotional violence is 75 physical violence is 39 and sexual violence is 28 12 in another study it was found that psychological violence was at the rate 991 physical violence was 364 and sexual violence was 54 13 dindas and ege reveals that 29 of women are exposed to verbal violence 259 of them are exposed to emotional violence 14 of them are exposed to physical violence 114 of them are exposed to economic violence and 8 of them are exposed to sexual violence 14 in study of guler and his colleagues 15 it stated that 407 of women are exposed to violence 15 in study conducted by altınay and arat 16 on 1800 married women it was stated that one out of every three women are subjected to physical violence by their spouse at least once during their lifetime in yaman efe and ayazs study 17 it was found that all of the women in the study are exposed to domestic violence 546 of them were low level 384 were middle level and 7 were exposed to high levels of violence the result of the researches suggest that the prevalence of women exposed to violence in turkey and in the world is high 271011 beside defining the facts of violence against women treatment support and rehabilitation health professionals especially nurses who are always in contact with the society have important duties in reducing the violence in the society and forming a culture without violence including protection and early intervention nurses should do their duties of knowing the victim of domestic violence encouraging her for expressing her problem without feeling guilty providing her privacy and security collecting appropriate data directing her to other professionals when needed and guiding about support systems 18 because nurses have duties in a number of different fields they have a considerable impact to prevent treat and reduce the domestic violence nurses have the opportunity to observe influence and train the families in where they are for these reasons nurses could have multiple help and contributions to the victims of violence 19 in addition nurses should have knowledge of the households and other environments where violence is experienced should break the cycle of violence and ensure to reduce of the long or short term effects of violence on the women and her family 20 it is thought that nurses being involved in advocacy and counseling roles is essential for strategies to prevent violence against women so women who are exposed to violence could be informed about their legal rights and guided to the appropriate channels in recent years different studies conducted in turkey showed that one out of every three women is exposed to violence at some point in their lives even though the lack of statutory data on violence against women is causing to have limited information whether violence against women increased or not the high level of figures suggests that it is a multidimensional social problem which is fueled by structural dynamics for this reason it necessary in the case of turkey to understand the different dimensions of violence thoroughly and analyzes their different aspects in this sense understanding the dimensions of violence against women and specific to turkey analyzing the aspects of violence against women based on gender inequality are needed due to these reasons this study was conducted in order to evaluate the domestic violence against women living in manisa and to determine the risk factors affecting this situation methods participants and design the study was conducted in the central district of manisa between 15 november 2013 and 01 january 2014 the province of manisa where the research is conducted is in the west of turkey in the aegean region 501 of the population are men and 499 of the population are women yearly population growth rate is 983 the amplitude of the young population in the province of manisa attracts attention 36 of the population of the province is under 25 according to 2013 census when the data of the province of manisa about education is evaluated two aspects attract attention the data of the province is above the average of turkey in terms of literacy and schooling and there are still problems about the inadequacy of the level of education the rate of illiterate people over the age of 15 throughout the province of manisa is 36 83 of the illiterate people are women and 17 of them are men 21 the scale of domestic violence against women which we used in our research is applied to women who have married once or have lived together with a partner because of the fact that the majority of women and men in our country prefer official marriage married women were included in the study the target population of the study consisted of women aged 1888 living in 13 towns and 85 villages in central manisa the minimum sample size of the study which was exemplify of universe which was calculated as 1038 people by using the epi info 70 software and taking the frequency of domestic violence against women in our society as 42 confidence limit 95 and the margin of error 3 as there were likely to be losses in the sample the sample size was determined as 2000 women women over 18 who married at least once were included within the scope of the research women to be included in the study were selected from the registration of the department of data processing unit of support services manisa provincial public health directorate via stratified simple random sampling people chosen and determined randomly from the family serial numbers from the registries of cities halfcities and rural areas were included in the sample questionnaires in the study the data were collected by using the womens information form consisting of 32 items which was prepared by the researchers in accordance with literature and the scale of domestic violence against women all data collection tools were used in turkish in a way the participans could undertand the womens information forms consisted of questions about their sociodemographic and marital features income status residence family type and educational background scale of domestic violence against women developed by kılıc in 1999 scale of domestic violence against women determines domestic violence committed by the husband on the woman the scale consists of 50 items and 5 subdimensions subdimensions are physical violence emotional violence verbal violence economic violence and sexual violence each group can be used independently each subdimension consists of 10 items items related to physical violence are numbered 161116212631364146 51015202530354045 and 50 the total score obtained from the scale shows the level of domestic violence against women the scale is a likert type scale from 1 to 3 with responses of never sometimes and always participants obtained scores from each statement in the scale as follows never sometimes always out of 50 items 16 items numbered 2 5 7 8 9 12 14 22 28 30 32 33 38 44 47 and 49 were reversely coded the lowest score to be obtained from the scale is 50 while the highest score to be obtained from the scale is 150 the lowest and highest scores to be obtained from each subdimension are 10 and 30 respectively high scores that women get from the scale show high level of exposure to violence while low scores indicate low level of exposure to violence cronbach alpha coefficients of the scale and subdimensions were determined to range between 073 and 094 22 in this study cronbach alpha coefficient of the scale was calculated as 071 procedure in the first stage of the study an announcement was made to midwifery and nursing students and students who applied to work as poll takers in the project were selected poll takers were trained by researchers for 1 day in the subject the content of the study ethical issues and how to apply the forms to be used after completing training poll takers were separated into groups of 10 individuals and each group was put under the responsibility of one researcher the required permissions were obtained from the governorship for using the questionnaires and the relevant district managers were informed accordingly in the second stage of the study the poll takers went to the addresses specified in the sample and informed individuals about the study and they collected data from the women who volunteered to women in the study the data of the research was collected by pollsters doortodoor in the houses of the people determined with the face to face meeting method the questions of the survey were read by the pollsters and the polls were completed in accordance with the discourse of the participants the addresses of women who refused to participate in the study or were not available were noted and a total of 2000 women were interviewed the womens information form and scale of domestic violence against women were used for the 2000 female who were interviewed the transportation and lunch expenses of poll takers were paid within the scope of the project in the third stage of the study the researcher responsible for each group collected the data checked them and recorded them on the database incomplete and erroneous forms were excluded and the data from a total of 1760 women were recorded on the system statistical analysis descriptive data are presented as number percentage and mean the data gathered from the groups were compared with the paired sample t test mann whitney u test oneway anova for repeated measures test all analyses were carried out using the spss for windows release 15 0 a p value of 005 was thought to be crucial for all analyses results considering the descriptive features of women comprising the study group it was determined that the women had an age average of 3715 ± 1214 considering their educational background it was determined that 59 of the women were illiterate 68 had never gone to school but they were literate 121 were university graduates it was also determined that 275 of the women worked that the women had a lower educational level and their rates of employment were very low in general with regard to women exposure to violence in individuals in the study group it was determined that women were mostly exposed to verbal and physical violence women were exposed to violence mostly from their husbands and fathers according to the declarations and perceptions of the participants in our study 162 of the women stated that they frequently experienced violence it was determined that women exposed to violence usually preferred to keep silent when the distributions of the score averages women received from the scale of domestic violence against women are examined it is seen that 300 of women have score averages above the score average of the scale and they are exposed to violence more than the others when the subdimension score averages of the women are examined it is determined that physical violence subdimension score averages of 54 of the women are above the average of the subdimension and they are exposed to physical violence more than the others emotional violence subdimension score averages of 778 of the women are above the average of the subdimension and they are exposed to emotional violence more than the others verbal violence subdimension score averages of 511 of the women are above the average of the subdimension and they are exposed to verbal violence more than the others economic violence subdimension score averages of 662 of the women are above the average of the subdimension and they are exposed to economic violence more than the others and sexual violence subdimension score averages of 159 of the women are above the average of the sub 3 a statistically significant difference was obtained in the statistical analysis made between the score averages of the women from the scale of domestic violence against women and such variables as age group education status employment status social insurance status immigration status place of residence marital age year of marriage of woman age education status and employment status of the husband and whether the husband has another wife according to the findings women who are aged above the age average have education levels equivalent to and lower than primary education have no social insurance have come to the region through immigration live in squatter settlements have belowaverage marriage ages have aboveaverage year of marriage have higher total violence scores and are exposed to violence more than the others also the women whose husbands are aged above the average have education levels equivalent to and lower than primary education have unemployed wives and have other wives are reported to have higher total violence scores and be exposed to violence more than the others lastly women who expressed to have suffered from domestic violence have discussion violence against women is a social problem that at the most basic level threatens womens lives and which prevents them from participating fully in social and cultural life it remains current in turkey as in many other countries in turkey the proportion of married women who stated that they had been exposed to physical violence is 36 in other words approximately 4 out of every 10 women had experienced physical violence from their husbands or partners 10 in another study of women 407 of women stated that they had been exposed to domestic violence among these women 91 had experienced violence from their husbands 227 from their husbands relatives and 197 from their own relatives 15 in our study it is determined that women are exposed to physical violence most and this violence is practiced by their husbands firstly and by their fathers secondly in the most of the studies carried out in turkey exposure to violence rates of women vary between 40 and 80 1011172324 our findings show a parallelism with the findings across the world it is possible to suggest that women mainly experience violence from men it has been observed that women are exposed to violence by their husbands no matter what educational level social status or economic conditions they or where they live 3 it has been noted that 30 of women in the world and 37 of women in the eastern mediterranean region including in turkey are exposed to physical andor sexual violence by their husbands or partners at some time in their lives 2 the reports on general principles of european union agency for fundamental rights showed that the amount of spousal abuse in the countries of european union ranged from 13 to 32 in 2014 7 although most of the women are exposed to domestic violence studies conducted show that some women are exposed to violence more than the others 25 26 27 the basic factors that determine the social status of women involve education employment and social security the right to education and employment is among the rights of women on the basis of fundamental human rights however it is known that womens participation in education and business life is obstructed by families relatives and acquaintances across the country 10 one of the most important risk factors for violence against women is the lower educational level of women 2627 as the educational level of women decreases the rates of being exposed to violence increase while one out of every five women with a higher education is exposed to violence one out of every two women with a lesser degree of education are exposed to violence 310 increasing womens educational levels in general will develop their personal skills employability and consequently their socioeconomic levels it will thus decrease their risk of being exposed to violence 128 in our study it was found out that women with education levels equivalent to and lower than primary education have higher total violence scores and are exposed to violence more than the others in turkey the educational level of women is not at the required standard according to the national research into violence against women that was conducted in turkey 2014 19 of men and 32 of women are either illiterate or despite being literate have never gone to school while only 101 of men and 61 of women are university graduates 10 according to the population and health research that was conducted in turkey in 2013 161 of men and 282 of women are either illiterate or although literate have never gone to school while 291 of men and 205 of women completed high school and higher education 21 in both studies the rate of illiteracy or of lack of attendance at school despite being literate was almost twice as large among women than men in our study there is a 50 difference between the rates of illiteracyliteracy without schooling among women and men to be illiterateonly literate and to be university graduates the study results show a parallelism with studies being conducted countrywide in which women have lower educational levels than men considering the employment rates of women and men it can be observed that almost three women out of four are unemployed and have no independent income which is noteable women and men have similar average ages and it is possible to assert that women have a lower social status in terms of their educational level and working conditions compared to men in a study conducted in pakistan it was determined that women getting married at young ages are exposed to domestic violence more than the women getting married in adulthood and are deprived of education and social insurance due to early marriage 25 research on domestic violence against women in turkey which covers the whole country reports that physical and sexual violence increases with the advancing age but when the last 12 months are taken into consideration young women are exposed to violence more than the other age groups researchers concluded that women suffer from violence at younger ages and the first years of the marriage 11 in our study total violence scores of the women who have aboveaverage ages and years of marriage and get married at earlier ages were found to be higher it was concluded that as age and years of marriage increase the rate of lifetime exposure to violence increases and women who get married at young ages are exposed to violence more than the others according to another study conducted throughout turkey the percentage of men who commit physical violence among those aged 45 and over is higher than the rate of men who commit violence in 1524 age group as the age of men in a group increases the rate of those who commit physical violence increases 10 our study shows that total violence scores of women whose husbands are aged above the average are higher and they are exposed to violence more than the others it is thought that the rate of committing lifetime violence increases among men as their ages and durations of marriage increase the studies conducted so far reported certain major factors affecting womens exposure to violence which include low education level of the husband unemployment of the husband and the fact that the husband has another wife 10111723242930 in parallel to these studies our study revealed that women with husbands who have education levels equivalent to and lower than primary education who are unemployed and who have more than one wives are exposed to violence more than the others in the literature it is noticeable that women suffering from domestic violence have low education and socioeconomic levels and do not work in any incomegenerating jobs 1011172324 29 30 31 in our study the relation between violence and a woman who is not working and lacks social insurance displays a similar pattern to the relation between education level and violence when it is thought that education level employment status and social insurance play key roles in terms of the welfare levels of the women it can be stated that women with lower welfare levels are exposed to violence more than the others similarly the study conducted throughout turkey shows that one of two women who have low welfare levels and one fourth of all women with high welfare levels are exposed to violence in any period of their lives 11 both literature and results of this study have demonstrated that exposure to violence increases among women as their levels of welfare decrease previous studies conducted in turkey reported that the frequency of domestic violence against women differs depending on the geographical regions where women live 10111723243031 it was determined in our study that women who migrated to the region in question from the eastern part of turkey and live in shatter settlement have higher total violence scores and suffer from violence more than the other women although the region where the study was conducted is located in the western part of turkey the results of the present study share similarity with the other studies conducted throughout the country since most of the women living in shatter settlement migrated to this region from eastern turkey 101117232431 it is seen in our study that scale score averages of the women who state that they do not suffer from violence are outstandingly high it can be understood from our study that a considerable number of women do not perceive many behaviors of their husbands as violence and their awareness concerning violence are inadequate this finding may imply that women do not perceive certain violent behaviors of their husbands as violence similar results were obtained in previous studies 111532 as a result of the influence of the cultural values in the patriarchal social structure in turkey on women they are convinced that their husbands have the right to beat them these women think that it is normal to be exposed to violence as other women also experience violence from their husbands 32 implications it was determined that domestic violence against women is still common throughout turkey and women do not perceive many behaviors of their husbands as violence and the main factors contributing to this situation are social status and level of welfare when the findings of the present study are evaluated in combination with the results of the previous studies it becomes evident that they are similar to a large extent limitations our study has several limitations although the first intention was to conduct the study throughout turkey it was carried out in a specific region due to financial difficulty and time constraints during the study data were collected via personal statements despite the similarities between the findings of the present study and results of the studies covering the whole country the results of this study only belong to the region where it is carried out and cannot be generalized to turkey finally the crosssectional and descriptive design of the study limits conclusions about causality for some findings conclusions as a conclusion as in many studies on violence this study reports that the rate of domestic violence against women is high women do not perceive many behaviors of their husbands as violence and the main factor leading to this situation is social status major factors increasing domestic violence are reported to include relatively advanced ages of women and their husbands low education levels marriage at young ages unemployment lack of social insurance the fact that husband has another wife immigration and living in shatter settlement domestic violence against women is preventable approach of the society is of great importance in preventing violence and abuse societies should take action against violence cases through government programs legal arrangements media official and voluntary organizations education institutions etc in order to prevent violence it is believed that the results of the study will be a guidance to local authorities formal and voluntary organizations educational institutions and relevant researchers in the prevention of violence against women competing interests the author declared no potential conflicts of interest with respect to the research authorship andor publication of this article

background this study reports on a large crosssectional study of violence against women in turkey and outlines the risk factors associated with intimate partner violence the purpose of this study was to identify in order to evaluate the domestic violence against women living in manisa and to determine the risk factors affecting this situation methods we implemented a crosssectional descriptive study in the manisa province of turkey the research data were collected by using a womens information form consisting of 32 items and scale of domestic violence against women the study was conducted with 1760 women who complied with the inclusion criteria results it was determined that score averages of 300 of women from the scale of domestic violence against women were above the score average of the scale 7138 ± 1071 and they were exposed to violence more than the others a statistically significant difference was obtained in the statistical analysis made between score averages from the scale of domestic violence against women and such variables as age education employment status social insurance immigration status place of residence marital age year of marriage of women age education status employment status of husband and whether the husband has another wife p 005 conclusions it was also found out that the rate of domestic violence against women is high women does not perceive many behaviors of their husbands as violence and the most important factor leading to this situation is social status it is believed that the results of the study will be a guidance to local authorities formal and voluntary organizations educational institutions and relevant researchers in the prevention of violence against women

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introduction in recent years the phenomenon of food waste has increased the attention of researchers policymakers environmentalists and social activists 1 2 3 as one of the urgent crosscutting issues of the environmental economic and social sectors the complexity of food waste requires the consideration of the principle of sustainability in problemsolving 2 of 22 strategies 45 combating food waste is included in the un 2030 agenda for sustainable development according to goal 12 responsible consumption and production by the end of the decade global food waste must be halved at retail and consumer levels and food loss must be reduced 6 reducing food waste would also be relevant for reaching other goals of the agenda 1 no poverty 2 zero hunger 8 decent work and economic growth 13 climate action or 15 life on land 6 however some of the food waste combat desiderata were put on standby in the last two years due to the covid19 crisis stayathome and remoteworking strategies to prevent the spread of covid19 made many of us consume more than what was needed 7 8 9 we witnessed dramatic changes in food consumption habits due to the covid19 lifestyle and psychological stress that influenced the generation of food waste along the supply chain 1011 directive 2018851 on waste highlights the need for better waste management at the eu level the rational use of natural resources promoting a circular economic model and improving the energy sector 12 section of the preamble of the directive provides guidelines for preventing and reducing food waste aligned with the 2030 agenda the eu aims to reduce food waste by 30 before 2025 and 50 by 2030 these goals require the member states to take prevention and reduction measures additionally the directive draws attention to the responsibility of member states to develop a favorable framework for collecting and redistributing unsold food and increasing awareness among consumers about the distinction between useby and bestbefore dates 12 at the national level the romanian legislation article 1 of law no 2172016 for the reduction of food waste 13 defines food waste as the situation in which food leaves the circuit of human consumption due to degradation and is destroyed according to the legislation in force identifying the leading causes of food waste is the ground zero to develop effective solutions to reduce its impact however this task is rather challenging as economic social and political factors are intertwined in maintaining an economic model focused on constant growth and competition which often fails to consider the natural environment and our pressure on it researchers and activists highlight the need to address social and environmental concerns within capitalist system thinking if we aim to downscale prevalent problems such as inequality poverty climate change pollution or the depletion of natural resources 1415 the distribution of the economic benefits of capitalism is characterized by a high degree of inequality both between and within states 16 this study identifies the most relevant causes of food waste by revealing the perceptions of key stakeholders in the food waste sector based in clujnapoca romania engaging with relevant local actors in the food waste area offers valuable information on their perception of this phenomenon and informs the readers about the specificities of food waste causes in the romanian context the study provides a bottomup perspective of food waste mitigation and can fill in some of the literature gaps on food waste in the cases of romania and in particular clujnapoca we consider that the city of clujnapoca represents a suitable case study for analyzing the causes of food waste being one of the most populous cities in romania and under continuous development 17 these aspects justify the stringent need for effective waste management and pollution mitigation strategies 1819 moreover the municipality has attempted to become an example of innovation good governance and civil participation 1720 aspects that would facilitate the implementation of future measures against food waste for the purpose of the current study we invited members of the local public administration the business sector the nongovernmental sector and consumers as described in the methodology section we carried out thematic workshops with each of the four groups the communitybased system dynamics method is used to better understand the complex issues faced by a community cbsd is a participatory research method with a relevant educational dimension based on the input of members of a specific community it helps to map out and visualize the role that a particular problem has within the system of factors with which it interacts as well as the nature of these interactions thematic modeling sessions about food waste causes were intended to increase the awareness and understanding of the problem thus facilitating the identification of possible solutions to fight food waste 2122 on the topic of food waste as well as the direct causes of food waste no other study has used the qualitative approach of system thinking to reveal the stakeholders perceptions about the causes of the problem we offer a more comprehensive understanding of the determinants of food waste compared to other studies including a diverse panel of stakeholders more precisely other participatory approaches focused on determining the direct drivers of food waste mainly from the perspective of the producer or the consumer furthermore this approach has the merit of highlighting the similarities and differences of perceptions between the actors while providing a safe space in which each group can freely express their views and opinions the findings can be valued as a validation test for the fitness of current and future strategies aiming to strengthen the efforts to reduce food waste the level of engagement of stakeholders in reducing food waste can be predicted based on their perception of the problem qualitative research can offer information on areas where action is needed most to reduce and combat food waste and predict the success of such measures as stakeholders are responsible for their development dissemination or implementation therefore the objective of the study is to identify the causes of food waste in clujnapoca using a cbsd approach the rest of the paper is organized as follows the section from foodtofood waste in romania describes the socioeconomic conditions and the role of agriculture in romania followed by data regarding food waste trends and the wastes impact this section ends with a brief analysis of the legislation on food waste in romania the methodology section includes a short presentation of the research area of cluj a description of the stakeholders included in the study and the way the modeling sessionsworkshops have been organized the results are presented in section 4 reporting the causes of food waste identified during the workshops the loop diagram and the main findings the analysis and interpretation of the results follow the final remarks are included in the last section from foodtofood waste in romania the romanian food sector and the overall socioeconomic context poverty remains a socioeconomic challenge in romania which is expected to aggravate due to the current global economic crisis and the postpandemic context in 2021 344 of romanians were at risk of poverty or social exclusion ranking the worst among the eu states 28 in the same year romanians spend more than a quarter of their income on food the highest percentage among the eu states 29 agriculture is one of the key economic areas in romania it is estimated that in 2017 more than half of the total territory of romania represented agricultural land 3031 however working in the agricultural sector has become less appealing due to low wages especially for young people the number of people working in the agricultural field has decreased from 28 in 2008 to 20 in 2020 32 reducing food waste could improve the standard of living of many households in the country and the use of resources in agriculture although it can be challenging to measure the increase in turnover that farms would have if their products did not end up as waste the opportunity cost of growing crops and animals that generate no income is substantial land area water fertilizers food medicine machinery and human resources invested in food that is wasted could be used for other purposes extent intensity and consequences of food waste providing precise and reliable data on the overall extent of food waste is rather difficult due to inconsistencies in defining the problem the diversity of actors and the general complexity of the food chain 3334 for romania the lack of official food waste data is an additional challenge although the food waste data from other european countries are present in different eu statistics romania is not part of them 35 at the global level the world food programme estimates that approximately 13 of the food produced for human consumption is wasted which is worth around usd 1 trillion every year 36 in 2019 931 million tons of food waste were produced globally with households generating 61 of it 37 all this food could feed 2 billion people more than twice the number of undernourished people across the globe 36 according to the first largescale analysis of the eus food waste 38 88 million tons of food were lost or wasted annually costing around eur 143 billion and accounting for 20 of the production of the economic block however new data were collected using the common methodology of the eu for monitoring food waste 39 eurostat estimates that 57 million tons of food were wasted in the eu in 2020 worth around eur 130 billion 40 additionally 10 of the food that reached eu consumers became waste households were responsible for 55 of the waste followed by processing and manufacturing production restaurantsfood services and retail 40 preventing food waste could alleviate the suffering of the 362 million people in the eu who cannot afford a quality meal every second day 41 studies revealed that in romania more than 22 million tons of food are wasted annually or approximately 25 of the total food waste produced at the union level 4243 a study 44 that analyzed the food waste trends in romania the republic of moldova and macedonia concluded that 83 of the romanian participants threw away food at the same time fruits vegetables and bread were the top three categories of foods that turned into waste at the household level as mentioned previously the 2020 analysis of the food waste produced in the eu states does not include any data on the situation in romania 40 however the food waste index reports of unep show that romanian households were responsible for 13 million tons of food waste the confidence in the accuracy of the data is very low 37 environmental concerns such as climate change and pollution have also increased the relevance of tackling food waste 4546 the extent of the problem at the global level is rather severe and if food loss and waste were a country it would be the third biggest source of greenhouse gas emissions responsible for 810 of total emissions 37 in europe agriculture accounts for approximately 10 of greenhouse gas emissions 47 burning fossil fuels releases ghg emissions during all stages of the foods lifecycle from production to food processing transportation storage and cooking the food waste phenomenon adds an additional dimension to the environmental burden of the food system as decomposing unconsumed food produces relevant amounts of methane a highly potent ghg 48 49 50 if we consider all the stages during which ghgs are emitted production is the highest contributor accounting for around 73 of the impact thus proactive approaches are highly needed and better waste management would only reduce 6 of the global warming potential of food waste 49 however the negative environmental impact of agriculture and subsequently food waste goes well beyond the concerns regarding ghg emissions and climate change land freshwater and fossil energy are needed for agricultural production and animal farming at the global level 23 of the total cropland area and 24 of the water for agriculture is used to produce food that will end up as waste 51 adding to the burden on our food systems in addition pesticides and fertilizers are wellknown sources of water and soil pollution 52 food waste accounts for 23 of the fertilizers used globally 51 moreover 12 of the diffuse nitrogen water pollution from the eus agriculture can be attributed to food waste increasing the eutrophication of water bodies and posing serious environmental consequences for the affected ecosystems 53 although measures are taken to address all these issues being more aware of our food waste represents an opportunity to reduce the environmental impact of agriculture 54 and to better adapt our food system to future growing demands 55 addressing food waste in romania as part of the eu romania took some steps to address the issue of food waste an example is law no 2172016 on the reduction of food waste 13 which stipulates that reducing food waste is a relevant objective for all economic operators in the agrifood sector operators must take various measures to prevent food waste such as discounting or donating food products that are about to reach the sellby date law no 2172016 has the merits of defining and acknowledging the problem of food waste and presenting the hierarchy of solutions for combating it however the law has been perceived as rather strict and rigid especially in facilitating food donation currently economic operators can donate nonperishable foods only during the last ten days before the sellby date of a product perishable foods and animalorigin products are not allowed to be donated 1356 this limitation is problematic when retailers and distributors become aware of their overstock sometimes long before the tenday framework since the law does not allow food donations before the last ten days of its shelf life economic operators have no choice but to either provide storage for that stock until it can be donated or discard it to waste management companies both options are disadvantageous offering storage for overstocks occupies valuable space and increases the use of energy for products that will bring no revenue at the same time discarding perfectly good products goes against the commitments to reducing food waste another legislative project on reducing food waste passed the romanian senate in october 2022 the project proposes some relevant measures such as developing a national online platform to report food waste data developing a national strategy for food waste prevention and reduction increasing responsibilities for public authorities and economic operators and simplifying the food donation system 42 according to the romanian national institute of statistics 34 receiving operators such as food banks are working to reduce food waste in romania 20 of them joining the efforts in 2021 31 materials and methods analyzing the food waste phenomenon in the case of clujnapoca romania can help develop an indepth view of the problem its causes and consequences and its specificities within the local community 5758 while the findings may not be fully applicable to an international context because of the qualitative approach 59 they can fill in the missing data on the food waste problem in romania and highlight the need for further qualitative and quantitative investigations exploring the topic through this method provides the backbone for an interpretation and analysis of the stakeholders perceptions regarding the food waste causes moreover a case study conceptualization and analysis helps to reveal the nexus between the environmental and social dimensions of food waste as a crosscutting issue 60 the analysis of a complex and multicausal problem such as food waste requires an understanding of the factors that influence it and the relations between them the system dynamics approach focuses on the simulation and modeling of the causal relationships that are specific to a problem and its context 2261 group modeling is one of the methods used for system dynamics which can ensure that relevant individuals are directly involved 21 cbsd proposes the same type of analysis designed to encourage system thinking through modeling by involving community members in the process 21 cbsd is a qualitative approach in which the firsthand experience of community members represents the pillars of conceptualization during the modeling sessions it provides a valuable setting for understanding and analyzing the problem facilitates exchanging viewpoints and finds solutions moreover it creates a harmonized perception of the topic which can be crucial for the future success of strategies and policies developed in the field 62 for this study we analyzed the causes of food waste with the help of four categories of food stakeholders from the local community of clujnapoca these are consumers public administration food waste businesses and the ngo sector study area cluj county cluj county is located in the northwest of romania and it is the center of the historical region of transylvania the countys surface is 6674 km 2 with a population of 711630 inhabitants 31 the county municipality the city of clujnapoca is one of romanias most important university centers the county generates around 335000 tons of solid municipal waste annually 63 currently this waste is stored in inappropriate spaces especially in illegal landfills 63 the most striking case was in pata rât the illegal landfill that became home to around 1500 people evacuated from clujnapoca after the year 2000 64 in 2018 the european court of justice ruled that romania had breached directive 199931ec 65 as it did not close its illegal landfills including pata rât 66 after intensive pressures from environmental and human rights lobby groups the landfill was closed and the area rehabilitated in 2019 67 selection of stakeholders and interviews development in the present study four relevant categories of stakeholders were considered consumers public administration ngo and a startup business involved in the reduction of food waste two ngos were involved because they are active in food collection and redistribution awarenessraising the creation of educational campaigns and materials regarding food waste the startup business refers to a company that develops technological solutions for reducing food waste in commercial kitchens by providing means of monitoring measuring and reporting food waste a commercial kitchen is a cooking area that has been designed for food production mainly for the hospitality industry we considered that including the public and civil society sectors was important for obtaining a proper image of the perceptions of food waste in clujnapoca after identifying our interest groups and organizations the facilitator of the group used social media platforms to reach out to potential participants in each category presenting the research topic its objectives and the methods participation was voluntary and there were no incentives offered those who wanted to participate in the study expressed their informed consent after the preliminary discussions and at the beginning of the modeling sessions although the list of potential food waste stakeholders is rather extensive we decided to focus on four of the most relevant groups with an important impact on the development and implementation of strategies and policies we consider that effective food waste solutions will depend on the partnership between public private and civil society this study can be considered a preliminary step in this direction five group modeling sessions were held with people that expressed their interest in participating in the study eight consumers one representative of the local public administration four employees of a startup focused on food waste reduction in commercial kitchens and two separate sessions with two local ngo leaders although we acknowledge that including more members in some of the groups would have been beneficial time and network limitations generated the structure of the sessions the script used for the modeling sessions followed a similar structure for all groups still slight modifications were made on the spot depending on how the group members interacted and their interests in the topic the time of each session was between 1 h and 15 h the beginning of the session was dedicated to a brief presentation of the research topic the research purpose and the methodology used all groups were informed about the other categories of stakeholders participating in the study the general rules for the workshop were established 1 participants were encouraged to speak freely 2 to respect the opinions of other participants and to express their disapproval in a polite manner and 3 participants were informed that their identities would not be disclosed and that they could leave the workshop at any time due to time limitations and the fact that the members of each group knew each other in advance we decided not to dedicate any time to group exercises or energizers at the beginning of the sessions we introduced the participants to systemic thinking using two examples of loop diagrams one concerning population increasedecrease 68 and another concerning cardiovascular disease 69 we informed the participants that a similar loop diagram will be developed as the outcome of the sessions using a projector the operational definition of food waste was presented to the groups food waste is understood as the situation in which food leaves human consumption due to degradation and is destroyed 13 a brief discussion took place with the members of the business group regarding food waste exceptions for example they considered that food meant for human consumption that is given to animals or transformed into biomass energy should not be considered as waste additionally a member of the ngo 2 group referred to the natural resources that are also lost whenever food waste occurs and a member of the administration group argued that the definition of food waste should focus on the waste that occurs from retailer to consumer and exclude productionprocessing losses after this part of the session each member of the group was asked to list three causes of food waste that they considered to be the most relevant 70 we considered it to be beneficial to increase the level of complexity during the following steps for the groups with more participants we used the mentimetercom software to gather the answers ensuring that each person was able to provide their input without being influenced by other participants the facilitator used the software to distribute the openended question to which the participants anonymously responded using their phones after connecting through a unique code the software then compiled all the answers into a word cloud which was then projected on the screen the verbally given answers or the results generated by the software in a word cloud were placed on a large sheet of paper or a whiteboard when it was available the groups with multiple members were encouraged to observe when some variables appeared more than once showing that numerous people voted for them as significant causes of food waste the facilitator thematically grouped the variables listed at this point in each session interestingly all the groups focused on the variables related to an individualhousehold retailer and horeca food waste while excluding factors related to productionprocessing the participants were then asked to add other variables on the board that are direct or indirect causes of food waste in order to stimulate the discussion and help the groups to generate new ideas the facilitator suggested how the participants could identify new variables asking some additional questions such as what leads to consumerism what is the influence of variable x on other factorsvariables these questions encouraged the participants to consider new factors and reflect on the indirect causes of food waste 71 the purpose was to build a comprehensive image of the causes of food waste to illustrate at least in part the complexity of the problem to create a safe space in which every participant could feel comfortable taking the floor the facilitator proposed to do a round of passing the pen from one individual to another this ensured that everyone had the chance to speak after a simplifiedcodified version of the idea was agreed upon with the participants the facilitator added a new variable to the whiteboard next the connections between that new variable and others were drawn nonetheless whenever the discussion evolved organically the facilitator did not interfere and passing the pen was resumed after the dialogue had stopped additionally whenever the group had difficulties generating new ideas the facilitator redirected them to elements from the board that had not been discussed so far as the exercise progressed we observed that the group participants became more comfortable adding variables and creating links between them it was interesting that right at the end of the brainstorming the business group started to identify some variables that they suggested could be relevant for all other variables in the next part of the session the facilitator explained to the groups how reinforcement and balance causal relationships work using the population increasedecrease example from the beginning of the exercise 68 the participants were encouraged to focus on the links identified up to this point and assess how the variables influence each other to simplify the process the facilitator eliminated the negations attached to the variables whenever possible the business group identified that some variables for example economic growth or social media could be considered as both reinforcing and balancing for other variables the workshop ended after each group was asked to take a last look at the board and add anything missing finally the facilitator thanked the members for their participation and informed them of the future steps of the study results food waste causes that emerged from the cbsd approach the variables discussed during the sessions can be seen in table 1 some of them have been standardized in the cases in which similar ideas but with different names were presented in multiple groups however differences in the interpretation of the same variable within different groups are illustrated in table 1 table 1 list of variables discussed during the modeling sessions food waste causes groups 1 explanation based on participants understanding accessibility of food a n2 easy access to food resources can diminish the importance that a community attributes to food a reference to precooked meals animal damage c destruction of crops by wild animals behavior change n1 how individualscommunities can adapt how they act in a given context buffets waste b food waste generated by buffets refers to both overproduction and waste that consumers generate by overfilling their plates business competitiveness n1 having an advantage over competitors in the market being preferred by consumers and obtaining good profits capitalist global economic system a n2 worldwide economic system that promotes continuous growth by encouraging competition coercive measures a n2 obligationsrestrictions imposed by the public authorities meant to correct a specific issue in a community collection points facilities for compost a c infrastructure needed to deal with biodegradable waste a as a sensitive issue in the urban area communication between household members b regarding food shopping wanted meals and distributions of tasks regarding buyingcooking can reduce instances of overbuyingovercooking understanding the difference between terms and their meaning as reflected in legislation public awareness and behavior economic crises n1 a period in which the economy deteriorates significantly characterized by inflation unemployment stock market drop and lack of investment education b a n1 n2 c acquiring knowledge in various fields b education was judged to have an impact on the entire food waste system n1 formal educationlargescale education n2 formal education egocentrism n2 tendency to focus on the wellbeing of oneself regardless of the negative consequences that their behavior might have on the rest of the societynatural environment environmental food waste awareness b a n1 n2 c knowledgeinterest regarding the natural environment its vulnerabilities and how it must be protected knowledge of the extent impact and solutions to food waste fast pace of living b daytoday disruptions of the everyday routine unanticipated change of plans it can have a negative impact on how individualshouseholds plan their meals fear n1 the emotional response that individualscommunities have in times of crisis which has an impact on their behavior food collection and redistribution capacity n1 the ability of a society to distribute its food resources efficiently reduce food waste and ensure the satisfaction of the needs of multiple categories of actors food preparation c how raw ingredients are cooked both for households and restaurants food quality c it was perceived as a way to differentiate between various items food safety c it was linked to quality with an impact on how consumers perceive expiration dates geopolitical crises n1 political instabilityconflictswars governmental intervention a n1 n2 measures taken by the public administration to solve a specific issue historical hardships n1 past negative experiences of a community that impact their currentfuture behavior holiday celebration b celebrating various events with familyfriends preparing festive meals on those occasions table 1 cont food waste causes groups 1 explanation based on participants understanding horecaretails overstock b the tendency of businesses to purchase large quantities of food higher than the consumer demand horeca overproduction b the tendency of organizations to cook excessive amounts of dishes higher than the consumer demand household overproduction b c the tendency of individualshouseholds to cook more food than needed human error n1 reference to human error associated with labelingpackagingtransporting food products which will make them improper for retail sale human resource capacity n1 c n1 reference to the characteristics of the human resource which impact their efficiency in a particular domain c capacity of farmers to protect their crops from animal damage humans being connected to their food n2 the capacity of humans to understand the real value of food individualhousehold overbuyingoverstocking b n1 c the tendency of individuals to purchase more food products than they need for consumption n1 usually in response to previous negative experiences with food periods of hardship or food scarcity influence of religion n1 the ability of religious organizations to influence the valuesbehaviors that a specific society has during a determined period influencers b public figures with extensive outreach this can refer to both people who raise awareness regarding food wasteenvironmentalism but also people who promote consumerism infrastructure c reference to composting collection points and facilities or to the infrastructure needed to protect crops from wild animals interest in reducing food waste b the desirewillingness to take measures against food waste investmentsubsidies for local eco products n2 the allocation of material resources and knowhow to local smallscale farmers in an efficient manner legislation n1 the process of making or enacting laws local resilience n2 the ability of local communities to adapt when fluctuations in the global economy occur the ability of a community to rely on its resources market offer a the variety of food products that can be found on the market marketing b the process of promoting certain food products can refer to both the promotion of ugly or perfect products massproduction n1 the efficient and standardized industrial food system which produces large quantities of less expensive food mealshopping planning b anticipating the food needs of an individualhousehold adapt the purchased amount modern family dynamic a the dissolution of gender stereotypes regarding mens and womens roles in a household the increased focus of women on developing professional careers the excessive production of food that surpasses demand proper storage c adapting storage conditions according to the specificity of a particular food product prototype food products n1 food products that a company develops to expand its offer and gain a competitive advantage can be disliked by consumers and not purchased public campaign a a method through which public authorities can increase interestawareness in a particular topic resistance to change n1 the tendency of individualscommunities to uphold past established values norms and behaviors coupled with a negative reaction to novelty retailer overstock n1 purchasing excessive amounts of food from producers which is not matched by consumer demand income b c an increase in the financial means available to individualshouseholds impacts the possibility of purchasing food romanian socialcultural factors b cultural and historical characteristics that define how romanians relate to food schools a institution to deliver formallargescale education selfrespect n2 treating the physical and mental state with care social media b an online platform on which various people organizations can disseminate information with a large reach it can have a positive and negative impact on reducing food waste depending on the type of content solutioninnovation n1 the development of new strategies to solve a specific problem strategies to deal with excess food b process of anticipating food waste and preparing solutions technologicalbased planning tools b software apps and devices which can help individuals and retailers keep track of their food resources food needs and characteristics of the items time management a c increased interest in having more free time and spending it on pleasant activities transition from materialism to postmaterialism a change in individualsocial values when a level of economic prosperity is achieved focus on increasing life quality and selfdevelopment the tendency of consumers to avoid purchasingconsuming food products which do not comply with strict cosmetic requirements impacts the behavior of retailers and producers understanding of the food system n2 awareness and knowledge of the role of the food chain actors and their contribution to food waste production the perceived risk of food waste a tendency to regard biodegradable waste as less problematic than other types of waste such as plastic mainly related to the amount of time that it takes for each type of waste to decompose waste management n2 the largescale problem of our modern society in which a series of actors are involved 1 alocal public administration bbusiness sector on food waste reduction cconsumers n1ngo representative 1 n2ngo representative 2 loop diagram the outcome of each modeling session was a loop diagram of the main food waste determinants during the sessions the causes of food waste and the relations between them were identified the balancing and reinforcing loops were determined in the aftermath of the meetings the diagrams for each stakeholder group are included in appendix a the final loop diagram includes the variables mentioned during more than one session the relations between the variables were established based on the group modeling sessions to better visualize each of the reinforcing and balancing loops of figure 1 we included table 2 which presents all the constitutive elements of the identified reinforcing and balancing loops reinforcing loops balancing loops r1 environmentalfood waste awareness government intervention understanding the food system education b1 education income individualhousehold overbuyingoverstocking r2 governmental intervention education b2 education understanding the food system governmental intervention environmentalfood waste awareness individualhousehold overbuyingoverstocking r3 governmental intervention understanding the food system education b3 education understanding the food system food waste r4 consumerism retailer overstock producer overproductionwaste b4 education understanding the food system food waste distinction between best before vs sellby dates r5 accessibility of food consumerism ugly food rejection food waste b5 environmentalfood waste awareness ugly food rejection producer overproductionwaste r6 education income household overproductionlarge portions modern lifestyle math of the meetings the diagrams for each stakeholder group are included in appendix a the final loop diagram includes the variables mentioned during more than one session the relations between the variables were established based on the group modeling sessions to better visualize each of the reinforcing and balancing loops of figure 1 we included table 2 which presents all the constitutive elements of the identified reinforcing and balancing loops discussion stakeholders perceptions of the determinants of food waste were identified based on the modeling sessions that produced the loop diagrams the results consist of a comprehensive list of factors which impact the generation of food waste and the diagrams highlight the interactions between them although many of the causes identified during our exercises are mentioned in the literature on the topic 92370 our aim was to provide an aggregated image of the main causes of food waste and the actors involved moreover it highlights the specificities of the romanian context derived from their historical social political and economic background some important variable categories can be derived from the answers provided by the groups during the modeling sessions an important theme is related to the educational dimension multiple groups considered that a lack of education and awareness of food waste and the environment directly impacts the scaling of the problem in the same category we can include the awareness of different expiration dates or a proper understanding of the food system the need for better consumer awareness of the different expiration dates of food products has been identified in other studies and is included in the eus policies 1272 furthermore consumers cannot properly assess the value of food due to a lack of understanding of the food system and its processes 70 the evolution of the relationship between humans and food is another important cause of food waste at the individual level the lack of a connection between people and their food coupled with consumerist practices 73 and ugly food rejection 74 marks the decrease in the overall value that people attribute to food the rise in income and the widespread availability of food as a result of the capitalistic competitive market are some of the reasons for these behaviors consumerism abundance and low food prices diminish the incentives to reduce overbuying 70 additionally this economic reality created a setup where modern people can shift their interest in food since we can now buy precooked meals or use delivery services spending time doing pleasant activities is considered more important while modern socioeconomic factors impact consumer behavior historical aspects are also relevant to the romanian case periods of historical hardship experienced by society remain impactful on how people relate to food if we consider the tendency to overbuy stock food or prepare large meals changing behaviors can be difficult especially if communities are resistant to change furthermore the overall socioeconomic context and consumers demand and expectations have an impact on the behavior of other relevant actors in the food chain which contribute to food waste 75 76 77 moving on we can argue that the stakeholders perceptions illustrate the complexity of the food waste phenomenon the groups identified various relevant actors from individualshouseholds to public administration retailers horeca producers and influencers in addition the groups could observe the relations between these actors for example governmental intervention can impact how producers and retailers operate through legislation coercive measures or the responsible redistribution of financial resources toward local farmers another example is the interaction between individuals retailers and producers the consumers demand for a wide variety of products that are easily accessible is a direct cause of retailer overstock this factor has a further impact on overproduction considering the same actors the rejection of ugly food at the consumer level has a direct impact on the food waste produced by both retailers and producers however since 2009 there have been no legislative requirements regarding the appearance of food 78 79 80 economic social and political factors have been identified as relevant causes of food waste economic factors such as income or the capitalist global economic system have an impact on the behavior of consumers as well as on that of producers retailers and horeca who are in a constant competition on the market to match customers expectations social factors especially those related to the educational sphere play a relevant role in the food waste system with direct and indirect impacts on the behavior of all actors an interesting observation lies in the dual relationship between the educational and the political variables increasing public awareness regarding the food waste problem is a powerful incentive for government action at the same time public intervention through campaigns and policies can improve the understanding of food waste among citizens in fact many studies indicate that education and awareness campaigns can reduce food waste 8182 however as signaled by the participants in our study scaling up these efforts is necessary to achieve widespread behavioral and systemic changes public authorities have the capacityresponsibility to signal the relevance of combating food waste and provide largescale formal education focused on the food system and its environmental consequences furthermore the development and implementation of legislative measures has direct consequences for other actors the consumer and administration groups mentioned the need for collecting pointsfacilities for compost although such a measure does not directly impact food waste reduction and constitutes a reactive measure to the problem it highlights the need for better waste management which is very stringent in romania composting has economic benefits and reduces the negative environmental impact of waste 83 from a practical perspective the study brought to the fore the views of various stakeholders in the food waste sector of clujnapoca which could inform policymaking to design bottomup food waste reduction strategies and create bridges between experts practitioners policymakers and citizens the participation of public administration and startup business representatives in the interviews can ease for example the identification of organizational weaknesses that may play a role in the occurrence of food waste feedback from all these stakeholder categories facilitates the development and implementation of measures to combat food waste 84 providing guidelines for strategic and cohesive planning which considers the interaction between various food wasterelated variables furthermore regardless of the stakeholder category the findings show that we should all be more aware and responsible for addressing food waste prevention must be prioritized amongst food waste management strategies in summary this study illustrates the complexity of the food waste phenomenon and the need for a further elaboration of creative solutions that consider the diversity of the actors involved it also highlights the importance of educational and informational campaigns and public administration interventions in increasing the level of awareness and reaction capacity of consumers producers retailers and horeca in combating food waste conclusions the current study focused on the main determinants of food waste identified using the cbds participatory approach the cbsd was used to develop thematic modeling sessions with five groups the findings illustrated that food waste could be regarded as a wicked problem its complexity implications on economic social political and environmental spheres the number of actors involved and the multilevel dynamic between local national and international factors should be considered when developing food waste management solutions several theoretical contributions managerial implications and future research directions can be derived from the present study considering the theoretical contribution of the study we highlight that there are different evaluative tools for decisionmaking in waste management for example the environmental impact assessment risk assessment or system thinking although system dynamics was applied in different areas related to waste management participatory system dynamics modelling such as cbsd is less present in the waste literature the research highlighted the interactions between the causal variables that helped to create a clearer image on the dynamism of the food waste system thus the existence of reinforcing loops and balancing feedback loops was outlined the reinforcing loops amplified the dynamic system patterns of behavior showing that solutions to counteract food waste should mainly target their constituent variables in other words sustainable food waste solutions must attempt to break the vicious circle of reinforcing food waste factors from a managerial perspective the reduction of food waste is beneficial at both the individual and the business levels the findings revealed that the participants considered the lack of education and awareness of food waste as having direct amplifying impacts on food waste generation therefore the strategies to combat food waste should support education and information campaigns that can mitigate food waste for example they can reveal the negative social economic and environmental impacts of egocentrism overconsumption or overstocking understanding the causes of food waste could stimulate prevention or minimization behaviors regarding food waste both in private life and in companies another intervention point derived from identified food waste causes is the development of compost infrastructure that can reduce the environmental burden of landfilling food waste while generating income and organic fertilizer therefore the public administration should create a network of composting points that are nearby userfriendly and safe for community needs additionally because participants named ugly food rejection as a food waste cause retailers should find ways to increase their acceptance for example through discounting while farmers could direct them to processors where appearance is not relevant the results should be considered in the context of several limitations the small number of participants restricted the generation of a higher number of food waste causes including larger and more diverse stakeholder groups in further research can reflect the perspectives of all parties involved in the food system for example producers retailers and waste management companies can provide valuable information on the causes of food waste or the limitations each group has in addressing it moreover carrying out common sessions with various stakeholder groups can be an opportunity to spark debate and ensure the flow of ideas between parties another possible improvement is a higher number of facilitators responsible for mediating the sessions and elaborating the loop diagram in this way any possible personal bias can be minimized finally fragmented and ineffective decisionmaking pathdependency and the lack of proper communication and engagement between various actors and institutions in the field of waste management remain serious challenges in romania that is why engaging local communities and stakeholders in participatory research remains crucial to policymaking in the field of food waste data availability statement data are available upon request from the first author informed consent statement informed consent was obtained from all participants involved in the study appendix a all the loop diagrams elaborated during the group modeling sessions can be observed in this section they are illustrated in the chronological order in which the workshops took place

this study identifies the most relevant causes of food waste according to the perceptions of key stakeholders in clujnapoca romania communitybased system dynamics cbsd a qualitative approach was used to reveal the determinants of food waste cbsd was intended to encourage the system thinking of participants in the field of food waste consequently cbsd helped us map and visualize the role of each identified cause in the system and the nature of their interactions for the present study four categories of stakeholders were involved consumers public administration food waste business and the ngo sector involved in food waste reduction the result of each modeling session was a loop diagram of the main food waste determinants a common perception reflected within each stakeholder group was that food waste could be minimized through upstream actions the participants highlighted proenvironmental knowledge awareness and values as the prerequisites for fighting food waste it was found that the lack of education and awareness of food waste directly impacted food waste generation in addition the role of education was underlined by participants as a contributor to changing individual and household practices such as overbuying the lack of connection between consumers and the food production process coupled with consumerist practices and the rejection of ugly food contributed to the decrease in the overall value people attributed to food governmental intervention through legislation was indicated by the cbsd participants as being key to increasing societal awareness and shaping the behavior of food chain actors we concluded that food waste is a wicked problem and the interlocking of the economic social political and environmental spheres and the multitude of stakeholders interests values and perceptions should be considered in designing sustainable solutions to combat food waste finally this research testifies to the importance of engaging with diverse panels of stakeholders who through the multitude of opinions and perspectives on the causes of food waste can further create knowledge about the most appropriate ways to combat the food waste phenomenon

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i introduction the outbreak of the covid19 pandemic in late 2019 unleashed unprecedented challenges that reverberated throughout the global education landscape 1 as educational institutions worldwide grappled with sudden closures shifting to remote learning and adapting to everchanging health guidelines the pandemics impact on students became a subject of paramount concern 2 among the diverse student populations affected the experiences and academic performance of black asian and minority ethnic students emerged as a focal point for research and policy discussions 3 understanding the unique challenges faced by bame students during the covid19 pandemic is essential not only from a social justice perspective but also for the broader goal of promoting equitable and inclusive education systems 4 historically bame students have encountered disparities in access to education achievement gaps and systemic barriers that have long persisted in educational institutions 5 the covid19 pandemic has highlighted and exacerbated preexisting disparities and inequalities faced by individuals from bame backgrounds 6 our literature review is undertaken with the recognition that the covid19 pandemic has not affected all students equally bame students often contend with a complex interplay of factors including socioeconomic inequalities digital access disparities mental health challenges and the disproportionate impact of the virus on their communities consequently examining the existing body of literature regarding the pandemics impact on the academic performance and study experiences of bame students is crucial for several reasons its crucial for understanding their pandemicrelated experiences informing targeted support addressing research gaps and promoting equitable education ultimately this review aims to contribute to inclusive policies and resilient education systems this study aims to investigate the impact of covid19 on the study experiences and degree awarding gap of bame students focusing on those enrolled in open university level 1 computing modules as a case study by examining the existing literature and considering the implications for student attainment this research seeks to understand the specific challenges faced by bame students and explore potential opportunities to mitigate these inequalities the degree awarding gap which refers to disparities in academic outcomes between students from white ethnic backgrounds and those from bame backgrounds has been a persistent issue in higher education 7 8 9 10 previous research revealed significant disparities in the proportion of students achieving top degree classifications notably bame students at the open university were found to be 20 less likely to achieve excellent grades 11 furthermore the covid19 pandemic has disproportionately affected bame communities in terms of health risks 1213 economic disadvantage 81415 housing instability 12 employment difficulties and mental health impacts 16 this study employs a mixedmethods approach combining quantitative data analysis and qualitative insights from focus groups with tutors and key stakeholders the quantitative analysis examines the performance and progression patterns of bame students in level 1 computing modules utilizing data from the open university covid19 dashboard and previous research at the ou 11 the focus groups provide valuable insights into the lived experiences of bame students during the pandemic addressing factors such as economic disadvantage the digital divide housing conditions employment and the impact of racism and discrimination 8 12 13 14 15 16 this research has practical implications for educators and institutions seeking to support and enhance the academic experiences of bame students 17 by understanding the specific challenges faced by bame students and addressing the structural factors contributing to inequalities targeted interventions and support strategies can be developed to promote equality and inclusivity in higher education 13 the study also contributes to the existing literature by providing a comprehensive understanding of the impact of covid19 on bame students study experiences and performance within the context of open university level 1 computing modules 11 a background and literature review the degree awarding gap between students from bame backgrounds and white students has been a longstanding issue in the uk while this disparity existed before the covid19 pandemic the outbreak has exacerbated and exposed the preexisting ethnic inequalities in various domains including health employment and education this section provides an overview of the existing literature on the degree awarding gap and its implications for student attainment it also explores the disproportionate impact of covid19 on bame individuals and communities emphasizing the higher risks of exposure to the virus and the resulting poorer health outcomes experienced by bame populations additionally this section discusses the multifaceted social and economic factors contributing to these disparities such as economic disadvantage the digital divide housing conditions employment disparities racism discrimination and mental health issues the covid19 pandemic worsened existing disparities in degree attainment between bame and white students 6 the degree awarding gap which existed prior to the pandemic remains a significant issue 89 bame individuals face higher health risks from covid19 due to preexisting structural conditions not solely genetic factors 1214 economic disadvantage the digital divide housing employment disparities racism discrimination and mental health contribute to the disproportionate impact of covid19 on bame individuals 81213 universities including the open university have a crucial role in mitigating these inequalities by addressing the digital divide and actively promoting inclusivity 13 this research project focuses on investigating the impact of covid19 on the academic performance and study experiences of bame students at the open university aligning with institutional priorities of equality diversity and inclusion 6 b opportunities to mitigate inequalities universities including the open university can play a vital role in addressing and mitigating inequalities datadriven approaches early interventions and targeted support are key in addressing the specific needs of bame students 16 online learning environments offer opportunities to create equitable experiences and challenge stereotypes 13 inclusive curriculum content and supportive learning environments foster a sense of belonging for bame students 16 by embracing these opportunities higher education institutions can promote equality and diversity c unique aspects of the study the open universitys unique context as a distance learning institution is crucial in understanding the experiences of bame students during and beyond the covid19 pandemic bame students at the open university have distinct experiences as their studies are integrated with their everyday lives as homebased learners this differs from the experiences of students at traditional brick universities additionally exploring the experiences of students from brick universities who transitioned to distance learning during the pandemic provides valuable insights into the experiences of bame students in different educational settings d aims objectives and institutional priorities the aims of the research project are to investigate the impact of covid19 on bame students academic performance and study experiences at the open university specifically focusing on computing modules at the core level the objectives include gaining a comprehensive understanding of the factors contributing to the degree awarding gap assessing the impact of covid19 on bame students academic achievements and study experiences developing predictive models to forecast the longterm effects of covid19 on bame students and sharing research findings and good practices within the field of computing and communications the project aligns with the institutional priorities of promoting equality diversity and inclusion improving the learning experience of all students and understanding the impact of the pandemic on teaching and learning the themes identified in the literature review form the basis for our research objectives and justify the need for this approach  ro1 understanding the degree awarding gap given the persistent disparities in degree attainment discussed in the literature our first objective is to examine how the degree awarding gap manifests in the context of open university level 1 computing modules particularly among bame students  ro2 assessing the impact of covid19 the literature review highlights the disproportionate impact of covid19 on bame communities we aim to assess how this impact specifically affects bame students academic achievements and study experiences within our chosen context  ro3 identifying contributing factors drawing from the social and economic factors identified in the literature we aim to identify which of these factors are most salient in influencing the educational experiences of bame students during and beyond the pandemic  ro4 predictive modeling for longterm effects given the potential longterm repercussions of the pandemic on education our research seeks ultimately to develop predictive models that forecast how the experiences of bame students may evolve in the postpandemic era ii methodology to address the issues highlighted in the literature review international journal of information and education technology vol 14 no 1 2024 and gain insights into the impact of covid19 on bame students academic performance and study experiences our research employs a mixedmethod approach this approach as proposed by creswell and plano clark 18 in their book designing and conducting mixed methods research captures the perspectives of both students and key stakeholders regarding the impact of covid19 with a specific focus on bame students while also considering its implications for future pandemics the advantages of this approach as outlined in creswell and creswell 19 and johnson 20 lie in its capacity to offer a holistic understanding serving as a valuable reference point for future crises by integrating numerical insights from data and student analytics and the covid19 impact dashboard with the lived experiences and perspectives of students and key stakeholders the quantitative component aided by time series analysis and correlation techniques through computer simulations 19 enables the identification of trends and patterns while the qualitative aspect delves into the why behind these trends 21 additionally a comparative study of students demographics aids in early identification of areas with poor attainment informing the development of targeted contingency plans moreover in light of the experiences with covid19 this research aims to contribute insights into how educational institutions can better prepare for and counteract the negative impacts of future pandemics by exploring the strategies and adaptations made during the covid19 crisis we seek to inform proactive planning and response measures this forwardlooking perspective underscores the broader relevance of the study and its potential to guide policy and institutional changes ensuring resilience in the face of unforeseen challenges beyond the covid19 pandemic this mixedmethod framework aligns with the research objectives offering a robust means of examining the multifaceted impact of covid19 on bame students educational experiences and outcomes while also shedding light on strategies for building resilience and adaptability in future pandemics iii quantitative analysis of covid19s impact on bame student attainment unveiling disparities at the open university the methodology involved a systematic approach encompassing data collection cleaning analysis and modeling data was collected on the awarding gaps for different ethnic groups at the open university as well as covid19 cases and other factors impacting academic performance the dataset included information on academic year course level bame student status ethnic group and course completion and passing percentages after cleaning the data a hierarchical analysis was conducted starting at the institutional level and narrowing down to crossfaculty analysis with a particular focus on level 1 computing modules at the institutional level the analysis revealed a decline in completion and pass rates for all ethnic groups from 201920 to 202021 with nonbame students exhibiting higher rates compared to bame students pass and completion rates generally increased as the academic level progressed with slightly higher rates observed for nonbame students in the crossfaculty analysis slight differences in completion and pass rates were found between bame and nonbame students with nonbame students generally having slightly higher rates further analysis specifically focused on level 1 computing modules the findings indicated lower pass and completion rates for bame students compared to their nonbame counterparts additionally disparities were observed among different ethnic groups within the bame category asian students displayed the highest completion and pass rates while black students had relatively lower rates compared to other ethnic groups mixed and gypsy students demonstrated completion and pass rates of 50 or above these findings highlight the need for additional investigation into the underlying reasons for disparities and the identification of potential barriers or biases that may impact the academic performance of certain ethnic groups addressing these disparities is crucial for promoting equitable outcomes and enhancing academic success for all students irrespective of their ethnic backgrounds the analysis employed a comprehensive approach considering various factors such as covid19 impact ethnic groups course levels and student characteristics the insights gained from this study contribute to a better understanding of the challenges faced by bame students during the covid19 pandemic and beyond the findings can inform evidencebased interventions and strategies to promote inclusivity support student attainment and develop contingency plans for future challenges a institutional analysis in table 1 an institutional analysis of the provided data for the academic years 201920 and 202021 reveals distinct trends in completion rates in 201920 completion rates were higher across all ethnic groups with nonbame students achieving 752 however in 202021 completion rates declined for all ethnic groups with nonbame students reaching 705 when examining completion rates by ethnic group specifically in 202021 nonbame students maintained a completion rate of 717 on the other hand among bame students completion rates varied across ethnic groups asian students displayed the highest completion rates at 709 while mixed black and gypsy students exhibited lower completion rates at 669 655 and 648 respectively notably there was a noticeable gap in completion rates between bame students and their white counterparts in both academic years bame students consistently displayed lower completion rates highlighting a disparity in academic outcomes compared to white students b level analysis the representation of bame students across different academic levels remained relatively consistent between the two academic years in 201920 the percentage of bame students ranged from 712 at level 0 to 1096 at level 3 similarly in 202021 the percentage of bame students ranged from 556 at level 0 to 1102 at level 3 when examining the pass rates in fig 1 it was observed that as students progressed to higher academic levels both bame and nonbame students generally experienced an increase in pass rates in 201920 bame students had pass rates ranging from 611 at level 0 to 776 at level 3 in 202021 bame students had pass rates ranging from 528 at level 0 to 69 at level 3 nonbame students on the other hand had pass rates ranging from 589 at level 0 to 829 at level 3 in 201920 and 464 at level 0 to 757 at level 3 in 202021 although bame students had slightly lower pass rates compared to nonbame students both groups showed an overall improvement in pass rates as the academic level increased c crossfaculty analysis the crossfaculty analysis focused on level 1 modules and provided insights into the experiences and outcomes of students from different ethnic backgrounds fig 2 illustrates the pass rates for level 1 modules in various faculties at the ou during the covid19 pandemic for the faculty provicechancellor both completion and pass rates for level 1 were relatively lower overall but the difference between bame and nonbame students was less pronounced hereafter the focus of the analysis shifts specifically to level 1 modules in computing and communications this selection is motivated by the understanding that level 1 is a pivotal phase in a students academic journey laying the groundwork for their chosen field of study by narrowing the focus to level 1 the analysis aims to investigate the influence of different factors including ethnicity on student outcomes during this crucial early stage d analysis for l1 computing modules the module analysis indicates that in both academic years there were varying percentages of bame students enrolled in different modules the pass rates for bame students varied across modules as well with some modules showing higher pass rates for bame students compared to others overall the pass rates for nonbame students were slightly higher than those for bame students in most modules in these numbers indicate variations in both the percentage of bame students and their pass rates across different modules further analysis and consideration are needed to understand the factors influencing these disparities and to implement appropriate measures to promote academic success and inclusivity for all students regardless of their ethnic background building on the module analysis the study also incorporated insights from focus groups to gain a deeper understanding of the experiences and perspectives of students in computing and communications the focus groups provided valuable qualitative data that complemented the quantitative analysis shedding light on various factors that may contribute to the observed patterns in module outcomes iv qualitative analysis insights from focus groups research has consistently demonstrated that datadriven studentcentered approaches can effectively address awarding gaps in higher education 1722 therefore we intend to leverage the insights gained from our analysis to engage teaching staff and key stakeholders in dedicated focus group discussions the qualitative analysis phase involved conducting focus groups with tutors key stakeholders and student support team leads to gain further insights into the factors influencing completion and pass rates with a particular focus on potential barriers and biases affecting different student groups these focus groups aimed to gather additional data and perspectives to develop targeted interventions and support programs specifically addressing disparities among ethnic groups such as asian and black students the qualitative analysis explored various themes and factors identified in the literature including economic disadvantage the digital divide housing conditions employment racism discrimination hate mental health and unconscious bias a focus group with tutors to compare the perspectives of open university educators with the emerging themes from the literature a focus group was conducted with tutors who taught level 1 computing modules between 2019 and 2021 the tutors comprising both women and men of white britishnorthern irish ethnicity shared their insights on key topics prompted by the literature themes these topics included the impact of covid19 on ethnic minority students learning experiences and performance the types of support available to students and suggestions for enhancing the learning experience and academic performance of students from ethnic minority backgrounds b participants and procedure the focus group included five tutors with extensive experience as open university educators the conversation was recorded and transcribed with the participants consent the onehour focus group discussion took place on teams and was moderated by a member of the research team the moderator introduced key questions and topics ensuring equal participation among the tutors the transcription of the discussion served as the primary document for analysis c data analysis and results an inductive analysis approach was employed to identify themes and categories emerging from the tutors responses the analysis involved assigning descriptors to capture the main ideas expressed by the participants the results of the focus group revealed important insights related to the correlation of ethnicity with students learning experiences and performance while tutors generally lacked knowledge of students ethnic backgrounds they agreed that ethnicity itself was not a significant factor impacting students experiences and performance instead they highlighted several structural factors including poverty the digital divide housing conditions employment family responsibilities and mental health issues that had a significant impact on students learning experiences and performance particularly during the pandemic furthermore the focus group discussion shed light on institutional factors influencing students learning experiences and performance tutors emphasized the need for a collaborative approach to support students highlighting the variation in the level of pastoral support provided by tutors solutions suggested by the tutors included the introduction of a distinct pastoral role funding for laptops and equipment repairs to address the digital divide and povertyrelated challenges and considerations for housing and family circumstances during online exams v discussion the findings of this study situated within the context of the covid19 pandemic and its disproportionate impact on bame students add a significant contribution to the existing body of literature the findings of the focus group contribute substantially to the existing literature providing valuable insights that are specific to a distance learning institution like the open university 23 this study sheds light on the persistent inequalities and disadvantages experienced by bame students in the context of distance learning emphasizing the open universitys responsibility to develop solutions that extend beyond crisis situations such as the covid19 pandemic 24 the alignment between the perspectives of tutors and the structural factors identified in the literature underscores the existence of similar levels of inequality and disadvantage among bame students at the open university 25 while the study acknowledges the limitations of selfselecting tutors and the need for a more comprehensive inclusion of bame level 1 c c students perspectives the insights gathered from the focus group participants can inform the implementation of interventions and support measures to address the identified challenges 26 it is important to note that issues related to racism discrimination hate and unconscious bias identified in the literature were not fully explored due to the tutors limited awareness of students ethnicity 27 however the study recognizes the potential role of these factors in shaping bame students learning experiences and performance at the open university 28 the insights gained from the focus group analysis provide valuable perspectives on the lived experiences of tutors and international journal of information and education technology vol 14 no 1 2024 offer actionable suggestions for enhancing support systems and creating a more inclusive learning environment with a specific focus on students from bame backgrounds 29 this inclusive approach aligns with the broader goal of promoting equitable and inclusive education systems 3031 another focus group was conducted with edi and sst stakeholders at the open university but its detailed discussion is reserved for another publication however some information can be shared as a brief summary fg2 participants consisting of both bame and white british stakeholders highlighted the impacts of covid19 on bame students learning experiences and performance such as in 32 they discussed the significance of structural factors like poverty housing family responsibilities mental health issues safeguarding concerns and vaccine hesitancy 31 institutional factors such as systemic racism unconscious bias institutional policies lack of diversity and inconsistent contact during the pandemic were also raised the stakeholders put forward recommendations related to targeted interventions revisiting policies building community increasing diversity analyzing data creating individual learning plans improving tutor engagement enhancing website usability providing effective unconscious bias training and safeguarding edi work from financial and job cuts vi conclusion this study reveals the significant challenges faced by ethnic minority students during the covid19 pandemic which have a substantial impact on their learning experiences and academic performance the findings emphasize the critical need to address both structural and institutional factors to promote equity and inclusivity in higher education implementing recommended strategies will help create a supportive and inclusive learning environment empowering ethnic minority students to thrive academically this paper examines the impact of covid19 on the study experiences and academic performance of ethnic minority students enrolled in open university level 1 computing modules through a comprehensive mixedmethods approach the study combines quantitative data analysis with literature review findings and insights from two focus groups conducted with open university educators and key stakeholders our research using a mixedmethods approach has identified that these challenges stem from economic disadvantage the digital divide housing instability employment difficulties family responsibilities mental health issues racism discrimination and unconscious bias these findings highlight the urgency of implementing recommended strategies to create a supportive and inclusive learning environment additionally institutional factors including systemic racism unconscious bias policy gaps a lack of diversity inconsistent contact during covid19 and resistance to targeted support impact the sense of belonging and access to support for ethnic minority students to address these challenges several recommendations were proposed these included targeted interventions to support ethnic minority students revisiting institutional policies to reduce barriers fostering a sense of community and belonging increasing institutional diversity analyzing hard data on bame students experiences developing individualized learning plans improving unconscious bias training and ensuring that financial and job cuts do not disadvantage equality diversity and inclusion work and the focus on the needs of minority ethnic students in summary this study highlights the complex challenges faced by ethnic minority students during the covid19 pandemic and underscores the importance of addressing structural and institutional factors to promote equity and inclusivity in higher education by implementing the recommended strategies institutions can create a supportive and inclusive learning environment that empowers ethnic minority students to thrive academically and achieve their full potential conflict of interest the authors declare no conflict of interest author contributions dk leaded project initiated the project performed an initial literature search collected necessary data performed qualitative analysis and wrote the initial draft of the paper skm assisted dk in obtaining ethical approvals reviewed qualitative analysis provided feedback and insights collaborated on the design of survey questions for the focus groups and contributed to the review and revision of the paper ak extended literature search facilitated and conducted the focus groups with skm performed qualitative analysis identified emerging themes from the focus groups and contributed to the review and revision of the paper all authors contributed to the review and final approval of the paper

this study investigates the evolving impact of covid19 on the learning experiences and study performance of ethnic minority students enrolled in level 1 computing modules at the open university a mixedmethods approach combining quantitative data analysis literature review and two focus groups was employed to provide fresh insights findings from the literature and focus groups highlight persistent challenges faced by ethnic minority students including economic disadvantage digital divide housing instability employment difficulties family responsibilities mental health issues racism discrimination and unconscious bias importantly this study reveals the dynamic nature of these challenges illustrating how they have evolved throughout the ongoing pandemic the study underscores the pivotal role of structural and institutional factors in shaping students everchanging experiences in response to these dynamic challenges recommendations include targeted interventions policy revisions that reflect the shifting landscape innovative communitybuilding initiatives a renewed focus on diversity promotion enhanced support services unconscious bias training and revised tuition strategies addressing these dynamic challenges is crucial for fostering equitable educational opportunities and outcomes for ethnic minority students this research significantly contributes to promoting equality inclusivity and a more comprehensive understanding of the everevolving experiences of ethnic minority students during the pandemic and beyond

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digital platforms reorganizing urban interactions and operations digital platforms such as alphabet alibaba amazon and facebook are programmable digital infrastructures controlled by platform operators … who curate the interactions of interdependent complementors and users they now represent some of the most valuable corporations of our times as they profit heavily from accelerating network effects relatively low transaction costs as well as a lack of applicable regulations signifying ecosystems of interaction digital platforms substantially condition and contribute to the reorganization of cities all around the world they fundamentally transform the economic as well as social fabric of substantial aspects of our everyday lives such as work communication transport and accommodation and have paved the way for what has been coined platform economy a plethora of different labels such as ondemand gig and sharing economy have been developed not surprisingly a multitude of definitions and understandings exist including different sometimes even contradictory approaches to categorizing platform models fumagalli et al for instance differentiate between advertising platforms cloud platforms industrial platforms product platforms work platforms as well as logistic platforms a large majority of these digital platforms actively shape markets as socalled marketmakers thus engaging users through a participatory economic culture and mobilis ing code and data analytics to compose immanent infrastructures thereby they are infiltrating a diverse range of markets such infiltration not only causes disruption to established markets but also develops completely new ones reshaping consumption practices while also redefining value creation processes and reorganizing value chains further platforms influence and even create their institutional and regulatory framework effectively becoming the market and therewith shaping our economy and society however this image of platforms is empirically only weakly developed conceptualizing their space in a wider organizational system is of importance if a more nuanced and full picture of platforms and how they evolve over time is to be gained consequently this frontiers paper proposes that the concept of embeddedness that has shaped the foundation of essential research in international business provides a suitable and helpful overall framework for future studies regarding platforms generally embeddedness describes the integration of different subjects into socioeconomic systems and networks while regulatory normative and culturalcognitive institutions form the basis for social embedding the relationships between different actors from social socioeconomic or organisational contexts are understood as network embeddedness economic geographers have consistently underlined the constantly embedded character of economic practices yet they underestimate the impacts on the spatial organization of the platform economy which represents a mostly underresearched aspect of urban transformation consequently this paper proposes the embeddedness concept to address this blind spot bridging the disciplinary divide between urban studies and economic geography offering an opportunity to understand how digital platforms are embedded in our daily social and economic life the paper is structured as follows firstly platform urbanism and its farreaching implications on urban transformation is critically discussed revealing the need to comprehend the embedding processes in order to better understand conceptualize and influence digital platforms evolvement and behaviour secondly the paper aims to reveal the main reasons in regard to the difficulties in pinpointing digital platforms embeddedness consequently this offers a possible explanation as to why the discipline of economic geography is largely neglecting platform economy and platform urbanism related discussions thirdly it seeks to propose future research unravelling the embeddedness of the platform economy platform urbanism and urban transformation the growing influence and pervasiveness of platforms has led to numerous terms depending on the context in which they are discussed such as platform capitalism power logic or society the increasing presence as well as power of digital platforms in urban spaces has led to the establishment of platform urbanism as digital platforms are woven into urban life produce urban space and participate in urban governance they have positioned themselves as an indispensable part of urban life in the digital age as they control urban interactions in a diverse range of urban operations such as transport and housing digital platforms have become a new significant urban governance actor that is not only reterritorializing existing infrastructure but controlling critical infrastructures of urban societies prominent examples of platformbased business models causing radical market changes in cities can be found across various branches uber and lyft airbnb amazon as well as google facebook and youtube particularly the platforms airbnb and uber both currently negatively affected by the covid19 crisis and the accompanying restrictions have attracted much scholarly attention and reveal impressively how digital platforms fuel urban transformation cocolagant and gago highlight the increasing insecurity and displacement concerns for tenants that the airbnb business model is generating while it simultaneously acts as an instrument that contributes to the financealization of housing further they link airbnb with gentrification several studies argue that airbnb should be understood as a new urban institution that is transforming relations between market state and civil society actors as it inter alia assists expanding cultural commodification while simultaneously turning citizens into place entrepreneurs similarly uber represents an interstitial platform infrastructure that depends on existing infrastructures like road networks sidewalks and other public spaces the example of amazon representing a great beneficiary of the covid19 crisis due to governmental ordered lockdowns and accompanying accelerated online sales reveals how a digital platform is augmenting substituting or reorganising physical retail spaces thereby transforming shopping streets and whole city centres while retail platforms are helpful in facilitating retailers entry to ecommerce and have the potential to contribute to small brickandmortar retailers resilience in times of pandemic crisis due to many closed brickandmortar shops digital transaction platforms such as amazon are heavily criticized due to their market power and their usage of data being responsible and in control of the infrastructure that allow retailers and customers to get together digital platforms can raise fees change their algorithms and expect sellers to advertise if they want to maintain visibility in search results moreover and particularly profitable for platforms they are selling products on a marketplace that they simultaneously operate thereby pushing out suppliers by directly competing with them by entering their product spaces as in the case of amazon although digital platforms do not own the underlying assets that enable performance of the economic activity they stimulate they can dictate and reorganise value creation another clear example of the reorganisation of value creation is googles business model which plays a dominant role in helping customers find merchants locally merchants have a strong incentive to advertise on the google platform which in turn extracts value from the local market as for example the city centres and shopping streets and diverts it to the platform generally research agrees on the platform economys profound implications on several key aspects such as the organization of urban life and sociospatial relationships of daily workplaces platform urbanism is within geography and urban studies as a means to describe the intensifying linkages between technologies and cities as well as the accompanying rising manifestation and power of the digital platforms yet criticism and warnings seem to be a constant accompaniment of these studies 3 f predicts that we end up with unaccountable and undemocratic organizations managing key digital infrastructures of our cities which currently represents an inevitable urban future of capitalism stripped down to its essentials due to their power to mediate flows of people and capital they contribute s to the daily making and remaking of local economic geographies and thus are undeniably embedded into the fabric of the cities in which they operate s consequently this paper strongly agrees with 13 argument that an understanding of such platform power cannot be complete unless one considers the embedded nature of digital platforms and the various dynamics at play consequently the paper intends to evaluate in more detail the main reasons in regard to the difficulties in pinpointing digital platforms embeddedness before discussing the usefulness of and potential research regarding the embeddedness concept unawareness unaccountability and nontransparency of digital platforms 93 argue that just like markets platforms are nothing natural but are objects of ongoing political contestations that forge the embedding of the platform economy into the regulatory framework of society the intellectual heritage of embeddedness lies in sociology and was coined by polanyi who used the concept in two contradictory ways a soft as well as hard polanyi embeddedness the hard one describes the arising of a reactionary countermovement whereby society attempts to reembed the economy through the creation of social protections such as labour laws and tariffs central to the hard conception is the commodification of labour the environment and money as fictitious commodities the soft polanyi has been essentially developed further by granovetter who describes the concept as the assumption that economic activities are embedded in systems of social and societal relationships consequently a company respectively a platform conceptualizes its main functions and actions in relation to its wider setting this approach to embeddedness has established a wideranging research agenda especially in economic geography yet only considering the soft polanyi criticizes that an extreme emphasis on the local dimension prevents from recognizing the role of nonlocal embedded relationships consequently hess introduces a threefold typology by differentiating interconnected societal network and territorial embeddedness 181 emphasizes i t is the simultaneity of societal network and territorial embeddedness that shapes networks and the spatialtemporal structures of economic action in order to achieve embeddedness negotiation of internal and external network relationships has to take place it also implies the adaptation to national regional or local frameworks embeddedness thus describes the integration of different subjects into socioeconomic systemsnetworks therefore the positions and capacities of individual subjects are placed in relation to other subjects from economic social or territorial systems space is understood as a construct of different actors and forms of embedding which form the basis for new development possibilities consequently similar transformation processes in different places always have different outcomes as they are determined by the existence of regional cultures and local institutions dissecting 4 statement that p latforms in the urban environment are fundamentally reshaping urban geographies while being apparently too big to control too new to regulate and too innovative to stifle this paper argues for three major interdependent reasons as to why it is difficult to pinpoint digital platforms embeddedness unawareness platforms often remain unacknowledged as such since many processes are neither directly visible nor perceived as platformrelated this invisibility applies not only to products and services but also often to the responsible companies as well as their employees and consequently to space itself while classical production plants or traditional shops can be assigned to a fixed location and thus a relationship to the physical environment of the companies is created the platform economy takes place largely in a virtual environment often within our own four walls this resides not only in the fact that we blithely take digital platforms in our bedrooms in form of our smartphones or that a representative of the platform sits with us at the dining table in the shape of siri and alexa while we are agreeing to their terms and conditions even in our most private spaces this also includes the fact that platforms create new markets with novel ways of generating value by establishing new commodities this includes private cars and houses turning citizens into entrepreneurs by offering their homes and automobiles as well as the personal data of customers turning the customers into products themselves thereby gamification the application of typical elements of game playing to other areas of activity typically as an online marketing technique to encourage engagement with a product or service plays an essential role it incentivizes the production of ever more relational data to further advance the very models of social behavior on which gamification is based as revealed by the examples of linkedin and facebook to increase the completion rate linkedin uses a simple but effective tool the progress bar after successfully entering all relevant data members also receive a badge they are now superstars the role of the user is no longer simply to use but to offer user feedback and produce data for the digital platforms converting transformation of daily routines into laboratory sites for product and service development this manifests itself in a hierarchical relationship between users and digital platforms leading to an extreme power asymmetry in which the platform clearly controls the nexus of relationships the ability of platform companies to assume dominant market positions and systematically change economic structures depends to a large extent on this power asymmetry which also finds its roots in their ability to circumvent regulations unaccountability as it is reasoned that digital platforms hold the power to create their own logic they can also influence the logics of other institutions such as the state and the market yet despite digital platforms perception as governing systems that control interact and accumulate they escape accountability due to their undemocratic and usually distant character revealing no interest in promoting local voices or investing in local priorities that can be attributed to one underlying characteristic of digital platforms often decoupling themselves from the commodities they sell channel uber and airbnb for instance label themselves as technology companies instead of transportation or accommodation companies respectively not owning a single vehicle or hotel room claiming that they are simply a marketplace further uber classifies drivers as independent contractors rather than employees therewith avoiding labour protections such as sick pay or minimum wages every single uber driver has a contract with uber international holding bv in this way by operating at a different spatial scale to their workers and avoiding local responsibility digital platforms remain unaccountable 1 refers to these circumstances as the virtual wild west a further liability evasion derives from what 108 label the key arena of regulatory struggles which is defined by a vast amount of termsofuse agreements 220 calls them uncontracts these invoke the notion of a public domain that enables legal privileges while being performative acts of consummation as data is converted into de facto property arrangements mobilizing an altered understanding of legality further as pointed out by 2 digital platforms disembed themselves from the tax jurisdictions of the localities they serve leaving treasuries shortchanged nontransparency in contrast to the unawareness nontransparency refers to the secrecy in which digital platforms operate internally the interplay of algorithms and venture capital offices provides one possible reason for the lack and difficulty of conducting studies on digital platforms they may be perceived as black boxes due to the proprietary nature of algorithms the secrecy of corporate ownership structures and the emphasis on confidentiality and privacy in the venture capital industry usually there is no office door to knock at as platforms may not have any physical presence in the cities they operate further as in the case of google or facebook there is no phone number to ring something most consumers would expect to be able to get in touch yet they allow users some access by agreeing to a set of terms and conditions in order to enter private property reserving nearly total control to the digital platform the owner respectively which is also enhancing the unaccountability of the platforms as they are left with little or no public oversight this is in particular true as platforms can change their algorithms eg a transaction platform can modify its recommendation algorithms to put more emphasis on price or search engines algorithms that determine what one sees when a search query is typed into them importantly the three factors are interdependently they overlap influence and mutually reinforce each other they all lead to the fact that platforms evolve around ambivalent even contradictory processes 465 argue that a focus on the apparent opacity of platforms may reify them as external to rather than thoroughly embedded in the relations among devices people and the urban yet while they disembed ded from the spacetimes they mediate they simultaneously are embedded in daily routines and the urban fabric in some circumstances to an almost unknown degree this strategic deployment of conjunctural geographies allows platforms to hold an instrumentarian power to modify and monetize social behavior further they even coproduce their own institutional and societal embeddedness indeed this frontier paper argues that the embedding processes are becoming even more complex as the roles of different actors are increasingly blurred and their interactions are less spatially relevant embeddedness and its usefulness for future research recently research in the digital platform economy has started to focus on embeddedness aspects these studies have found the concept of embeddedness valuable although they have mainly concentrated around the issues of labour in the platform economy fan et al examined the concept of societal embeddedness by investigating the influence of social embeddedness on organizational legitimacy and the sustainability of the globalization of the sharing economic platform using the example of uber china wood et al explore the embeddedness of digital labour within the remote gig economy in southeast asia and subsaharan africa and conclude that normative disembeddedness leaves workers exposed to the vagaries of the external labour market due to an absence of labour regulations and rights while simultaneously being embedded within interpersonal networks of trust similarly 1 investigate inter alia the social embeddedness of more than 5000 russianspeaking freelancers from an international online labour market importantly wood et al as well as grabher and könig emphasize the importance of hard polanyi the commodification aspect respectively a component often ignored when using polanyis analysis of what he termed the great transformation to frame the rise of the platform economy confirming the accompanying increasing commodification 5 term the alternative hardpolanyi form of societal embeddedness normative embeddedness in order to distinguish it from extant uses indeed they call for commodification to be in the centre of societal embeddedness while seeing prospective outcomes of polanyis double movement they find that despite labour remaining embedded within workers interpersonal networks it is at the same time being disembedded from cultural and legal norms that would limit its commodification montalban et al critically ask whether platform economies represent a new process of embeddedness or a next step for deregulation following the crisis of the financialised regime of accumulation which consequently may favour some forms of disor reembeddedness disembedding processes are also described by graham and katta et al regarding uber and labour graham 4 argues that the sole reliance on the mediation of data and information makes digital platforms vulnerable to local alternatives consequently calling for avoidance replication regulation as well resistance katta et al discusses an interesting example due to the covid19 pandemic and the associated lockdowns most uber drivers were left without a viable income due to public pressure however uber offered modest employment benefits including limited paid sick leave in california for instance the states recent ab5 law presents an existential threat to the companys business model implicitly acknowledge that uber is far more than the proprietor of a digital marketplace this reveals that regulations and policies can have a tremendous influence on the embeddedness as well as the actual existence of the respective digital platform another example represents amazon in india where the government ruled that simultaneously being a platform for thirdparty sellers and a vendor itself is impossible these examples confirm grahams argument that digital platforms are vulnerable enabling that embeddedness provides a pathway to encoding local accountability into the gig economys script indeed this might be the start of what could be observed in the aftermath of the industrial revolution when labour via the establishment of trade unions and other institutional involvements was gradually decommodified this draws parallels to stehlin et al s 14 argumentation that due to platforms spatial embeddedness they cannot simply wipe out the localized configurations of political economic power territorial authority infrastructural history and sociospatial inequality … and begin with a tabula rasa therefore geographic research on platform urbanism must deepen our understanding on how platforms are situated within the blurring interconnections and actors of the city the concept of embeddedness serves as a valuable tool to understand and pinpoint essential dynamics and relationships of the platform economy broadening our understanding of the underlying powers and arenas as well as participants that play a crucial role in the platform economy therewith overcoming the unawareness unaccountability and nontransparency towards and of digital platforms further without denying the importance of current research focusing on what might be termed new traditional labour this paper argues that the commodification of seemingly irrelevant labour by consumers should also move in the centre of attention as the borders of home leisure consumption and work blur contributing to the unawareness of digital platforms power and reach a full picture of the embeddedness and the respective disembeddedness processes of platform companies has to be gained in order to proceed with the shaping of the platform economy which currently represents an inevitable urban future of capitalism stripped down to its essentials 8 posing of two fundamental questions how embedded are digital platforms in the economy and conversely how embedded is the economy in digital platforms are essential but not farreaching enough we have to broaden the concept of embeddedness especially due to enormous power of platforms to create large parts of our urban and societal world therefore i follow pecks plea for a more sustained but also open critical and creative engagement with polanyis legacy deriving mainly from the three factors detailed above a variety of research questions and suggestions are apparent of which few should be named here which implications flow from the changing role of consumersusers on the embeddedness of digital platforms how can the increasing amalgamation of home leisure consumption and work be translated into embeddedness how can we distinguish them and is it necessary to distinguish them how does embeddedness differ between largesmall platforms and what roles do different sectors play what role does the cultural backgrounds of decisionmakers within the platforms play how does accountability influence the embeddedness of digital platforms and vice versa and on a more general basis as pointed out at the beginning definitions and categorization of platforms vary and sometimes even contradict each other might the embeddedness itself represent a good foundation for the categorization of digital platforms generally studies such as wood et al as well as graham clearly demonstrate the value of an integrated understanding of polanyis theorization of embeddedness for analysing contemporary economic transformations embeddedness might help us rethink the concept of digital platforms as fluid multilayered companies that have no fixed spatial location outside of their corporate headquarters who have an ability to link themselves to the local to concentrating reward and retreat to their ephemeral digital dualisms when abdicating responsibility authors contributions not applicable declarations competing interests there are 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 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digital platforms understood as multisided matchmakers have amassed huge power reimagining the role of consumers producers and even ownership they increasingly dictate the way the economy and urban life is organized yet despite their influential and farreaching role in shaping our economic as well as sociocultural world our understanding of their embeddedness namely how their activities are embedded in systems of social and societal relationships and how they conceptualize their main functions and actions in relation to their wider setting remains rudimentary consequently the purpose of this frontier paper is threefold firstly it reveals the need to discuss and evaluate dis embedding processes in platform urbanism in order to understand the underlying dynamics of platform power and urban transformation secondly it aims to reveal the main reasons in regard to the difficulties in pinpointing digital platforms embeddedness thirdly it seeks to propose future research unravelling the dis embeddedness of the platform economy this paper argues for three main reasons namely unawareness unaccountability and nontransparency of digital platforms that drive the lack of embeddedness and reaffirms platform power this is mainly based on the configuration of new commodities platforms strategic avoidance of labour protections and other regulatory frameworks as well as platforms secrecy in which they operate this frontier paper argues that transferring the concept of embeddedness to the platform economy might serve as a valuable tool to understand and pinpoint essential dynamics and relationships at play therefore proposing embeddedness as a basis for future research on the platform economy it strongly argues that a more detailed understanding is urgently needed in order to be able to understand accompany and actively influence the development of the platform economy in regulatory termsidentifies three main reasons for the difficulties of evaluating digital platforms unawareness unaccountability and nontransparency identifies inter alia the lack of embeddedness research on the commodification of consumer work

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introduction contemporary organizations recognize the importance of human resources as a key element in an organization and as a key driver of its different activities they also recognize that an organizations survival and development depend entirely on its human resources efficiency how it deals with them and its ability to motivate such resources to perform the required tasks efficiently and effectively consequently improving human resources performance under globalization competition and changing environment can only be achieved by understanding organizational behavior in organizations due to its important role as a link between productivity level on the one hand and employees needs on the other hand the studys importance stems from its attempt to fill the gap in research concerning the concept of organizational justice and its relationship with job involvement this study is considered one of the first studies dealing with organizational justice and its relationship with job involvement in saudi ministries justice integrity values and neutrality application in the organization are one of the basic requirements for organizational behavior formation and positive attitudes among its employees therefore the increased workers sense of justice will increase their confidence in top management and increase their satisfaction and improve their behavior on the contrary employees sense of nonjustice will lead to many negative consequences including job dissatisfaction and declining performance among behaviors that can be affected by employees sense level of organizational justice and job involvement which is considered a positive trend that reflects employees maximum effort to meet job requirements and thus has a significant role in promoting and increasing organizational efficiency in organizations also the organization should strive to achieve justice among staff in every action or decision to increase job satisfaction staff involvement and productivity therefore this study aims to achieve the following objectives • investigate employees perception of organizational justice in saudi ministries • investigate job involvement level in saudi ministries and its relationship to some personal and organizational variables • investigate the relationship nature of the extent of staff sense of organizational justice and involvement level in saudi ministries • contribute to increasing the effectiveness and efficiency of saudi ministries by making recommendations that raise their job involvement level of individual perception to organizational justice and thus increase job involvement level hence this study intends to investigate the relationship between organizational justice and job involvement in saudi ministries by answering the following questions a what is employees sense level of organizational justice in saudi ministries b what is the employees job involvement level in saudi ministries c what is the impact of employees sense of organizational on employees job involvement in saudi ministries literature review melhm the main objective of this research was to determine the effect of organizational justice on functional combustion from the perspectives of secondary school teachers in qalqilya governorate the descriptive analytical method was used the questionnaire was used as a tool to collect data qalqilya teachers or 60 of the research community the results of the field study showed that the responses of the respondents towards the level of organizational justice in the girls secondary schools in qalqilya governorate were moderate on both dimensions high on the dimension while it was very high on the dimension the results showed that there was a significant effect of the organizational justice dimensions on the functional combustion from the views of secondary school teachers in qalqilya governorate from the perspectives of secondary school teachers in qalqilya governorate attributed to the two variables on all dimensions and the total score altawi alzahrah the study seeks to identify the effect of organizational justice on administrative empowerment in algerian companies the study found the presence of impact statistically significant between organizational justice dimensions and administrative empowerment as there are an low level of organizational justice in the surveyed enterprises due to the weakness of the administrative procedures applied fairly and that the behavior of some managers who are not characterized by equity all this led to the availability of a low level of empowerment in these institutions the study recommends the need to increase attention the of company managers to achieve organizational justice associated with empowering employees leads to achieving the desired objectives by knowing the impact the justice dimensions on empowerment in a study conducted by researchers ali mahad et al for the purpose of knowing organizational justice organizational commitment and transformational leadership on the performance of the employees of the ministries of agriculture and fisheries in oman this study included nearly 400 employees working in both ministries the researcher distributed questionnaires to the study sample and used statistical programs to test the hypotheses in this study in this study the researcher reached the positive role of organizational commitment on the performance of employees as well as the moderate role of organizational justice on the performance of employees and the management of human resources on the contrary the study did not find a role for organizational justice in the relationship between transformational leadership and employee performance the researcher concluded the importance of transformational leadership and organizational justice on the performance of employees and their importance in raising functional efficiency and enhancing employee performance almasri the purpose of this research study is to observe the relationship between job involvement and the organizational citizenship behavior of doctors working at governmental hospitals this study also aims at identifying the level of job involvement and investigating the degree of doctors practicing the behavior of organizational citizenship the researcher has used the descriptive analytical approach in describing and analyzing the phenomenon the results of the study showed a positive relationship between job involvement and organizational citizenship behavior as it showed a positive relationship between job involvement dimensions and the organizational citizenship behavior the research included a set of recommendations and the most important are the work on developing doctors emotional job involvement at the governmental hospitals in the gaza strip enforcing the behavioral involvement for doctors at the governmental hospitals increasing the awareness level of organizational citizenship importance for doctors and its results for patients particularly and hospital generally working on maximizing and optimizing job involvement and organizational citizenship for doctors regardless of their characters differences and caring about them since they are recently considered of the most important human resources a study conducted by imad and his colleagues on a sample of nurses in a public hospital in jordan aimed to determine the relationship between organizational justice and turnover intention the study sample consisted of 370 nurses and quantitative analysis was used for the purpose of interpreting the obtained results a set of hypotheses was built for the purpose of verifying the objectives of this study the researchers reached a set of results the most important of which is the presence of a positive effect between organizational justice and the intention of employee turnover as well as a positive effect between organizational justice and alobaidi the research aimed to identify the justice regulatory and organizational commitment in the ministry of higher education and scientific research and determine the nature of the correlation between two variables and know about the impact between them to achieve the goal of research and have led referendum sample of members of staff in the ministry including managers of departments and officials by using some statistical methods research has come to the set of results including the existence of correlation between two variables and by at the level of significance while the results referred to increase the strength of relationship between the variable fair dealing and faith in organization and was the most important conclusions represented by link and the effect of the dimensions of justice regulatory and the dimensions of organizational commitment in varying degrees and research ended on considerable that justice organizational variables of interest in the increased rates of organizational commitment in the sample examined while the recommendations were the encouragement to adopt a regulatory environment develop the level of organizational commitment by providing regulatory environment in which justice prevails with review of all the policies and practices based on the mistaken traditional view in the administration according to the principle that justice for all this study is different from the previous studies because it is the first study that deals with the reality of practicing organizational justice and its relationship with job involvement in saudi ministries in addition this study is one of the important studies that addressed the new concept of management concepts to investigate its implementation extent in an important sector that has a clear impact on saudi citizens daily life theoretical framework first organizational justice is an individuals sense of justice in an organization and behavioral reaction to such sense most organizational justice researchers agree that there are three basic issues on which individuals base their sense of justice in an organization nadiri and tanova 2010 1 first issue focuses on organizational outputs for employees such as salaries rewards incentives and workload justice distribution term is used to describe this type of justice consequently distributive justice indicates distribution fairness sense of organizational outputs individuals mostly focus in their career outcomes is comparing those outcomes with those of their peers in the same organization or abroad in similar organizations thus distribution justice focuses on employee equality theory between employees because it focuses on outputs and inputs final distribution in organization this theory prevailed during the 1960s and 1970s until 1975 when other organizational justice studies focused on integrity and impartiality of procedures and laws through which inputs and outputs are distributed to staff in organization 2 the second issue involves procedures and laws through which organizational outputs are distributed such as salary and work burden between employees this type of justice is called according to researchers as procedural justice the researchers explained that working individuals tend to accept decision or procedure and consider it fair when they participate in its making they confirmed that in situations in which there is a conflict the outcomes justice of decision is achieved through a system of managerial procedures that guarantees the parties to the conflict a certain degree of control over this decision by providing an opportunity to defend their attitudes and submit their evidence before decision taking although thibaut and walker are the first who discuss procedural justice but leventhals model is the basis for many of the following studies which handled the concept of procedural justice this model is based on the existence of six rules of procedures justice in order to judge that any distribution process in the organization is fair and these six rules are as follows aintegrity integrity means decisions application on all without exception but stability means that those decisions follow the same procedures whenever taken bnondiscrimination means that there are rules and instructions that prevent personal desires of decisiontaker to influence the decision at all stages caccuracy which means that there must be sufficient and accurate information for decision maker and should be taken by qualified and appropriate person e representation which means granting organizations members the opportunity to participate in decisionmaking that results in the distribution of outputs to these workers reflecting the concerns and concerns of workers affected by the decision f morals mean that organizations decisions must conform to employees norms and values that are affected by such decisions the sense of injustice occurs when these decisions violate organizations individuals moral values and principles 3 the third case focuses on personal treatment received by individuals who are affected by decisions in their dealings with such decisions makers of and whether such treatment is based on respect and dignity therefore the term interactional justice is used to denote this type of organizational justice treatment justice involves the personal treatment nature that employees perceived when decisions are applied to them in the organization it reflects employeesopinion regarding the personal treatment he feels when director or decision maker applies procedures and decisions on him it does not reflect decisions outputs neither justice nor the decision itself justice but reflects the interaction between decisiontaker and decisionreceiver since implementation of managerial decisions and procedures require some communication between decision maker and decision receiver according to bies and moag this interaction may explain why employees feel injustice even when decisions and decision outcomes are fair there are four criteria used to judge the extent to which employee feels the fairness of dealing with the decision maker 1 trust where employees feel when the decision taker is frank and honest during his interaction and contacting them 2 respect employees feel when the decisionmaker shows politeness when treating them 3 relevance employees perceived it when decision taker engaged in nonrelevance issues that are not related directly with the decision such as asking the employee about his age race or religion which may give organization s employees negative indicators when decision taker is asked such questions 4 justification it occurs when decision taker provides sufficient explanations for the taken decision justification its causes and clarifying its outputs and negative and positive impacts of such decision justification absence may make employee feels unfair even if the decision is correct second job involvement job involvement is creation work environment that enables employees to have an impact on decisions and actions that affect their jobs employees involvement or participation is management and leadership philosophy on how to enable employees to contribute to continuous improvement in organization and increasing productivity chagatai argues that job involvement represents the degree to which individual integrates with the job that he exercises and feels its importance therefore it is related to mental and emotional aspects together since involvement is affected by many influences including emotional level this is evident from its positive effects on the individual such as higher selfesteem satisfaction and happiness and on the contrary when involvement level is reduced then the negative impact is clear on individual feelings such as anxiety distress depression and despair 2 job involvement is one of the most important approaches used to develop and improve work life quality also the interaction between job involvement and organizational commitment makes individual who is involved in his job has an organizational commitment to his organization and stay more and is keen to develop its activities 3job involvement is related to work importance in individual life so the more important the work the more loyal the employee to his organization which in turn affects the performance of individuals thus employees involvement in their work has a significant impact on employee productivity and efficiency strategies to promote job involvement abadi jaf and lawler hall mentioned some strategies to promote job involvement through 1 job itself employees feel that they have the opportunity to specify the objectives related to do the work 2 2 work environments through improving work environment and conditions and performance work methods 3 leadership this is made through training to understand how leaders work and the skills that an employee needs in leadership 4 opportunities of personal growth by promoting learning culture 5 contribution opportunities through listening and responding to any contributions provided by individuals characteristics of job involvement represented by a set of factors study methodology study method this study is based on the descriptiveanalytical method data sources it was relying on two types of sources of data collection a secondary data it has been obtained through arabic and english books and periodicals formal reports journals thesis and articles issued by official authorities b primary data to determine organizational justice and its relationship with job involvement we have been conducting a pilot study with some employees of sample saudi government ministries the purpose of this pilot study is to review the dimensions of organizational justice and its relationship with job involvement the second step is developing a questionnaire to collect the needed data from the study population study limitations a human limits all employees in government ministries in saudi b scientific limitations organizational justice with its different dimensions and job involvement in saudi ministries study population study sample the study population includes all employees in saudi government ministries with different job names due to the large size of the study population and for the selection of a representative sample for this publication a random sample from these ministrys employees was used where questionnaires were distributed to ten ministries questionnaires we recollected that is 903 as a response rate questionnaires were disregarded due to incompleteness so questionnaires were valid for statistical analysis purposes intern study hypothesis based on the objectives of this study the researchers build the next hypothesis first hypothesis there is a statistically significant relationship at level between organizational justice and employees job involvement in saudi ministries this hypothesis was divided to subhypotheses a there is a statistically significant relationship at level between distribution justice and job involvement in saudi ministries b there is a statistically significant relationship at level between procedures justice and job involvement in saudi ministries c there is a statistically significant relationship at level between dealing with justice and job involvement in saudi ministries second hypothesis there is a statistically significant relationship at significant level between organizational justice between sample responses due to the following personal and organizational variables third hypothesis there is a statistically significant relationship at significant level between job involvement between sample responses due to the following personal and organizational variables study instrument based on the data nature of the researcher found that questionnaire is the most appropriate instrument to achieve study objectives the researcher designed an initial questionnaire and submitted it to o a group of referees who provide advice and guidance and then an initial field test study was carried out one a sample of ten employees some proper modifications were made to form the questionnaire in its final form which has been distributed to all sample subjects the sample in order to collect the required data for the study the questionnaire was divided into two parts as follows first part study populations personal data consisted of 4 statements second part it handled study sample trends regarding organizational justice and its relationship with job involvement in government ministries and was divided into two as follows • dealing justice represented by statements 2027 second dimension discuss job involvement and consisted of 20 statements 2847 instrument validity and reliability questionnaire statements were structured to ensure the validity and reliability of its statements as follows instrument s statements validity two methods were used to find out the questionnaires statements validity referees validity the questionnaire was presented to five professional referees all necessary steps were made either deletion or modification in light of provided suggestions by referees table indicates that males percent in study sample was 611 of the total study sample while female percent was 389 males percent more than female percent in the sample is due to the increased number of male staffs in saudi government ministries table indicates that study sample is concentrated on those who have experience 510 years with 467 of the total sample those who have 1120 years experience ranked the second amounting 291 of the total sample while the percent of those who have experience less than five years with199 of total sample finally employees whom their experience more than 20 years amounting43 questionnaire statements analysis ttest was used to determine the study sample response mean on questionnaire statements organizational justice statements analysis distribution justice statements alsharah a m t organizational justice and its relationship with job involvement in saudi government ministries table above shows that most of items means in dimension were more than this indicates that there is sample agreement on this dimension statements save statements which were less than the mean this indicates study sample disagreement regarding the existence of clear bases for promotion in the ministry in addition to existence of clear and fair bases regarding distribution of material and moral incentives in the ministry statements and have the higher means this indicates that the study samples subjects consider that workload they perform is appropriate and fair and that there is justice in distributing part time working hours in the ministry 8 above shows that most of items means in dimension were more than this indicates that there is sample agreement on this dimension statements save statements which were less than the mean the table above shows that most of items means in dimension were more than this indicates that there is sample agreement on this dimension statements save statements which were less than the mean table shows that most of items means in dimension were more than this indicates that there is sample high agreement on this dimension statements statements have the higher means this indicates that study samples subjects consider that thy are satisfied and pleased after thy give an assistance to ministrys customers and thy have a high commitment and loyalty towards their ministries and thy always seek to develop themselves through training courses procedures justice statements job involvement statements analysis hypotheses testing first hypothesis there is a statistically significant relationship at level between organizational justice and job involvement of employees in saudi ministries alsharah a m t organizational justice and its relationship with job involvement in saudi government ministries table shows the result of the second sup hypothesis test where the result indicates that the correlation coefficient is equal to and that the significant value sig which is less than the significance level of 005 this indicates that there is statistically significant relationship between procedures justice and employees job involvement in saudi ministries the third sup hypothesis there is a statistically significant relationship at level between dealing justice and job involvement in saudi ministries table shows the result of the third sup hypothesis test where the result indicates that the correlation coefficient is equal to and that the significant value sig which is less than the significance level of 005 this indicates that there is statistically significant relationship between dealing justice and employees job involvement in saudi ministries to test the second hypothesis between study samples responses on organizational justice due to the following personal and organizational variables t test and anova test were used for two independent samples to determine if there were statistically significant differences the above table shows that there are statistically significant differences between estimated means of research sample due to experience in the ministry where the significance value is less than the significance level those who have more than 10 years of experience had obtained the highest mean this indicates that employees with long years of service in saudi ministries are more satisfied more satisfied and more aware of organizational justice to test the third hypothesis significant level between job involvement between sample responses due to the following personal and organizational variables ttest and anova test were used for two independent samples to determine if there were statistically significant differences the above table shows that there are statistically significant differences between estimated means of research sample due to experience in the ministry where the significance value is less than the significance level those who have more than 10 years of experience had obtained the highest mean this indicates that employees with long years of service in saudi ministries are more satisfied more satisfied and more committed and loyalty towards their ministries discussion 1 the study results proved that there is a statistically significant positive relationship at level between organizational justice in its various dimensions and employees job involvement in saudi ministries 2 the study results indicate that there is a sense of organizational justice availability with all of its dimensions in saudi ministries since the means were more than the above average employees sense of distribution justice ranked first then dealing justice while procedures justice ranked last 3 the study results showed that there is high employee job involvement in saudi ministries samples responses illustrated that employees in saudi ministries give priority to job interest than personal interest they are satisfied and pleased after providing ministrys 4 the study results showed that the samples subjects responses were low and below the mean regarding the availability of promotion clear bases and the availability of clear and justice bases for material and moral incentives distribution and the availability of clear procedures to pursue violations and irregularities in work which indicates sense weakness of some aspects of justice by employees in saudi ministries 5 research samples subjects responses results illustrated that there are no statistically significant differences between study samples responses regarding organizational justice and employment involvement due to gender this may be due to the fact that both are subject to the same work conditions job burdens and job stresses in saudi ministries 6 research samples subjects responses results showed that there were statistically significant differences between research samples responses regarding organizational justice and job involvement due to age qualification and years of experience it was clear that as long as employee is older scientific qualification is high and has long service in the ministry he works with and is more satisfied and convinced and has more sense of organizational justice and more jobs involved in the job he has worked for years conclusion based on the results we can conclude that a positive effect showed between organizational justice in different dimensions and employees job involvement in saudi ministries the sense of organizational justice availability shows as follows employees sense of justice ranked first then dealing justice while procedures justice rated last as well as the variable of employee job involvement showed a high rank which indicates the satisfaction of employees after providing the ministrys customers with their assistance also it appeared that the unsatisfied employee in the case of unclear promotion bases and justice bases for material and moral incentives distribution as well as the researchers reached the conclusion that there are no significant differences regarding gender variables and there is a significant difference regarding to variables of age qualification and years of experience there are some limitations of this study that appeared due to applying it to some ministries which need to continue this work for the ministers who cant reach them in addition apply this study to industrial companies and financial institutions 1 encouraging top leaders in saudi ministries to exert more efforts for the purpose of achieving organizational justice by adopting an organizational climate in which justice integrity continuous review of regulations instructions and ways of implementing and correcting wrong practices to achieve justice among all is prevailing 2 officials in saudi ministries must develop employees job involvement by satisfying material and moral needs through restructuring wages salaries incentives rewards and benefits systems to distribute them fairly 3 there is a need to increase attention to tasks and responsibilities identification and there is a need to distribute job burden on employees in a fair manner which ensures avoidance of conflict in work and achieving the fairness of the work distribution justice and to perform the works efficiently and effectively 4 saudi ministries should seek to set a firm system and clear procedures for pursuing job abuses and irregularities and to be applied to all without exception any employees whatever their administrative position is 5 enhancing employee job involvement in saudi ministries by creating an organizational climate characterized by justice among employees and participation in decisionmaking and showing employees respect for the employees in a manner that preserves their dignity and their human feelings 6 there is a need to increase attention to training courses subject in saudi ministries and to design it to get rid of negative behaviors such as favoritism and should direct these courses towards promoting positive behaviors such as honesty and good morals in dealing with employees and achieving justice based on competence and efficiency which contributes in employees job involvement 7 the current study recommends researchers carry out more studies and research for the purpose of investigating other factors that contribute to saudi ministries employees job involvement and other sectors alsharah a m t organizational justice and its relationship with job involvement in saudi government ministries internal consistency questionnaire statements internal consistency was calculated on the pilot sample amounting 30 statements through computing correlation coefficients between each paragraph and the total degree of dimension as follows validity of structural consistency of study dimensions table shows correlation coefficients between the mean of each dimension axes of with total mean of questionnaire statements which shows that indicated correlation coefficients are significant at 005 level which ranged between since significance level of each statement is less than 005 and r calculated value is more than r tabulated value questionnaires statements reliability reliability steps were made on pilot sample using cronbachs alpha to measure questionnaire reliability table shows that reliability coefficients are high results and discussion results studys sample characteristics the following tables show the most important results of collected data analysis from the study sample table shows the result of the first hypothesis test where the result indicates that the correlation coefficient is equal to and that the significant value sig which is less than the significance level of 005 this indicates that there is statistically significant relationship between organizational justice and employees job involvement in saudi ministries employees approval of the existence of a strong relationship between organizational justice and job involvement means that whenever degree of sensitivity of saudi ministry employees to organizational justice increased job involvement is increased the first sup hypothesis there is a statistically significant relationship at level between distribution justice and job involvement in saudi ministries table shows the result of the first sup hypothesis test where the result indicates that the correlation coefficient is equal to and that the significant value sig which is less than the significance level of 005 this indicates that there is statistically significant relationship between distribution justice and employees job involvement in saudi ministries the second sup hypothesis there is a statistically significant relationship at level between procedures justice and job involvement in saudi ministries alsharah a m t organizational justice and its relationship with job involvement in saudi government ministries is greater than the significance level this may be because genders are subject to the same work conditions job burdens and work stress in saudi ministries

purpose this study aims to investigate employees perception of organizational justice and its relationship with job involvement in saudi government ministries theoretical framework organizational justice in the organization is one of the most important factors that shape attitudes and behaviors of employees towards their organizations and focuses on employees understanding the extent of integrity laws and procedures followed by employees therefore any defect or error in these laws and regulations or methods of implementation will lead to a negative result regarding the involvement of employees in their work and the extent to which they are connected to the job in which they work because of their sense of injustice in their organizations hence this study is intended to investigate the relationship nature between organizational justice and job involvement in saudi ministries designmethodologyapproach the study population includes all employees in saudi government ministries with different job names due to the large size of the study population and for selecting a representative sample for this publication a random sample from these ministries employees was used a descriptiveanalytical method was used due to its appropriateness to this studythe study concluded a set of results the most important is that there is a positive relationship between organizational justice in its various dimensions distribution justice procedures justice dealing justice and employee job involvement in saudi ministriesthe study showed high employee job involvement in saudi ministries and there is a sense of organizational justice availability with all its dimensions in saudi ministries originalityvalue this study is considered one of the first studies dealing with organizational justice and its relationship with job involvement in saudi ministries consequently the study results will provide decisionmakers in the saudi public sector with important information on the organizational justice level and its relationship with employees jobs in saudi ministries so this helps them in making proper decisions to improve efficiency and effectiveness and enhance productivity

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multiple chronic conditions in relation to disability and social participation data from the clsa l griffith 1 a gilsing 1 e van den heuvel 2 s nazmul 1 p st john 3 p raina 1 1 mcmaster university hamilton ontario canada 2 eindhoven university of technology eindhoven netherlands 3 university of manitoba winnipeg manitoba canada while much is known about the effect of individual chronic conditions on peoples ability to undertake their everyday activities less is known about effect of having multiple ccs we will present data from over 20000 canadian men and women on population patterns of selfreported ccs and how different combinations of ccs impact disability and social participation preliminary data suggest that although the proportion of people with 2 ccs increases with age and tends to be higher in females than males the difference between genders narrows with age as well combinations of chronic conditions with the same disease count differentially impact activities of daily living and social participation in men compared to women and in middleaged compared to older adults understanding these differences could help to increase the efficiency and quality of clinical care and improve public health associations between sensory loss and social networks participation support and loneliness p mick 1 m pichorafuller 2 w wittich 3 1 university of british columbia kelowna british columbia canada 2 university of toronto toronto ontario canada 3 universite de montreal montreal quebec canada the effects of sensory loss on social structure and function in different age and sex groups are poorly understood we analyzed a population based sample of 21241 canadian adults to determine if hearing loss vision loss or dual sensory loss were associated with social network size social participation availability of social support and loneliness respectively and whether age or sex modified the associations vl was associated with reduced social network size in males and low social participation in all agesex groups dl was associated with reduced network size and participation in 6585 year olds all forms of sensory loss were associated with reduced social support and loneliness the results might be explained by mobility challenges resulting from vl and dl and communication problems arising from hl vl and dl individuals with sensory impairments should be targeted for interventions that increase social engagement and support and reduce loneliness understanding inequalities and inequities in health and wellness among older canadians y asada 1 j hurley 2 s kirkland 1 ml grignon 2 1 community health and epidemiology dalhousie universityhalifaxnova scotiacanada2 mcmaster universityhamiltonontariocanada this presentation focuses on equity in successful aging among older canadians by taking advantage of rich information offered by a new national flagship study the canadian longitudinal study on aging and by advancing the health inequity measurement approach that we have developed we report inequalities and inequities in health and wellness of older canadians results of our study provide rich understanding of the diverse experience of and heterogeneity in health and wellness among older canadians our study also lays the methodological foundation for tracking inequalities and inequities in successful aging of the canadian population over time as followup data become available in the coming years moreover by examining multiple dimensions of successful aging this study informs policy interventions with respect to some of the key priority health areas among older canadians such as frailty and overall strength session 3400 iagg north american region falls preventionnew initiatives from the canadian geriatrics society falls special interest group chair m montero odasso university of western ontario london ontario canada discussant db hogan university of calgary calgary alberta canada falls are a quintessential geriatric syndrome its study and the approaches developed for their prevention contributed to the establishment of geriatric medicine as a distinct field

the canadian longitudinal study on aging is following 50000 men and women aged 4585 every three years for at least 20 years of the total 20000 tracking participants are randomly selected within agesex strata in each province and 30000 comprehensive participants are randomly selected within agesex strata from within 2550 km of 11 sites across the country victoria

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introduction many countries require police to provide a caution to suspects regarding their legal rights upon interrogation although specifics can vary certain rights remain generally consistent across jurisdictions and typically include a right to remain silent and access to legal counsel the consequence of choosing to waive these rights can differ for example inferences cannot be drawn from an individual electing to remain silent in scotland but can in england and wales prompt delivery of the caution is often required typically at the time of arrest however this can vary by jurisdiction it may be repeated or delayed until questioning at the police station and at any subsequent interviews the delivery is typically oral andor written more often orally if an arrest is being made within the community for example there have been several highprofile cases where later discovery of a misunderstanding of rights even if that person claimed understanding at the time of cautioning has led to obtained information being dismissed in court one particularly renowned case is miranda v arizona where ernesto miranda had been charged and sentenced to prison following conviction for rape and kidnap the supreme court ruled the case required retrial where mirandas signed confession was dismissed after it was concluded his rights had not been adequately explained and therefore excluded him from his right to avoid giving selfincriminating evidence the us supreme court maintained that a suspects waiver of rights can only be made if they are considered to have done so voluntarily knowingly and intelligently miranda was ultimately convicted in retrial where the prosecution was based on evidence that did not include the confession ryba brodsky and shlosberg suggested that individual characteristics and situational variables should be considered when determining whether it would be appropriate to assess an individuals comprehension of their interrogation rights they referenced a list of individual characteristics as described in coyote v united states that include age intelligence education and experience with the criminal justice system it is believed that these factors continue to be considered in related decision making even though the cited characteristics were not based on empirical evidence assessment methods in assessment of caution comprehension several methods have been developed to assess understanding of cautions such as grissos instruments for assessing understanding and appreciation of miranda rights the comprehension of caution test miranda rights comprehension instruments and the standardised assessment of miranda abilities these tools use various means of assessing comprehension often with consistent assessment features and then apply a scoring rubric to assess performance the caution may be read in full and thenor each of its elements with comprehension being assessed through paraphrasing or free recall these may be presented in combination with a written version definitions of common legal words that may feature in a caution are often assessed finally individuals may be asked whether a sentence means the same or something different to each element as a means of assessment that does not require independent generation of a verbal response these tools are often used by forensic practitioners for example to aid legal competency assessments and studies have used these tools to consider understanding within various populations empirical studies looking at caution comprehension the degree to which cautions are understood amongst members of public has received empirical attention within recent decades predominately within the uk canada and the usa a scottish study by hughes bain gilchrist and boyle for example considered understanding amongst a sample of the general population only 5 of their sample was considered to understand a verbally presented caution in full despite 95 of participants claiming such comprehension similar findings have been found within other general population samples as well as amongst higher academic achievers some specific groups have been found to struggle notably in assessment of caution comprehension such as juveniles and adults with an intellectual disability it may be assumed that a person who has either been convicted or questioned in relation to a potential crime and hence been cautioned would be likely to have a sound understanding of its meaning however several studies have demonstrated that even amongst this group there is only a limited understanding of the underlying meaning of the caution language comprehension to understand information presented verbally the listener must hold the information being communicated in mind something that may be achieved via rehearsal within the phonological loop of verbal working memory the central executive is then theorised to direct attention to the salient information and access verbal knowledge as stored in longterm memory to make sense as relevant however the amount and pace of information being communicated may vary and the listener may not have control or be able to predict this therefore to determine the meaning of the caution a complex bidirectional and active process is required to modify the essence of the communication as information increases it is suggested that if the information being communicated contains complex language or is large in quantity this can lead to cognitive overload and therefore misinterpretation or misunderstanding comprehension of a verbal caution several factors may increase the complexity of cautions and therefore the cognitive skill required to achieve adequate understanding this includes the complexity of vocabulary which can include words that usually require a higher level of education to understand and are not often heard outside legal contexts the length of cautions can vary significantly and often exceeds suggested listening capacity limits the element of being able to choose whether to waive interrogation right is often stated at the beginning of a caution and therefore requires one to retain that option whilst making sense of the subsequent complex information being communicated these factors may explain why the findings of studies that consider cognitive ability in caution comprehension have repeatedly pointed to a relationship between caution comprehension and intelligence and verbal abilities in adults and young people chaulk et al also found an association with working memory within an adult sample there has also been some mixed evidence that mental illness can impair performance in assessment of caution comprehension where mild to moderate effects are suggested amongst the most severely impaired relevant offender characteristics it is arguable that certain characteristics commonly found amongst offenders indicate impairment in the suggested capacities required to understand a verbal caution a uk review suggested that around 5070 of offenders had no qualifications and literacy skills within the lowest range of a national standardised framework it is also estimated that the prevalence of people with intellectual disabilities may be disproportionately higher than in the general population up to 96 mental illness is a significant problem amongst prisoners with psychosis and major depression being particularly prevalent when compared to general population figures rationale it is well established that adults with intellectual disabilities are significantly impaired when it comes to understanding the caution however it is helpful to empirically consider other variables that may influence comprehension and are important to be aware of therefore the review excludes people with intellectual disabilities to ensure significant impairment of iq does not overwhelm other characteristics that might be of relevance the review considers the literature assessing this within a single population adults within the criminal justice system this population was selected given the practical relevance of examining the group for whom the caution is intended it is also a group within which various characteristics exist that are possibly contributing to performance in assessment of caution comprehension aims the aim of this systematic review is to assess the evidence base on factors that impact comprehension of a police caution amongst adults within the criminal justice system such as demographic characteristics and cognitive and or psychiatric variables method eligibility criteria studies that assessed caution understanding amongst suspects and offenders were considered for inclusion the following eligibility criteria were applied to article selection data extraction demographic data including age gender recruitment population number of prior arrests and years of education were extracted if provided within the article any measures of cognitive ability such as iq and its indices were extracted as well as any further psychological measures assessing cognitive functioning or moodmental illness quality assessment of studies the lead investigator developed an assessment to critically appraise study quality this was informed by previously published quality checklists the critical appraisal skills programme and scottish intercollegiate guidelines network methodology checklists with questions tailored or added to best consider the review question the criteria focused on rationale sample characteristics assessment measures analysis of results and acceptability of conclusions drawn these were assessed over 14 quality criteria which could be scored as 2 1 or 0 as a check of reliability an independent reviewer a thirdyear trainee clinical psychologist applied the quality assessment to six randomly selected papers to reduce risk of bias cohens j suggested moderate agreement in ratings j ¼ 78 p 001 all initial disagreements were discussed and resolved collaboratively there were no noticeable areas of disagreement across criteria that were considered more prevalent results the electronic literature search retrieved 438 papers with 285 remaining after the removal of duplicates a screening of article titles left 76 papers as potentially relevant to the review question a review of these abstracts left 46 papers for those abstracts considered unclear the full text was reviewed against the inclusionexclusion criteria this left the remaining 12 for inclusion a review of the reference lists of included papers returned one more paper a flow chart of this process is provided in figure 1 generally the papers included did not solely assess caution comprehension amongst adults within the criminal justice system or solely verbal caution presentation therefore only the relevant data and related analyses were considered table 1 contains a brief overview of the tools used to assess caution comprehension the conclusions within table 2 are only those relevant to the current review question this systematic review utilises a narrative approach to reviewing the literature it is recognised that this descriptive approach to data synthesis has drawbacks for example drawing out potential small effects and presenting a risk of researcher bias in reportingconclusions however the included literature is heterogeneous with various measures of comprehension and methodologies that preclude pooling together of data for example by using a metaanalytical approach quality ratings the standard of papers was generally limited this was most apparent in a lack of consideration andor reporting of confounding variables determination of sample size or adequate acknowledgement of study limitations however they did generally include a clear relevant development of rationale with explicit objectives and reported conclusions the samples were typically representative of the populations being considered no studies were remarkably better methodologically than the others and could not be considered to have more robust findings therefore no greater weight was placed upon the conclusions of any one study over another sampling studies tended to apply minimal inclusion criteria which increased the potential for confounding variables that may influence scoring across participants the rogers et al papers did not provide ranges for assessed iq for example two papers included participants with iqs below 70 and the everington and fulero paper assumed average intelligence of their relevant sample without formal evaluation although classification of an intellectual disability requires more than an assessment of iq it is possible these samples include individuals who could be classified as suchfor example cooke and philip included people in their sample who they described as finding it difficult to cope in prison which cooke and philip suggested was likely due to poor intellectual functioning people with intellectual disabilities are a population for which evidence has suggested impaired performance on caution comprehension as studies did not include stringent exclusion criteria it is possible some participants would have other cognitive or neurodegenerative conditions such as dementia that may reasonably be assumed to influence performance the review suggests that potential confounders were not adequately controlled for within the analyses of any included articles therefore without explicit consideration of these and related features impact of potential confounders on comprehension cannot be explored or excluded a broad range of ages were represented across the studies only two included articles considered any association of age with assessment of caution comprehension frumkin no relationship between experience with the criminal justice system and comprehension no analysis considering educational attainment 2 everington fulero usa defendants n 30 age m ¼ 335 years prior convictions m ¼ 333 no et al 2012viljoen et al 2002 with no relationship found this contrasts with an apparent positive association suggested from performance amongst juvenile offenders indicating that this effect potentially plateaus as individuals reach adulthood albeit suggested from only a limited literature base in considering adults this review included studies with participants aged 16 years and over however it is recognised that age of adulthood can vary across jurisdictions one study included participants from the age of 16 years with several including participants from the age of 17 years most studies did not match for gender over the 10 studies where the gender split was provided or possible to derive 316 were female although a rudimentary comparison this is considerably higher than the proportion in us prisons according to the federal bureau of statistics none of the included studies analysed the impact of gender on performance however statistically small differences between sex on verbal and working memory abilities would suggest that differences may be unlikely as these are currently considered central cognitive components to understanding in considering years of education this was shown to have little to no association with overall comprehension or possibly only with understanding of the specific words used in cautions notably of the included articles this relationship was only considered in the rogers et al papers cognitive influences the studies reviewed repeatedly suggested a relationship between iq and performance on assessments of caution comprehension the quality of iq assessments varied across sadsc ¼ sadschange version gss ¼ gudjonsson suggestibility scale ilk ¼ inventory of legal knowledge assessments of caution knowledge coct ¼ comprehension of caution test cmr ¼ comprehension of miranda rights tocc ¼ test of charter comprehension mss ¼ miranda statements scale mrs ¼ mrs miranda rights scale mvs ¼ miranda vocabulary scale mq ¼ miranda questionnaire fri ¼ function of rights in interrogation studies with one study drawing from previously assessed iq using a comprehensive measure whilst others used only abbreviated or prorated versions in considering the versions used the original wechsler abbreviated scale of intelligence was most common across the articles which has had its validity in relation to a full assessment of intellectual functioning questioned the wasiii however used twice has been suggested to have improved validity when the domains contributing to overall iq were considered separately their respective assessments of verbal abilities were repeatedly identified as having the greatest relationship with comprehension which is logical when considering understanding of verbally presented information this has also been found in studies assessing nonadult offender samples for example juveniles adults with an intellectual disability and an ethnically diverse sample of college students and adults of those studies included in the present review only chaulk et al specifically considered performance in wais subtests they found that verbal working memory as assessed by the digit span test indicated a possible relationship with comprehension but less so than verbal comprehension listening comprehension may have a predictive role in understanding an oral caution with reading and listening comprehension related to understanding of caution vocabulary however the range of studies considering this remains limited two studies reported a small negative relationship between suggestibility and caution comprehension suggestibility in the assessed context is the likelihood that a persons recollection of an event will be modified based on exposure to subsequent information for example from leading questions this association must be considered carefully as the gudjonsson assessment tool used in both studies requires memory of a read fictional story possibly a proxy measure of verbal ability and memory capacity as opposed to exclusively suggestibility this possibility was recognised by gudjonsson but not empirically explored and is perhaps most pertinent to individuals with challenges in memory capacity such as those with intellectual disabilities psychiatric influences consideration of the impact of psychiatric diagnoses on caution comprehension was limited to four included articles they indicated that the influence of psychological impairment or psychiatric diagnoses on performance was limited to none this first appears counter to the suggestion that mental illness can impair cognitive functioning however the ethical requirement of participant capacity to consent to taking part in the studies prevents opportunity to include participants who may be more severely cognitively impaired by their illness such as the floridly psychotic or severely depressed hence it is feasible there may be an association between comprehension of caution and mental illness for those individuals at the more severe end of the spectrum who are experiencing active symptoms of illness at present a lack of data precludes any strong conclusions in this area influence of prior arrests the studies repeatedly indicated that the number of selfreported prior arrests and therefore presumable prior experience of cautioning were not related to performance in assessment of comprehension this association was also found when fenner et al explicitly asked about numbers of prior caution exposures and cooke and philip considered the number of selfreported prior offences the association is in keeping with the rogers et al study where they did not find that experimentally repeated exposures improved performance in assessment of caution comprehension however it is possible that participant reports of prior arrests could be minimised or exaggerated and it is unlikely that all participants would necessarily know especially for example when reported figures can be over 100 it is also possible that a number of these participants had the caution explained to them in the past which may have affected their performance at assessment only fenner et al explicitly asked this and found that explanations had occurred 034 times across participants however the suggestion that prior experience of cautioning was not related to current comprehension was repeatedly found regardless of study quality this is converse to grissos original development of an assessment of caution understanding that did suggest that prior arrests were related to understanding experimental method all the studies included have arguably limited ecological validity the assessments were completed by researchers and not the police with absence of the stress typical of police interrogation stress has been shown to negatively impact cognitive functioning and therefore presumably affect caution comprehension the measures used to assess comprehension were varied but there was generally a lack of psychometric data to support their validity andor reliability the measures may not provide information regarding participant understanding of the implications of choices being made or reallife action some studies have also included assessments considering this such as the function of rights in interrogation it is possible where participants do not say or describe certain aspects of the caution that responses do not always reflect misunderstanding however it is recognised that free recall is a commonly used indirect method of knowledge assessment and the general consistency of the findings would suggest that this potential effect is limited the specific wording and complexity of the cautions would also vary depending on the assessments used in each study with some studies assessing more than one version in the one assessment session the miranda statements scale for example assessed various versions of a caution ranging from easy to difficult in complexity this variability in wording may be considered more reflective of the reallife situation where police can typically use nonprescribed phrasing to communicate interrogation rights whilst the rights are often consistent across jurisdictions when comparing performance in understanding of the right to silence and access to a lawyer the limited studies suggested that the right to silence was the most commonly reported and understood of the rights this is consistent with the suggestion that phrasing of this right is typically the least complex discussion the conclusions drawn in the reviewed papers should be considered carefully they typically used limited sampling controls used varied measures of assessing caution comprehension and varied in the quality of cognitive and psychiatric assessment tools used more generally they had limited ecological validity and therefore perhaps overestimated understanding where situational factors may play a role it is suggested that individual characteristics that had historically been considered most relevant to potential challenges in caution comprehension may not always be empirically supported findings across the studies suggested that performance on assessments of caution comprehension was limited with an individuals iq and verbal abilities considered most closely associated to this although it may be theoretically assumed that adequate verbal working memory is required to help understand verbally presented information only one study considered this and found a small association with comprehension years of education age and prior experience of cautioning all had limited to no bearing on understanding there is also limited to no suggested impact of mental illness on performance in the included studies although the most ill are unlikely to have been considered suitable for participation due to concerns regarding capacity to consent indeed rogers and drogin have suggested few effects on caution comprehension at mild to moderate severity but that such influences emerge with more extreme severity limitations of systematic review nine of the articles included in this review were from the usa with two from canada and two the uk seven of the usa articles were funded by the national science foundation law social sciences programme a number of those articles from the programme explored performance in certain tests that were part of a larger assessment battery completed with each participant therefore it is possible though not always clear that findings over these articles were pooled from the same sample which would bias results the variability in cautions between jurisdictions limits the drawing of generalisations from this review nonetheless the rights being communicated are generally consistent across jurisdictions however the wording complexity and length can vary considerably between as well as within jurisdictions this lack of variability may have been a product of the search strategy however broad search terms were used to increase the volume of studies retrieved and a review of reference lists only indicated one further study this suggests that the strategy captured appropriate studies well the inclusion criteria permitted both convicted offenders and suspects to be included in the assessments the themes did appear to run across the samples of people involved in the criminal justice system however it is still theoretically possible that participants who had not yet been tried for a suspected crime would be more likely to feign or potentially have something to gain from not understanding indeed rogers henry et al and rogers robinson and henry have been working on developing an instrument to help indicate those individuals who may be feigning misunderstanding implications the findings suggest a need to truly consider the rationale for providing a caution verbally when studies repeatedly indicated insufficient understanding amongst those individuals for whom it is intended it may reasonably be suggested that a full assessment of caution comprehension should be conducted for all defendants as a standard practice this potential for misunderstanding ones interrogation rights is concerning when one considers the power a confession carries in jury decision making kassin et al explored police interrogation practices and described inappropriate strategies that some officers may utilise to achieve such confessions this is a concern when there have been some examples of increasing scientific advances disproving confessions obtained by individuals for crimes they did not commit it had also been suggested that there is a potential for this knowledge of misunderstanding caution wording to be misused for example police using complex language or phrasing not further checking understanding when the accused indicates comprehension or expressing the caution in a way that gives the impression it is a procedural step that does not carry much weight future directions it is suggested that future research could focus on situational factors that may influence comprehension for example using more naturalistic experimental methods such as mock interrogation it is also important to consider alternative means of communicating rights such as always including a written version or applying techniques to a spoken caution that are considered to improve the understanding of verbally presented information it is important to ensure that caution delivery is monitored and that appropriate training is providedthat is appropriate wording presentation and knowledge checking that goes beyond a closed yesno question perhaps by asking individuals to explain their understanding this can prevent the dismissal of important evidence which is based on later discovery of caution misunderstanding or even the potential of feigned miscomprehension being used to manipulate the system conclusions the quality of literature exploring comprehension of a verbal caution within adults in the criminal justice system was considered generally limited with inconsistent focus on potential predictor variables the outcomes currently suggest that iq and verbal abilities may be most closely related to understanding however the quality and heterogeneity of the reviewed literature limit the extent to which this can be adequately inferred there is not enough evidence of a relationship between understanding and education psychiatric diagnoses andor experience in the criminal justice system this is important to consider when a number of these variables seem intuitively pertinent to caution understanding research should continue to identify variables individual and situational that may impact comprehension but also focus effort toward methods of providing a caution that can support understanding ethical standards declaration of conflicts of interest michael rendall has declared no conflicts of interest ken macmahon has declared no conflicts of interest ethical approval this article does not contain any studies with human participants or animals performed by any of the authors

this review systematically examines the literature exploring comprehension of a verbally presented police caution and the suggested factors influencing this amongst adults within the criminal justice system an electronic literature search returned 438 titles with screening leaving 13 articles considered appropriate for the review question the majority of these were usa studies with two uk and two canadian studies heterogeneous study methodologies permit only a narrative approach to pooling the data findings indicate that a considerable proportion of this population have difficulty fully understanding the caution higher iqs and verbal comprehension are positively associated with performance the studies also indicate that some factors that may appear intuitively related to comprehension such as prior caution exposure education age and mental health may not be linked to performance the literature generally used broad inclusion criteria which increased potential for confounders and reduced opportunity to draw out probable predictors

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introduction this study supports the view and standpoint that nationality is the right to have rights it is a fundamental human right it can be argued that you need life to enjoy other rights including the right to a nationality nevertheless what is life when there is no sense of identity this is why the united nations high commissioner for refugees began a campaign to end statelessness called ibelong evidently the right to a nationality is just as important as the right to life in todays world and should be treated as such this research also used analytical legal research and applied legal research methods where analytical legal research is a qualitative research method it is a type of study that requires critical thinking skills as well as the examination of facts and information relevant to the research being undertaken on the other hand applied legal research is a means of locating a solution to a pressing practical situation it is a basic and practical approach to the situation at hand it entails conducting comprehensive study on a specific area of law gathering information on all technical legal laws and principles used and forming an opinion on the prospects for the client in the circumstance i concepts of nationality and citizenship nationality and citizenship are used interchangeably as synonymous words the bundling of these terms is primarily a result of the modern territorial nationstate and the viewpoint of nationalism which asserts congruity between the state and the nation it is also formed to rationalize itself in the name of the people and the sovereign nation that it claims to incorporate and represent the nationalization of citizenship concept however includes both the merging of nationality with citizenship and the interchangeable nature of nationality and citizenship fransman comprehensively distinguished between nationality and citizenship by opining that nationality portrays and categorizes the relationships between an individual and the state under international law while citizenship is the internal national relationship of an individual within the nation while nationality is mainly used in the international realm and for international purposes citizenship is used more domestically therefore the concept of citizenship is strongly associated with belonging to a community being a part of a community and culture of the community this is why one may be a citizen of a nation and be subject to the jurisdiction of the relevant nation and not be a citizen of that nation a perfect example is the filipinos who are basically under and subject to the government of the united states of america as well as entitled to and enjoy protection from the us government abroad heywood opined that citizenship therefore represents a relationship between the individual and the state in which the two are bound together by reciprocal rights and obligations another striking difference between nationality and citizenship is in the aspect of companies ships and aircraft they all have nationality and not citizenship for legal purposes also while nationality is simply just being a national to a nation citizenship is attached to being involved and being part of a community the culture of the people of the community and is more than just the legal international journal of social science research and review volume 6 issue 7 july 2023 status of a person relative to a particular nation or nations citizenship is an advantage of nationality nationality is a link between a person and a state it can also be said to be a human right citizenship on the other hand is granted to an individual having fully complied with legal formalities by the government of a country ii the right to a nationality as a fundamental human right according to article 15 of the united nations universal declaration of human rights everyone has the right to a nationality no one shall be arbitrarily deprived of his nationality nor denied the right to change his nationality by this the udhr has conferred upon every individual the right to have a legal link with a state thus nationality is not only responsible for providing a person with a sense of identity it also provides the individual with the protection of a nation as well as many civil and political rights the political theorist hannah arendt writing on the aftermath of the second world war argued that the dilemma of stateless people in the interwar period resulted in the authenticity of a right to have rights this right to have rights is associated closely with the right to membership of a political community and the right to an identity the right to a nationality has been intricately linked with the right to have rights in multiple cases such as perez v brownell andtrop v dulles in perez v brownell warren cj held citizenship is mans basic right for it is nothing less than the right to have rights remove this priceless possession and there remains a stateless person disgraced and degraded in the eyes of his countrymen also in trop v dulles it was stated that the punishment of denationalization violates the eighth amendment because it deprives the expatriate of the right to have rights historically states and not individuals were subjects of international law thus today with the numerous international human rights treaties the ability of sovereign states to restrict individual rights is limited nonetheless making individuals subjects of international law nationality therefore creates provisions for individuals to have a legal relationship to a state and therefore provides a connection to international law now with the development of international human rights law there has been a total eradication of the traditional view that nationality laws are within the exclusive domestic jurisdiction of sovereign states the right to a nationality is a fundamental human right and should be treated with utmost attention this right simply implies the right of an individual to acquire retain or change a nationality however the right to a nationality is very essential because it provides the individual with a sense of identity if an individual does not have a nationalityis stateless it is impossible to fully enjoy other basic rights such as the right to education right to good healthcare the protection of the state and many other civil and political rights as stated earlier article 15 of the udhr bestows upon every individual everywhere in the world the right to have a nationality the right to a nationality sprung up in the 16th century in a spanish school of international law where francisco de vitoria opined that certain person cannot be excluded from citizenship thus the origination of the right to a nationality as a human right only took place in the mid20th century the right was however first mentioned in the american declaration on the rights and duties of man adopted 2nd of may 1948 and afterwards it was regulated under the udhr in discussing the right to a nationality it is pertinent to note that matters of nationality fall within the exclusive domestic jurisdiction of states international law provides that the right of states to decide who their nationals are is not an absolute right therefore states must comply with the human rights obligations on matters pertaining to nationality that is why their laws must be consistent with international conventions international custom and the principles of law generally recognized with 1930 iii international protection of womens and childrens right to a nationality against statelessness according to article 1 of the un general assembly convention relating to the status of stateless persons of 1954 a stateless person is simply a person who is not considered as a national by any state under the operation of its law they are therefore barred from enjoying the protection rights and benefits offered by a nationality there are two kinds of statelessness de jure and de facto statelessness the above definition of statelessness according to the convention relating to the status of stateless persons refers to de jure statelessness reasons being that it arises from the absence of the formal bond of nationality where nationality is determined according to a nations domestic laws giving nations the absolute competence to confer or withdraw their nationality thus the operation of a nations domestic laws may leave a person without any nationality de facto stateless persons are individuals outside the country of their nationality who for legal reasons are unable to avail themselves of the protection of that country in this section several international instruments relating with the protection of womens and childrens right to a nationality against statelessness will be analyzed according to article 1 of the 1930 hague protocol relating to a certain case of statelessness in a state whose nationality is not conferred by the mere fact of birth in its territory a person born in its territory of a mother possessing the nationality of that state and of a father without nationality or of unknown nationality shall have the nationality of the said state although the aim of the rule is to prevent statelessness it regulates situations when a mother can transmit her nationality to her children obviously as it would only be possible for a mother to transmit her nationality to her children in cases where children would otherwise become stateless is against gender equality when the 1930 hague convention on certain questions relating to the conflict of nationality law is considered article 8 and 9 require special attention according to article 8 if a woman acquires the nationality of her foreign husband she will lose her original nationality on the other hand if a womans nationality law provides loss of nationality in case of marriage with a foreign man this could only be possible if foreign mans nationality law grants nationality to the married woman although gender equality is not taken into consideration regarding acquisition and loss of nationality statelessness is tried to be prevented and right to a nationality is respected it should be added that there is a rule regarding children born out of wedlock in the convention but it doesnt say anything about how to prevent statelessness in such cases it only provides that when a legal bond is established between the child and the father the childs loss of the existing nationality depends on the acquisition of another nationality the declaration on the rights of the child of 1959 also adopted the right to a nationality as a resolution of the un general assembly however it is a soft law and has never gained a binding force principle 3 of this declaration only offers the child the right to a nationality from his or her birth the convention on the reduction of statelessness of 1961 is another international instrument that has helped in the reduction of statelessness although it does not contain the right to a nationality article 8 paragraph 1 interdicts the deprivation of nationality therefore states are obliged not to deprive anyone of their respective nationality if such deprivation would render them stateless except for a few exceptions like fraud article international journal of social science research and review volume 6 issue 7 july 2023 4 of the convention requires special attention as it is related to children it provides that a contracting state shall grant its nationality to a person not born in the territory of a contracting state who would otherwise be stateless if the nationality of one of his parents at the time of the persons birth was that of that state as can be understood the aim of the rule is to prevent statelessness at the time of birth by applying the principle of jus soli and by respecting gender equality the international covenant on civil and political rights of 1966 in general does not contain the right to a nationality however article 24 paragraph 3 only provides the right to acquire a nationality to children according to un human rights committee states should take necessary measures both in their national legal systems and in their relations to make sure that every child will have a nationality at time of hisher birth a convention was adopted in 1973 titled convention no 13 to reduce the number of cases of statelessness in bern according to article 1 of the convention a child whose mother holds the nationality of a contracting state shall acquire that nationality at birth if he or she would otherwise have been stateless this provision also prevents statelessness of children born out of wedlock convention on the elimination of all forms of discrimination against women played a very important role regarding prevention of gender inequality within this framework the convention provides a rule which requires equal rights for men and women regarding acquisition change and possession of nationality additionally article 92 obliges contracting states to provide equal rights to men and women on transmission of their nationality to children consequently single or married all women will be able to transmit their nationalities to their children the convention on the rights of the child of 1989 was adopted to protect childrens rights in general against any form of discrimination the principle of nondiscrimination is well established and well spelt out amongst other guaranteed rights of the child in article 2 of this convention the main question of concern is what makes child discrimination special and different from other forms of discrimination children often require special measures in determining discrimination and protection it is however very important to take into account their distinct vulnerability with regards to the nation as well as visàvis their families and others children can also be discriminated against as a result of the actions of their parents for example getting pregnant outside wedlock which results in a child born out of wedlock faced with a number of discriminatory practices especially with nationality issues the un committee on rights of the child supports the idea that if children born out of wedlock are not recognized by their father states must provide rules regarding transmission of mothers nationality to children in their national legal systems according to article 7 the child shall have the right from birth to acquire a nationality additionally states parties shall ensure the implementation of these rights in accordance with their national law and their obligations under the relevant international instruments in this field in particular where the child would otherwise be stateless iv conceptualization of nondiscrimination and equality the aim of this section is to outline the relation between nondiscrimination and equality their definitions and how they are understood by various national legal systems due to the constant misuse and confusion of both concepts this study however sees the importance of distinctively discussing them before proceeding with the discussion on nondiscrimination and the right to equality it is particularly important to review the concept of discrimination and its relationship with the concept of equality international journal of social science research and review volume 6 issue 7 july 2023 therefore the discussion of nondiscrimination and equality is categorized by a significant conceptual and methodological misperception nondiscrimination and equality are complicated ideas with an extensive level of deliberations arguments and discussions on their meanings use and justification notwithstanding understanding how these concepts are interpreted and applied will be significantly useful in the contribution to the appropriate enforcement mechanism of equality law in the countries concerned across the globe an indepth understanding of these concepts requires an understanding of each and how they both relate to the other it is extensively acknowledged that nondiscrimination and equality are positive and negative statements of the same principle equality can be defined as the individual having equal value with others in terms of being human quite simply equality is the absence of discrimination and conversely perpetuating the principle of nondiscrimination between groups will produce equality equality has two facets the positive and negative side the negative side of equality is what is often referred to as discrimination in most of the international and regional documents like udhr article 2 and iccpr article 21 equality is guaranteed with the provision of nondiscrimination whereas to define discrimination the following elements must be in place it must stipulate a difference in treatment has a certain negative effect and is based on a certain prohibited ground according to un human rights committee discrimination means …any distinction exclusion restriction or preference which is based on any ground such as race color sex language religion political or other opinion national or social origin property birth or other status and which has the purpose or effect of nullifying or impairing the recognition enjoyment or exercise by all persons on an equal footing of all rights and freedoms nondiscrimination and equality both constitute the principal theme of a typical modern international law of human rights both principles are the foundation of every human rights law that has developed since the second world war shestack opined that nondiscrimination and equality are central to the human rights movement nondiscrimination offers a solid foundation for human rights to be fully enjoyed therefore it is important to investigate the sources of nondiscrimination the principle of nondiscrimination in nationality laws is a principle in which states are obligated to ensure that nationality is granted to everyone on equal footing the mandate that everybody should be treated equal before the law seems to be one of the vital requirements of the rule of law at the heart of international law today are two principles first states must guarantee that the right to a nationality is enjoyed on equal footing by everyone in accordance with the principle of nondiscrimination secondly states have the obligation to prevent and reduce statelessness the assignment on the prevention of discrimination and protection of human rights was fashioned by the un to specifically deal with queries of discrimination however over the years several grounds have been founded upon which discrimination is prohibited it should be added that equality and nondiscrimination are principles of international that form jus cogens and they are terms that can sometimes be used side by side and sometimes to mean the same thing v gender inequality and children born out of wedlock gender discrimination in civil registration law hinders womens ability to register their children at birth and for the purpose of this study particularly for children born outside of wedlock birth registration is considered to be a first right for every child by the un discrimination against women and children born out of wedlock also limits avenues to verify the paternity of nonmarital children international journal of social science research and review volume 6 issue 7 july 2023 gender inequality is also called gender discrimination or discrimination based on sex and according to article 1 of the cedaw the term discrimination against women shall mean thus any distinction exclusion or restriction made based on sex which has the effect or purpose of impairing or nullifying the recognition enjoyment or exercise by women irrespective of their marital status on a basis of equality of men and women of human rights and fundamental freedoms in the political economic social cultural civil or any other field regarding nationality gender equality refers to wifes and husbands acquisition of each others nationality under same conditions and transmission of their nationalities to their children under same circumstances however unhcrs survey on nationality legislation found that equality between men and women regarding the transfer of nationality to children has not yet been attained in 25 countries and these countries are located in almost all parts of the world most nationality laws in africa discriminated on the basis of gender at the time of independence and up until recently if the father was not also a citizen female citizens could not pass on their nationality to their foreign spouses or to their children many provisions found in nationality laws regarding birth registration may clearly dismiss women from registering their children at birth some nations may only allow women register births in very exceptional conditions while some nationality laws only allow women to register births when they can prove a valid legal marriage certificate indirectly proving the child was born in wedlock and not out of wedlock as a result of gender discrimination in nationality laws a woman may then become stateless if she does not automatically receive the nationality of her husband or if her husband has no nationality also a woman can equally become stateless if after she receives her husbands nationality the marriage is dissolved and she loses the nationality acquired through marriage but her original nationality is not automatically restored which the convention on the nationality of married women is against there are different forms of gender discrimination in ways whereby women can be discriminated against in nationality laws they are • a woman is likely to encounter deprivation of her nationality upon marriage to a foreigner or change in her husbands nationality before 1910 a wife automatically possessed her husbands nationality under almost all state nationality laws except for some south american countries which often resulted in statelessness by marriage • states often make special provisions for the naturalization of foreign spouses of nationals to only spouses of men and not foreign spouses of women a good example of this is sudan where a foreign woman can acquire sudanese citizenship by marriage but foreign man cannot 2011 and 2018 2018 also states are fond of having very stringent requirements for foreign male spouses as it is in the cases of nigeria • finally it has been observed that some states also discriminate against womens capability to pass their nationality to their children even though the birth was done in the mothers country of origin this is usually quite common with states using the jus sanguinis approach because some states applying this approach only grant nationality through the father like kuwait again in sudan children of sudanese man automatically acquire sudanese citizenship while children of sudanese woman should apply to competent authority for acquisition 2011 and 2018 2018 international journal of social science research and review volume 6 issue 7 july 2023 these discriminatory provisions deny citizenship to the children of a woman who is married to a foreigner while on the other hand granting citizenship to the children of a man who is married to a foreigner in many nations women cannot confer their nationality onto their children and for children born out of wedlock the case is different and treated differently which brings about discrimination on the acquisition of nationality leading to statelessness a recent survey on nationality laws carried out by the unhcr found that about 25 countries do not permit mothers to confer their nationality to their children on equal basis to their fathers which eventually leads to statelessness however some countries have had national law reform like that in iran in 2019 that permits iranian mothers to confer their nationality to their children less than 18 years before then iranian mothers were not allowed to confer their nationality to their children regardless of statelessness first id cards issued for children of iranian mothers foreign fathers abroad according to iranian nationality law nationality is granted based on the jus sanguinis and jus soli concepts both of which disadvantage women regardless of where they are born all children of iranian fathers are automatically given the nationality of iran but for many years iranian women were not allowed to pass on their nationality to their offspring due to the countrys nationality law but with the unhcr ibelong campaign and awareness iran has amended its nationality law now permitting mothers to transfer their nationality to their children if the child would otherwise become stateless wherever they are born however the government of iran still has the discretion in granting or rejecting the conferral nationality request which is still slightly discriminatory as it is not the same situation with fathers in 2017 madagascar madagascar unhcr welcomes new law giving men and women equal rights to transfer nationality to children 2017 sierra leone and the united arab emirates accepted the ibelong campaign and reformed their nationality laws to allow women confer their nationality to their children nevertheless qatar is a perfect example of a country that does not permit a qatari mother to confer her nationality to her child without any exception regardless of if it will result in statelessness this is a clear example for this study that explores how gender discriminatory nationality laws can lead to statelessness similarly in kuwait if a child is born out of wedlock or born to an unknown father or a father without a nationality the kuwaiti mother cannot transfer her nationality to her child leaving the child stateless until the child is of a majority age the precise number of stateless people in the world today is unknown but the unhcr makes a proper approximation that there are many millions of stateless persons globally of which an estimation of the current stateless people one third are children the beginning of a stateless child is a faulty birth registration system discriminating against women registering their children by themselves and children born out of wedlock throughout the period of the second half of the twentieth century the discrimination between children born in wedlock and out of wedlock fizzled out gradually in almost all the european nations as a international journal of social science research and review volume 6 issue 7 july 2023 result of the impact and effectiveness of the european convention on human rights and its applications by the ecthr a landmark case reviewed by the ecthr is marckx v belgium according to the judgment of this case in conjunction with article 8 and article 1 respectively of the echr it was said that the belgian law infringed on the right to private and family life in another striking case in france about a child discriminated against in accessing his mothers inheritance because he was born out of wedlockmazurek v france the french national court assessed and rejected mazureks appeal for his mothers inheritance mazurek having been rejected further appealed to the ecthr the ecthr relying on article 8 and article 14 found a violation of the echr by the french national court based on principle of discrimination because the french national court had treated people in similar circumstances differently without any justifiable reasons also in germany before the german reform in 1997 there were several cases of discrimination against children born out of wedlock usually they were referred to as illegitimate children and these children even though recognized by legitimate parents could not inherit from their parents striking cases to this effect are brauer v germany and anayo v germany however there is also a striking case in malta of a child born out of wedlock to a british woman and a maltese man genovese v malta his mother applied for maltese citizenship for her son but was rejected in view of sections 5 and 17 of the maltese citizenship act which stated that children born out of wedlock were only eligible for maltese citizenship if their mother was maltese and in this case the mother is british the maltese court gave a decision that the child cannot acquire the maltese citizenship because there has to be legitimation in this case marriage between father and mother the ecthr however declared the application admissible unanimously and held by six votes to one that there has been a violation of article 14 in conjunction with article 8 of the convention the court also underlined that nationality is part of a persons identity which is linked to the right to respect for private life vi the fight against statelessness and discrimination there are numerous causes of statelessness as it can result from a variety of circumstances such as conflict of national laws on renunciation state succession wars automatic loss of nationality etc however this paper narrows the numerous causes of statelessness to genderdiscriminatory nationality laws that is national law and practices that affect particularly women and children born out of wedlock this section of the study seeks to answer the very prominent question of what discrimination and inequality have to do with statelessness and why it is necessary to not just fight statelessness alone but to fight both statelessness and discrimination the unique fact about statelessness is that it cannot be addressed in isolation it has to be addressed alongside its causes and propagation which is why discrimination and inequality are strongly discussed as being the major causes of statelessness in the world today the problem of discrimination inequality and statelessness has posed new challenges to the international community hindered by the inactions and a game of shifting responsibility currently there are about 10 million stateless persons worldwide under the unhcrs protection mandate in addition to this there are also around 35 million palestinian stateless persons in need of international protection the fight against statelessness is a global issue that requires global attention and cooperation to fight against it the issue of reduction of statelessness was first deliberated by the general assembly and conventions the european convention on nationality of 1997 provides further confirmation that the regional standards now in place put europe at the forefront of the fight against statelessness and discriminatory national law the ecn however is a consequence of european countries not including the right to a nationality in the echr but it should be noted that there is no effective mechanism for enforcement of ecn unlike the echr however when compared with the echr the ecn is weak with its adoption the echr began to indirectly consider the things regulated in the ecn in the preamble of the ecn paragraph 7 which deals with the respect for family life gives the ecthr a clue about the respect for family life for nationality cases a perfect example of this is the kafkasli v turkey in this case the then european commission on human rights ruled that the regulations resulting from the status of a stateless person should not constitute an invasion of the applicants private and family life after the kafkasli case the ecthr started to review nationality issues like the genovese case this means the ecthr is helping european countries fight against statelessness and discrimination while nationality is not within the jurisdiction of the european court of justice each member state determines who its nationals are in the rottman case the ecj reviewed an issue regarding nationality where it was understood that the ecj plays a vital role in fighting against statelessness also in both america and africa the right to a nationality has explicitly been included in article 20 of the american convention on human rights and article 6 of the african charter on the rights and welfare of the child respectively with the interamerican court of human rights and african court on human and peoples rights as an enforcement mechanism to ensure obligation and cooperation conclusion and recommendations it is safe to certify that gender inequality is one of the major causes of statelessness especially for children born out of wedlock which is rarely emphasized on for this reason the unhcr is steadily promoting gender equality in nationality laws as part of its mandate to prevent fight and reduce statelessness in the world as a whole also as specified by both the iccpr and the crc all children irrespective of where they were born and how they were born should be registered immediately at birth and must acquire a nationality but these international instruments are not effective without the cooperation of national laws because the nationality of a child will be determined according to the laws of the nation involved this study proffers possible solutions and ways out of the said problem discussed thus this study concludes by recommending possible solutions for achieving a drastic reduction to statelessness in the world these recommendations are in fivefold firstly the problem of discrimination is at the root of statelessness precluding women from having the opportunity to transfer their nationality where there is a great probability of the child being stateless should be highly discouraged the rationale behind women not being able to transfer their nationality to their own children is one that is very absurd considering the paternity of the child could be argued but not the maternity it is undoubtedly clear due to natural circumstances that this is the mother of the child the solution to this is for states to fully adopt the principle of nondiscrimination in all ramifications pertaining to nationality if a child being born out of wedlock will lead to that child becoming stateless due to the absence of the father then the mother of the child should be allowed to transfer her nationality to the child without any discretion secondly it is impossible to address the issue of statelessness without paying attention to human rights so far this study has been able to prove beyond a reasonable doubt that statelessness is a violation international journal of social science research and review volume 6 issue 7 july 2023 of a fundamental right the right to have rights is the basis upon which every other right can be maximally enjoyed therefore states should respect and hold in great esteem their obligations to promote and protect human rights within their territory and act as agents for the protection of human rights in cooperation with other states outside their territory thirdly states should adopt a system this study calls on the point citizenship as part of the birth registration process this should be adopted in states that do not operate the jus soli approach it is understood from the roman law era where citizenship was initially practiced it was jus sanguinis this study reasoned that this could mean that citizenship is not just merely a privilege but a strong link between the individual and the state therefore this on the point citizenship is a temporary citizenship given by the state to a child who will become stateless due to circumstances this method of citizenship is given with strict conditions which are 1 the child loses the temporary citizenship if they fully acquire another nationality 2 the child loses this citizenship if the child leaves the state for a period of 510 years this is because there is no genuine link between the child and the nation of birth of the child 3 if the parents of the child have successfully transferred their nationality to the child 4 the child can also retain citizenship by becoming permanent if the parents of the child are not citizens and they decide to reside within the said state for a long period thereby establishing a genuine link between the state and the child it is important to note that this concept is not an avenue for dual nationality it is only a softer substitute of jus soli for nations who do not adopt the jus soli approach and it will be totally illogical to tell states to now begin to adopt an approach that has never been in their system for example nigeria adopts the jus sanguinis approach now in order for nigeria to help contribute in the fight against statelessness nigeria can choose to adopt this on the point citizenship that comes with conditions this is very relevant in the fight against statelessness as it is temporary does not create an avenue for dual nationality the state has full control over determining its conditions and most importantly it prevents statelessness from birth by this also states are indirectly ratifying both the 1954 and 1961 convention and fulfilling their obligations the unhcr should also encourage and incorporate the on the point citizenship in the ibelong campaign fourthly even though this study focuses on children born out of wedlock it also focuses on the problem of statelessness more generally as it also affects adults this fourth point is directed to stateless adults states should cooperate amongst themselves by ensuring that no one state fully allows an individual to renounce their citizenship until another is acquired successfully states should however try to facilitate naturalization processes as well as create easy access for the acquisition and the confirmation of documents process for individuals who are already stateless like the united kingdom that has different categories of citizenship states should provide an adequate mechanism or create another category of citizenship that will protect them from any form of abuse associated with being stateless and allow them enjoy certain basic rights if not all the rights as a regular citizen fifthly states and international organizations like the unhcr should support and adopt relevant research works by academicians on statelessness this is because rigorous research has been carried out on the subject matter which leads to great recommendations even nongovernmental organizations are required to show support in the fight against statelessness

to possess a nationality is essential to every human existence and should not be overlooked or disregarded but treated with the utmost seriousness this study explores the disadvantages of not having a nationality and the perilous effect of gender inequality in nationality laws which leads to statelessness for children born out of wedlock many academic researchers and policyoriented studies have investigated the condition of statelessness since its emergence including united nations institutions this study comments on the weaknesses and lapses of certain major international instruments and the interpretation and application of these international instruments on nationality and statelessness in addition to evaluating what has been done to combat statelessness it also reflects on what needs to be done and the strict adherence to the principle of nondiscrimination by nations organizations and individuals

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introduction childhood obesity remains a serious public health problem in the united states and lowincome and minority children are disproportionately affected 1 2 3 the reasons for this are likely the result of complex relationships between individual family and communitylevel factors and the built and social environment of the neighborhoods in which children live in existing prospective cohort studies a low level of physical activity along with genetic characteristics are the factors most consistently found to be associated with the development of excess fatness in children and adolescents 4 neighborhood environments provide barriers and opportunities for children to be physically active and determine childrens access to healthy and unhealthy foods crosssectional studies consistently show that aspects of the physical activity environmentthe availability of recreation areas parks or playgrounds near the home a shorter distance between home and school lower exposure to traffic and the presence and conditions of sidewalksare positively associated with higher levels of childrens physical activity 5 6 7 existing studies do not provide conclusive evidence of links between childrens physical activity and either residential density or road connectivity 56 8 9 10 both of which have been found to be associated with physical activity in adults 11 findings are mixed when the focus of the study is on the association between the physical activity environment and child weight status 9 12 13 14 15 16 17 five of the seven existing studies find a significant relationship in the expected direction 9 12 13 14 17 the other two find no association 1516 two crosssectional canadian studies found good access to playgrounds parks and recreational facilities increased the likelihood of a child being classified as normal weight 1213 one longitudinal study in southern california found park space and number of municipal recreational programs for children and youth wereassociated with a youths body mass index at age 18 14 another longitudinal study in indiana found neighborhoods with little green space were associated with an upward shift in bmi zscores over two years 9 however two other longitudinal studies that examined access to recreational opportunities and change in bmi zscores found no association 1516 another aspect of the physical activity environment lower traffic density near childrens homes was significantly associated with a lower bmi after controlling for numerous potential confounders in the only study that looked at traffic density and child weight status 17 existing evidence for a link between child weight status and an aspect of the food environment access to healthy food outlets is also mixed these studies focus on proximity to large and small grocery stores where healthy foods are more likely to be sold and proximity to convenience stores and fastfood eateries where caloriedense foods are readily available and inexpensive and fresh fruits and vegetables are rare a recent systematic review reported that the most consistent finding related to access to healthy food was a significant association between living closer to convenience stores and a higher likelihood of child overweight 1819 however three longitudinal studies based on national samples of us children found no association between child weight changes over time and accessibility to convenience stores one was conducted with children 6 to 17 years of age 20 one focused on 45yearold children 21 and one followed kindergartners through elementary school 22 two studies examined the association between child weight and proximity to large grocery stores which would provide access to healthy foods one study found that living farther from a supermarket significantly increased the risk of overweight in children and youth 23 while the second study found neighborhood supermarket density did not independently explain weight gain over time in a national sample of elementary schoolaged children 22 another systematic review failed to find any consistent association between the availability of fast food restaurants and child adiposity the three studies reviewed reported markedly different results in one study the availability of fast food restaurants was not significantly associated with adiposity in a preschool aged population in a second study the availability of fast food restaurants appeared protective in elementary schoolaged children although the protective effect varied by measures of adiposity and differed for children by age and sex in complex ways in a third study both the number of fast food restaurants and the number of nonfast food restaurants were positively related to measures of bmi and overweight in middle and high school students 6 a major challenge for all studies is to ensure that built environment effects are not attributable to differences in other aspects of the neighborhood context socioeconomic ones in particular a substantial number of existing studies investigate links between neighborhood social disadvantage and child weight status they tend to find that higher levels of neighborhood social disadvantage are associated with higher child adiposity regardless of the measures used 62425 social disadvantage in these studies is measured by aggregated variables from the census such as median household income lower percent home ownership and a higher proportion of nonwhite residents lower levels of educational achievement and higher percentage of singleparent households 25 there is also some evidence that neighborhood safety matters 6 most studies of neighborhood social disadvantage and child weight status do not include measures of the built environment in this study we seek a deeper understanding of these complex relationships by examining weight change over the summer in a population that is at higher risk of excess weight gain in childhood due to its racial and socioeconomic composition participants all attended one of 12 elementary schools in tallahassee serving a predominantly black economically disadvantaged population our focus on this population is important because existing evidence from a number of studies that examine disparities in weight gain among children over the summer suggests that racialethnic minority children may experience faster gains than others as may overweight children in general 2627 furthermore it helps fill a significant gap in the literature only three of the studies of the built environment and childrens weight status focus on a study population that is predominantly lowincome and nonhispanic black 121419 the objective of the current study was to investigate the association between neighborhood environments and weight gain over the summer in lowincome predominantly black elementary school children we hypothesized that children who live in neighborhood environments that provide more opportunities for physical activity and healthy eating will exhibit less weight gain less change in body mass index and less change in their bmi percentile than children living in neighborhoods with fewer such opportunities bmi is a measure of body fat based on both weight and height 28 and the bmi percentile is an indicator of the relative position of the childs bmi value among children of the same sex and age 29 although previous studies have examined weight change over the summer they have not considered the potential effects of the neighborhood built environment nor have they focused on predominantly black elementary school children from low income families using multiple measures of weight change 2630 methods data sources a data set was obtained from the third author from her national institutes of health funded grant examining the impact of schoolbased bmi screening on parent behavior and child health in a population of students from 12 lowincome predominantly black elementary schools in tallahassee the childs home address was made available to a consultant among the 3344 participants those who had different addresses in spring 2010 and fall 2010 and those who had incomplete or missing addresses were excluded from the study dataset in addition the children who did not have height and weight data in both spring 2010 and fall 2010 were not included finally due to small numbers we also excluded children whose raceethnicity was other than white or african american yielding final study data set of 2770 participants using geocoding software the consultant linked each participants home address to a land parcel and a census block group census block groups were used because they represent a close approximation of humanscale neighborhoods where activities are within a 5 to 10min walk of the center to capture the neighborhood characteristics of interest we obtained built environment data from the publiclyavailable department of revenue 2009 parcellevel database and from the 2009 leon county geographic information system and social environment data from the us census bureaus ongoing american community survey the measures of the neighborhood social environment used in this study are characteristics of census block groups the measures of the built environment were calculated by the consultant for buffers or zones drawn around each childs home address using a radius ideally all buffers in our study would have been drawn using a quartermile radius since a quarter mile is a standard estimate for the distance an average person is willing to walk to a destination however only a small number of participants had a park or a large or small grocery store within a quarter mile of home therefore we used a 1mile radius for our measures of access to parks and small and large grocery stores the consultant produced a deidentified dataset for use by the research team which included the childs individual characteristics ie age sex race eligibility for free or reduced lunch program and height and weight for spring and fall 2010 indicators of the neighborhood built environment calculated for a buffer around each childs home and social environment characteristics of the census block group in which the child lived this project was approved by the florida state university institutional review board on 5162012 hsc no 20128130 measures the study uses three measures of the childs weight status weight bmi 28 and the childs age and sexspecific bmi percentile obtained using the center for disease control and preventions childrens growth chart calculator 29 each measure has its advantages and disadvantages change in weight does not take into consideration change in height change in bmi does take into consideration height but does not factor in age and sex which is an important consideration in children bmi percentile is age and sex specific but is insensitive to change in very overweight children for example a 7 year old boy who is 4 feet tall and weighs 125 pounds has a bmi that falls in the 9999th percentile if he gains 10 pounds or loses 10 pounds over the summer he will still be in the 9999th percentile childrens height and weight were measured by trained study personnel neighborhood social environment the measures of the neighborhood social environment are all based on acs data for census block groups collected from 2005 to 2009 their purpose is to control for the social aspects of neighborhoods that affect child health and wellbeing our measures include indicators of social disadvantage as do most existing studies proportion households living below the federal poverty level proportion singleparent households with small children racial composition and an indicator of level of educational achievement in the neighborhood they also go beyond social disadvantage to include an indicator of the extent of large multifamily housing complexes and an indicator of residential mobility neighborhoods with more multifamily housing complexes may not feel safe for children due to traffic and may not have the social capital needed to keep streets safe from drugs and crime the same is true for neighborhoods with a high rate of in and outmovers neighborhood built environment our measures of the built environment include two types those related to the physical activity environment and those related to the food environment physical activity environment our indicators of the physical activity environment include a measure of the childs exposure to green spaces ie presence of a park with greenery that is primarily for strolling or sitting or wooded areas that are not primarily for energetic physical activity within a quarter mile radius from the childs home address a measure of the childs access to parks and recreational opportunities defined as presence of a park or recreational area that provides facilities for active recreation within a 1mile radius of the childs home address and the childs level of exposure to traffic measured as the percentage of roads within a 1mile radius of the childs home that carry a high volume of traffic as a proxy for how safe the neighborhood is for walking and riding a bicycle the first indicator is measured within an easy walking distance ie a 1 4 of a mile radius from the childs home address the second indicator is measured within a 1mile radius of the childs home address because only a small number of children had such facilities within 1 4 mile from home food environment our three indicators of the food environment include both the places that are more likely to carry healthy foodlarge grocery stores and small grocery or specialty food stores and those that are less likelyconvenience stores and fast food eateries the variable indicating the presence of at least 1 large grocery store and the variable indicating the number of small grocery or specialty food stores are measured within a 1mile radius of the childs home address because only a small number of children lived near such stores the third variable is measured within a quarter mile of the childs home and is a composite indicator including the number of convenience stores or fast food eateries analysis strategy we ran all regression models for the 3 different measures of change in participants weight status from spring to fall 2010 change in bmi percentile change in bmi and change in weight because of the multilevel structure of the data we used a mixed model approach to the analysis treating the census block group of the childs residence as the level 2 variable to control for the potential correlation between children within neighborhoods level 2 variables included the six neighborhood social environment variablesproportion housing units in large multifamily buildings proportion lowincome households proportion collegeeducated residents proportion singleparent households proportion black residents and proportion residents who lived in the same house as five years ago and the six built environment variables characterizing the area surrounding the childs homepark with play equipment within 1 mile green space within 1 4 mile large grocery within 1 mile number of small grocery stores within 1 mile number of fast food or convenience stores within 1 4 mile mean percentage of roads with high traffic volume within 1 mile level 1 variables the childs characteristics included age sex race and eligibility for free or reduced lunch and overweight status in spring 2010 participants were classified as overweight if their bmi percentile was 85 or higher 31 we ran mixed models including all of the seven social environment variables together and separately and all of the six built environment variables together and separately and with all of the childs characteristics only one characteristic of the neighborhood social environment the percentage of housing units in large multifamily buildings and one characteristic of the neighborhood built environment the number of small groceries or specialty food stores within a mile of the childs home emerged as important indicators in both the combined and separate models our final overall model therefore included 1 indicator of the neighborhood social environment 1 indicator of the neighborhood built environment and four childs characteristics age sex race and overweight status in spring 2010 we also ran mixed models stratified by overweight status in spring 2010 to examine whether the overall model was consistent for normal and overweight children the analyses were performed using sas software version 92 results child characteristics a total of 2770 elementary school children living in 128 different census block groups was included in this study the mean age for this population in spring 2010 was 83 years 163 ranging from 56 to 126 years table 1 provides the sample characteristics in spring 2010 slightly more males than females participated and the majority of the children were black and eligible for free or reduced price lunch over a third of the children were overweight with a bmi percentile ≥85 childrens home neighborhoods the food and physical activity environment around childrens homes varied sixtyone percent of the children lived within a mile of a large grocery store 2253 percent had one small grocery or specialty food store within a mile of their home and 1209 percent had 2 or more small grocery stores 2603 percent had a park with facilities or equipment that encourage active play within a mile of home and 1422 percent live within a 1 4 mile of a green space furthermore 1119 percent of children lived within an easy walking distance of one fast food eatery or convenience store and 747 percent lived near two or more such food outlets table 3 in addition on average a quarter of the roads within a 1mile radius of the childs home carry a high volume of traffic the mean proportion of households living below the poverty level in childrens home neighborhoods and the mean proportion of single parent households with small children were both about 030 the mean proportion of black residents in childrens neighborhoods was 052 the mean proportion of college graduates 056 the mean proportion of residents who had not moved in the past 5 years 072 and the mean proportion of housing units in large multifamily buildings 017 factors associated with weight status change over the summer table 5 depicts the final overall model predicting weight status change over the summer three of the child characteristics proved to be important predictors only race was not female children gained significantly more weight than male children and had a larger increase in their bmi and older children gained more weight and had a larger increase in their bmi than younger children these effects were not significant for bmi percentile which is to be expected since that measure takes into consideration the childs sex and age in addition the childs overweight status was an important predictor of weight status change with overweight children gaining more weight and increasing their bmi more than normal weight children over the summer as expected this effect was not seen for the bmi percentile measure since it can be insensitive to changes in overweight children controlling for these child characteristics we found one neighborhood social environment variable and one neighborhood built environment variable to be associated with weight gain over the summer living in a neighborhood with a higher proportion of housing units in large multifamily buildings an indicator of the neighborhood social environment was significant in two of the models and approached significance in the third bmi percentile change weight change bmi change living in a neighborhood with no or only 1 small food store was significantly associated with greater weight gain over the summer compared to living in a place with 2 or more small grocery stores for bmi change and weight change the association was weaker and nonsignificant for bmi percentile change because the childs overweight status in spring of 2010 was associated with greater weight gain over the summer we conducted stratified models to examine whether the same factors were associated with summer weight gain in overweight and normal weight children the importance of the neighborhood environment factors differed for these two groups of children the number of small grocery or specialty food stores was statistically significant only for children who were overweight in spring 2010 not for children who were normal weight overweight children who had no or only one small grocery or specialty food store within a mile of their home gained more weight over the summer than overweight children with access to two or more small grocery stores bmi change and weight change the pattern was the same for bmi percentile change living in a neighborhood with a higher proportion of housing units in large multifamily buildings on the other hand came close to statistical significance for children who were normal weight in spring 2010 but not for those who were overweight it came close to a significant association with greater weight gain over the summer across all 3 measures of change in weight status bmi percentile change bmi change and weight change see table 7 discussion this study helps address the need for more research that focuses specifically on children at high risk of overweight by examining the relationship between neighborhoods and summer weight gain in a population of 5 to 13yearold children who are mainly from lowincome black families in the us south over 37 of our sample was overweight in the spring of 2010 this is higher than the 20092010 national average of 326 percent for 6 to 11yearolds of all races and lower than the 427 percent national average for nonhispanic blacks of the same age 3 as expected study neighborhoods were poorer than the county as a whole on average study census block groups featured 31 percent of households with an annual income of less than 20000 the comparable acs figure for the county in 2009 is 27 percent over the course of the summer the sample as a whole gained weight as measured by bmi and weight girls and older children gained more weight and had a larger increase in bmi over the summer consistent with prior reports 2627 children who were already overweight at the beginning of the summer gained more weight and significantly increased their bmi compared to their normal weight peers these effects were not seen with the bmi percentile measure as it controls for both the effect of age and sex and can be insensitive to change in children who are already very overweight due to the ceiling effects inherent in the measure controlling for these child characteristics we found that access to no or only one small grocery or specialty food store was associated with greater weight gain in this lowincome minority sample small and large grocery stores tend to offer healthy options and therefore are both considered to be health resources our findings are consistent with lees national survey of us children followed across their elementary school years 22 lee conducted a separate analysis of black and hispanic schoolaged children and found that those who had greater access to corner grocery stores experienced significantly lower bmi shifts over time 22 our nonsignificant results related to other aspects of the food environment are also consistent with the lee study results the only other study that focused on the food environment and weight status in a lowincome minority population is crosssectional but did not investigate small grocery stores separately from large grocery stores or supermarkets proximity to these types of food outlets was not significantly related to child bmi percentile in the study 19 one explanation for our finding is that small grocery or specialty food stores are more likely to offer healthy food options than retail outlets like convenience stores or fastfood eateries both of which are ubiquitous in todays cities having greater access to healthy food options makes it easier for children and their parents to make healthy choices another complementary explanation involves the role of small grocery stores as community institutions places where people gather and where information is exchanged their presence may also indicate the availability of other healthpromoting resources that make healthy choices easier we also found that living in a neighborhood with a higher proportion of large multifamily buildings is associated with more excess weight gain over the summer compared to living in a neighborhood with a lower proportion it may be more difficult for a sense of community to develop in neighborhoods with more multifamily housing complexes and for residents to build the social capital needed to keep streets safe from drugs and crime this finding should be further explored in future research we found no association between living near an active park and change in weight status in this low income predominantly black population replicating previous published results of a natural experiment conducted with a lowincome minority population in the us south 12 simply living within a mile of a park with facilities encouraging active play does not necessarily mean that local children use the park for active play future research is needed to determine how close is close enough 12 one mile may be further than most elementaryage children would walk or be allowed to walk how close is close enough may also depend on how safe the walk to the park feels for both children and their parents because overweight children in our sample gained more weight over the summer than normal weight children we examined the importance of neighborhood environment factors for overweight and normal weight children separately we found that overweight children living near two or more small grocery or specialty food stores gained less weight over the summer compared to those whose neighborhood included no or only 1 such store this was true whether change in weight status was measured based on bmi percentile bmi or weight the association was not significant for children who were normal weight there is a need for further studies in overweight populations to explore why small groceries would have greater significance for children who are already overweight than for those who are normal weight for normal weight children the percentage of housing units in large multifamily buildings was associated with greater summer weight gain although the effect did not reach statistical significance this was true whether change in weight status was measured based on bmi percentile bmi or weight the association was not significant for overweight children although the smaller sample of overweight children may have reduced our power to detect such an effect there are several limitations to this study we did not have measures of dietary intake or physical activity which may have helped explain change in weight status 2632 we dont know whether children ate more or less or exercised more or less over the course of the summer recent research based on a national survey of us children in grades 1 through 12 finds that children surveyed during summer breaks consumed fewer vegetables and more added sugar and were more active than during the school year 32 we were also limited by the neighborhood environment factors that were available restriction of the population to lowincome predominantly black elementary students limits the generalizability of the study as it is not representative of children in the city and surrounding county however it provides important insights that may apply to similar populations in the us and in developing areas elsewhere furthermore there is less variation in the neighborhood environments of study participants from predominantly lowincome families compared to studies with citywide regional or national samples this may have reduced our ability to detect neighborhood environmental effects that would be detected in a sample with greater variability in their neighborhood environments despite the limitations this study has significant strengths it focuses on a low income predominantly black population with a higher proportion of children at risk of overweight and obesity and investigates change in weight status over the summer thus adding to the small number of longitudinal studies in this area of inquiry it includes objective measures of participants weight and height obtained by personnel trained for research purposes and three different measures of child weight status it also includes measures of both the neighborhood social and built environments study findings highlight the differential effects of neighborhood environment factors for overweight and normal weight children suggesting that future studies may want to consider the needs of these populations separately bmi percentile measures may not be sufficiently sensitive to change in overweight populations suggesting multiple measures of weight status should be employed conclusions neighborhoods can provide opportunities for children to maintain a healthy weight or encourage unhealthy weight gain existing studies indicate that overweight children may experience faster weight gain over the summer than normal weight children 2627 there is a need for policy relevant guidance for this subgroup our study is the first to find evidence that neighborhood effects on change in weight status over the summer are different for children who are already overweight compared to those who are normal weight our study suggests potential directions for future research as well as promising approaches to prevention of childhood overweight particularly in populations of children at high risk of overweight to better understand the role of small grocery and specialty food stores there is a need for studies that investigate where and how children and their parents or caregivers shop how they use local retail food stores and how they use existing health resources such as parks and community centers and whether there are any differences depending on the weight status of children interviews with store owners and observations of how residents use the stores would also yield important insights there is also a need for research that explores the mechanism whereby living in a neighborhood with a higher proportion of housing units in large multifamily buildings affects change in child weight status over the summer

neighborhoods can provide opportunities for children to maintain a healthy weight or encourage unhealthy weight gain which neighborhood characteristics matter most remains poorly understood we investigated links between neighborhood characteristics and weight change over the summer in children from 12 elementary schools with a high proportion of children from lowincome families in a midsized city in the us south mixed models and objective measures of height and weight were used study participants were 2770 children average age 83 range 56126 years older and female children and those who were already overweight were more likely to gain weight over the summer compared to younger male and normal weight children overweight children who lived near 2 or more small grocery stores gained less weight than overweight children who lived near 0 weight change p 00468 body mass index bmi change p 00209 or 1 store weight change p 00136 bmi change p 00033 normal weight children living in neighborhoods with more large multifamily buildings gained more weight over the summer although this association only approached significance additional efforts to understand which neighborhood factors have greater significance for overweight compared to normal weight children are warranted

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introduction the presentday economic crisis has affected libraries in many regions worldwide shrinking budgets have led to reductions in acquisitions services andor library staff spain is a country where the recession has been felt in a very stark way resulting in a growing unemployment rate unprecedented in history and causing major problems in public services and the welfare state spanish libraries have also been affected by reduced budgets and have had to adapt to a new context characterized by the lack of funding and the impossibility of providing adequate services the economic crisis has been felt in spanish libraries as in society in general since 2008 the year in which official statistics began to show declining figures in indicators such as the number of people who work in libraries or the funds available for acquisitions the years 2012 and 2013 have been the most difficult for libraries which have had to reconsider their models of operation reorganize services and assess their expenses as reported in this article spanish public libraries count on 99 percent public funding while university libraries are publicly funded at about 70 percent according to the estadística de bibliotecas data from the instituto nacional de estadística with the reduction in public funding all public agencies have experienced decreases in service delivery as has happened with libraries spanish libraries found themselves with shrunken budgets during the years of the crisis funding was especially reduced in the years 2012 and 2013 when the government applied drastic measures imposing a hiring freeze and a zero budget for acquisitions even so libraries were able to fulfill their social role and developed various initiatives in order to provide services based on citizen participation and creative strategies to tackle the budget squeeze this article describes how spanish libraries faced the crisis provided services and worked out solutions to their social problems and reports initiatives of user communities to support the operation of libraries all within the specific social justice framework of contributive justice the goal of this study was to understand how libraries fared during spains economic crisis from 2008 to 2012 and in the process to learn of the contributive approach adopted by libraries and their communities that other regions in the world can consider applying mixed methods also applying a contributive approach were used to address the two research questions • what financial policy personnel and usage changes have libraries faced during spains economic downturn • how have libraries fared during spains economic recession from the findings the lessons learned regarding contributive justice in libraries and their communities were gathered to create a contributive justice framework for libraries the four areas of contributions that make up the proposed framework are vital investments in the sustainability of all libraries and the social opportunities and benefits they provide to their communities literature review the economic crisis and its impact on libraries were covered in the international literature in the early years of the recession one of the authors who has addressed this topic the most is guarria in the recession budgets expectations and realities and the economic crisis and its effect on libraries the first article presents the results of two surveys of libraries in the united states that were conducted in 2009 and 2010 to learn about the effects of budget cuts the second article is based on a survey of us libraries especially university libraries both have the purpose of identifying the issues and providing guidelines to mitigate the consequences of the recession on libraries lloret romero follows a similar tack in her article libraries response to the crisis measures to mitigate its impact in which she makes recommendations for managing the crisis rooneybrowne published one of the first studies based on statistical data analyzing the situation of public libraries in the united kingdom and the united states also related to great britain and the united states are two reports the impact of the economic downturn on libraries and the economic downturn and libraries which presented data from surveys and focus groups with university library managers the spanish professional literature on the impact of the crisis on libraries is very recent and we can say that it is a topic of growing interest with results and reports being published on a regular basis along with discussions in social media and blogs prominent among the latter is the libraries 2029 blog which reflects on the role of the library and its problems similarly biblioblog 4th edition has published several posts about the crisis and libraries often reporting on a situation with statistical data and reports as they become available among the most recent reports the one from fesabid the spanish federation of societies of archivist librarians documentalist and museology stands out because of its focus on the economic and social value of libraries it is available in both spanish and english also recommended are studies from the grupo de trabajo estratégico para el estudio del impacto socioeconómico de las bibliotecas en la sociedad which has published the report the economic and social impact of libraries gómezhernández is recognized as the primary author tackling and addressing the impact of the economic crisis on spanish libraries in his first work in this area published in 2010 he outlines the context at the time and reveals statistically proven trends such as the increased use of library services that correlate directly with the effects of the crisis this same author published an article about the situation in 2011 and the increase of the impact of the crisis on spanish public libraries this piece was notable for foreseeing the worsening of the crisis in public libraries in 2012 one of the most negative years for the spanish economy and society in this article gómezhernández describes the problems that libraries were beginning to face due to lack of funding as well as the calls for action by librarians in defense of the common good a year later this author provided a stateoftheart report that presented data on the reduction of public budgets for culture and analyzed possible solutions going through what he calls adaptation and reaction for the survival and maintenance of services the relevant literature published in spain can be divided into authors who have provided a strong rationale in the debate or nonempirical work and those presenting data and experiences or empirical studies an important document on the impact of the crisis on libraries was published by anglada in the anuario thinkepi an information resource in the spanishspeaking world for library and information professional news and information his article ¿podemos hablar de crisis desde las bibliotecas is an excellent example of reflection that includes the debate on the role of the library in a digital society and advocates for libraries using three arguments libraries support personal growth learning and technological literacy libraries are not based on commercial consumption and libraries help the disadvantaged other articles have focused on the collection of data and experiences that demonstrate the impact of the crisis on libraries and the viable solutions that were implemented to reduce the effects of the cuts a good example is the empirical study by the andalusian librarians association that asked andalusian libraries how and where the economic crisis had affected them the survey was actually conducted from late january through april 2011 a period in which the effects of the budget reductions were beginning to be felt given that 64 percent of the responders indicated that their budgets were reduced the data can be verified by looking at the statistics that are published periodically the main statistical resource is library statistics reported every two years by the national institute of statistics of spain this report is mandatory and provides a true representation of all types of libraries it was the source used by hernándezsanchez arroyovázquez in their study on the effects of the economic crisis on spanish libraries their article is a comprehensive analysis of the evolution of libraries during the crisis and will be referred to later in this essay finally it is necessary to highlight that the most complete bibliography and list of experiences thus far is the one published by merlovega in his article acción ante la recesión which was published in march 2012 and addresses many of the issues covered in this article as well as in the project report bibliotecas en acción contributive justice an approach to social justice the work presented here responds to the call for contributions to this issue of library trends with a focus that social justice in lisservices involves achieving actionoriented socially relevant outcomes via informationrelated work a broad definition of social justice used here is the equality of rights for all individuals to benefit from social progress without discrimination when library and information organizations are engaged in promoting social justice the emphasis should be on library and information services providing equality of opportunities for both users and nonusers of any background to enhance their economic and social wellbeing which includes their rights dignity and voice as well as economic social and political empowerment there are various approaches to or types of social justice such as distributive or utlilitatrian the social justice approach found most appropriate for the work in this article is contributive justice it is applicable to both the circumstances of spanish libraries during an economic downturn and the process by which the data for this study were collected although it is not a widely known or discussed approach to social justice gomberg introduces contributive justice in his book addressing racism and unequal opportunity the structural negativity of unequal opportunity and how through understanding justice contributively rather than distributively the challenges of unequal distribution of labor and opportunities can be overcome in a contributive approach gomberg argues it is not about the benefits people receive rather justice is achieved by what one gives to others there needs to be both duty and opportunity to contribute because without contributions there isnt anything to distribute in this manner contributing to others increases what they get making distribution primary and this consequently enables them to contribute making contribution primary four norms are at the core of contributive justice a duty to contribute labor an equal opportunity to contribute labor a duty to participate in social decisions and an equal opportunity to participate in social decisions the shift in focus is on what we do rather than what we get sayer further elaborates that contributive justice can thus be about either the quantity or the quality of the contribution made by people to some project the notion of contributing is also the principle underlying crowdsourcing which is the process of obtaining needed resources services ideas or content by soliciting contributions from a large group of people especially from an online community rather than from traditional employees or providers immediate family friends or community members when referring to the crowdsourcing of ideas we talk about the wisdom of crowds or collective wisdom in regard to financing we name it crowdfunding and when speaking of services we characterize it as the collective economy crowdsourcing was applied in our data collection methodology mixed methods were used to obtain the data needed to address the studys two research questions first in order to learn what financial policy personnel and usage changes spains libraries experienced during its national economic downturn primary data sources were tapped these included library statistical data from the ine as well as from rebiun news received from subscribing to library news alerts and published materials identified from literature searches second to understand how library services have been impacted upon during spains economic recession crowdsourcing was used to collect data from may to october 2013 an open call was made requesting examples for a research project on libraries in action of how spanish libraries were managing since the start of the economic crisis the aim was to gather realworld cases to learn how spanish libraries were helping user communities in these challenging times and how user communities were helping libraries to maintain the continued provision of services the sharing of experiences is not only of benefit for this research but more importantly for libraries and communities in spain as they can compare their experiences in order to learn from effective practices and for those struggling in other regions that can try or model these practices for the latter they reveal the commitment tenacity and creativity of library communities in struggle because of the shared core value of libraries as a public good the call for dataparticipation was distributed on lists and posted on social media including the following • launched in 1993 iwetel is the largest spanishlanguage electronic forum on libraries information science and communication currently hosted by rediris • publicasl a spanishlanguage list on public libraries • josé antonio merlovegas facebook account reposting was encouraged and several subsequent reminders were made • the facebook page yo amo a mis bibliotecas • josé antonio merlovegas twitter feed which currently has over three thousand followers followers were encouraged to retweet and several subsequent reminders were posted the call was distributed only once at the beginning of may 2013 unless otherwise noted the call instructed contributors to submit examples to an open google document that was organized into six action areas which included descriptions and categories to ensure anonymity participants were able to contribute and edit without needing to register the name of the library associated with an example was provided by contributors but it was not possible to determine whether the contributor was a staff member or a user of a specific library or of another a few exceptions took place of individuals directly emailing their experiencesubmission to coauthor merlovega the confidentiality of these contributors has been maintained contributors did not receive any payment for their submissions bibliotecas en acción continues to be made available online but instead of the raw data gathered it now houses an edited compilation of the contributions to the study the google document had the dual objective of sharing library experiences as well as participating in crowdsourcing research data collection that was fundamentally collaborative simultaneous immediate and open no attempt was made to confirm the veracity of every single detail but as an open activity there have been no contradictions in the data collected many examples were received mainly from public libraries with a few from academic and hospital libraries the term public library is used here to define any library accessible to the public at no cost regardless of whether its funding is from public or private sources privatelyfunded libraries freely accessible to the public tend to be referred to as special libraries in north america libraries covered in this study are listed in the appendix content analysis was conducted to ensure that the contributed examples were coded into the appropriate action areas and in some cases contributions were moved to the category that was most appropriate the examples received by email were also added to the appropriate sections in the google doc which originally had six categories professional action civic action social action political action culturalheritage action and technological action at the same time that contributions were received experiences from news alerts and social networks identified in the research to address the first research question were collected and added to the google doc in so doing it was determined that two new categories were needed as noted in table 1 economic action and ontological action and that two action areas needed to be renamed from civic to community action and from technological to digital action these action areas have specific areas of focus and categorize a set of experiences or accounts submitted or identified in the data collection as noted in the following descriptions of each action area • professional action libraries are able to maintain basic services with less funding libraries reported actions on operating the daily activities of the library that included collection development user services and cultural programs • community action libraries engage users in their activities the user community supported and participated in nontraditional library activities such as those of a jobrelated personal or economic nature including providing donations to support library activities that otherwise would not have been offered for lack of funding renegotiated electronic resources licenses increased or modified consortial purchasing procedures etc • ontological action libraries champion their role in the information society the economic crisis has created an identity crisis in the library community calling on lis professionals and their associations to examine and defend the role of the library through research publications and professional dialogue a declining economy and its impact on spanish libraries the context for contributive justice the spanish economy has been in a recession since 2008 according to the majority of economic studies it was in 2008 and 2009 that the countrys economic indicators reflected the conditions of economic crisis which has had a direct impact on social educational and cultural indicators as we will see in this section of the article the unemployment rate has grown inexorably at a worrisome rate reaching 261 percent of the population in 2013 the highest rate in the history of the country this statistic is associated with another even more dangerous one which is the percentage of the population at risk of poverty and social exclusion which stood at 282 percent in 2012 spanish government expenditures in public services have followed a steady annual growth spain is a country particularly committed to public services which are maintained through direct and indirect taxes and compulsory contributions to the social security system the funding formula functioned effectively until the economy fell and the governments of spain at all levels have begun to implement policies of cuts in all areas table 2 shows an increase in general spending on public services but a reduction in the specific areas of education and culture where library budgets are situated the data broadly include the indicators of the central government of the country plus the budgets of regional and local governments one can see that the education and culture budgets have reverted to the level of five or six years previously it is important to provide some social data that explain the current situ ation in spain and serve as a context for understanding the worrying situation that the country is facing as it has been said the percentage rate of people without employment in 2013 was 261 percent with an even higher percentage rate for women and the population under 25 years old table 3 shows the evolution of unemployment in spain and its distribution by gender and age the overall unemployment rate more than tripled between 2007 and 2013 the years in which the economic crisis has been the most severe and where the results of government policies of cuts and lack of investment are most evident a significant indicator of the precarious economic situation is that more than half of the population under 25 years of age is unemployed the lack of growth and investment policies is resulting in the spanish population becoming progressively impoverished as shown in table 4 the percentage of the total population at risk of poverty in 2012 was 222 percent the data also show the difficult situation that is being experienced by spanish households during the crisis increasingly there are more people who are close to the poverty threshold which is set at 60 percent of the national median equivalent of disposable income one of every five spaniards is on the threshold of poverty in addition 157 percent of the spanish population in 2013 lived in households where the adults were working at less than 20 percent of their total work potential during the previous year this situation has been noted by public libraries which are supporting disadvantaged families and have begun to direct actions such 4 brings together the most significant data of the worrying annual increase in the population at risk of exclusion examining the data published by the ministry of education on education expenditure in spain one notes the results of the policy of cuts in education implemented by the government investments in education have been falling since 2009 while the expenditures of families grow each year table 5 also shows how the average expenditure on education per student and per inhabitant has decreased every year since 2009 behind the stark figures are policies of cuts in the number of teachers and scholarships that are traditionally funded education in spain is managed by regional governments which receive funding from the central government from taxes thus the data in table 5 refer essentially to the investment in the autonomous communities but also in national budgets the expenditure on culture in spain has also been diminishing since 20082009 the different levels of spanish government are investing less each year in cultural services which include libraries the management of cultural services is very decentralized in spain with the town councils investing the most available data through 2011 clearly show the withdrawal of financing by the differ ent types of governments in all cultural fields not only in library services the central government dedicates its cultural budgets to publishing archives libraries museums cinema theater etc both for infrastructure and concrete projects in the case of libraries the central budget is also targeted for the purchase of information resources moreover the contribution of regional and municipal governments also includes the payment of the salaries of the cultural heritage personnel including librarians the national general state budgets also clearly reflect the cut in funding for libraries which table 7 shows to have declined by 60 percent between 2008 and 2014 the line item for libraries in the general state budgets is dedicated to infrastructure and the cooperative purchase of information resources the tragic decline of the general state budget means that it has stopped investing in library buildings as well as in the purchase of books and magazines for public libraries the policy of cuts by the central government included measures that curtail funding of some items to regional governments which in turn then fail to meet the deficit targets established by the central government this policy has resulted in no receipt of funding for the purchase of books and magazines for public libraries in some regions in 2012 and 2013 many public libraries had no budget for the acquisition of collections spanish libraries data are collected every two years for the library statistics report which is coordinated by the national institute of statistics all library types are required to complete the ines questionnaire which collects data for libraries overall as well as by types of libraries and autonomous communities in spain there is a national library and a central or regional library for each autonomous community public libraries may depend on the different levels of administration central regional and local the data summarized in table 8 provide an overall number of libraries and service outlets as well as the number of libraries available per capita and the number of registered users the spanish population has grown from 427 million in 2003 to 471 million in 2013 the number of libraries has had a sustained growth however a slight decline has been observed in the number of service outlets which indicates that 63 library branches were closed between 2010 and 2012 an important fact that can be seen in table 8 is the increase in people who have a library card and the number of visitors to libraries this table brings together data from the central and public libraries the spanish library system corresponds to the administrative organization system with a central library for each autonomous community or region which in all cases is a public library therefore the data from the public libraries are combined with those of the central libraries which as has been said are also public libraries the number of visitors to public libraries doubled in the tenyear period 20022012 especially in the years of the crisis where the growth rate was higher than expected also there has been a steady increase in book circulation which shows that it is a service still widely used and which has grown in this period of crisis the economic data on spanish libraries clearly reflect the declining investment in the years of the crisis growth has been consistent but table 9 shows declines in expenditures for staff in 2012 and for acquisitions in 2010 staff expenditure fell because economic policies applied measures that impeded hiring new civil servants even when staff retired similarly the labor reform carried out in spain led to the firing of staff and lowering the wages of civil servants in spain 86 percent of the libraries are public entities and 99 percent of public libraries belong to a public administration meaning that the staff in public libraries are considered civil servants table 9 compiles important data about the decrease in acquisitions expenditures producing the crash in 2010 the year when one begins to another indicator of the effects of the crisis is the number of personnel in libraries library staff data are calculated by determining the number of people who work full time in a library or its equivalent for example two parttime workers are the equivalent of one employed full time the latest data available on the number of full time equivalent professionals in spanish libraries as shown in table 10 give a figure of 2092602 persons in 2012 a 26 percent decrease from the peak of 2147755 in 2010 since the economic crisis has caused layoffs and nonreplacement of library staff table 10 shows overall library staff data as well as those pertaining to staff in public and university libraries the number of professional librarians is also reported and shows a decline of 27 percent from 2006 to 2012 again the data in this table refer to 773 percent of spanish libraries the analysis of the average number of hours public libraries are open is also an indicator of the impact of the crisis looking only at public libraries which are neither educational nor central or national libraries one can see in table 11 the increasing number of libraries offering fewer service hours per week since 2008 which is considered the beginning of the crisis to 2012 there is a slight increase in the number of libraries that are only open less than 10 or between 10 and 20 hours per week the main reason is the lack of staff and funding for hiring them so many small public libraries hire librarians for a few hours to provide a minimum level of service the data on the decrease in library hours as an indicator of the effects of the crisis was noted by hernándezsánchez arroyovázquez who also related the recession to an increase in the number of libraries with major reductions in service hours the effects of the economic crisis on libraries can be seen very clearly in spanish university and research libraries the statistics from the spanish university libraries network show the decline in investment in collections and resources as well as in the expenditure on staff all of the spanish university libraries work cooperatively in rebiun so these statistics are very significant for understanding the reality of university libraries on a yearly basis rebiun collects statistical information which provides both data and indicators a first fact that can be objectively observed in table 12 is the reduction in staff expenditure in university libraries from 2010 to 2012 the cost of staff is shown as decreasing due to staff layoffs and attrition this same table also provides an important fact the decline in the expenditure of financial resources which in 2012 was 5 percent less than in 2007 after peaking in 2010 the lack of funding for universities has caused the cancellations of electronic material subscriptions and the decline in purchases of new monograph titles throughout the country license fees for the use of electronic resources have been renegotiated and reduced the rebiun statistical indicators are reported in table 13 where one can see very clearly the spending that takes place in spanish university libraries for example in 2012 the average spending per user for acquisitions was €7725 when this amount was €8676 in 2009 and €8460 in 2007 similarly the decline in staff costs and in libraries in general shows in the expenditure over time in spanish universities by user whether students teachers or staff the negative growth is evident from 2009 to 2010 which is the turning point as university libraries began to feel the negative effects of the economic crisis a bit later than did public libraries the preceding paragraphs provide the context to show the negative evolution of spanish libraries the economic employment and social conditions affect libraries as it could not be otherwise the question now is how libraries have faced the economic crisis to which another question can be added how have libraries supported communities at risk of exclusion the following section describes the results of the project of collecting information on initiatives that respond to these questions contributions and community spanish libraries surviving in an economic crisis spanish public and university libraries and their communities were found to have taken actions that maintained basic levels of service coaxed more from existing resources tapped and embraced the material financial and intellectural resources of their communities and leveraged free and lowcost technologies the examples of spanish library actions are contributions that emerged out of necessity and evidence of resilience in order to persist the spectrum of actions was organized into the following eight categories professional community social political digital culturalheritage economic and ontological the main categories of each particular action area along with examples are described below see bibliotecas en acción an edited compilation of the contributions to the study for more details on the experiences libraries reported professional action libraries are able to maintain basic services with less funding the research findings identified actions to keep the daily activities of the library operating including collection development user services and cultural programs the examples of professional action reported by libraries are categorized into the following five main areas user community supports the development of library collections examples include the following • librarians select resources and users purchase or donate the new materials or maintain journal subscriptions eg guadalajara public library salamanca public library • the library sells deaccessioned materials and proceeds are used to purchase new works eg salamanca public library • the library pursuesaccepts donations to purchase new works eg salamanca public library cantabria central library orihuela library and the montequinto municipal library which also lends its materials to groups and associations the public library of cuenca a regional library developed a donations policy which in 2012 resulted in gifts from an effort that targeted users organizations publishers local authors and others and in turn benefitted the municipal libraries in the region the library staff reviews its policies for efficiency in practice the lack of funding has compelled libraries to maximize thir cooperative services such as in 2012 with the library network of castilla y león which improved its interlibrary loan services as a solution to the difficulties in acquiring new books libraries have also found it necessary to employ strict indicators in making acquisitions in libraries such as at the civican library which has raised restrictive criteria before new purchases can be made such as the availability of a work in nearby libraries the diversity of subject content and publishers or the purchase in multiple languages the library staff performs cultural activities although librarians duties are varied during the recession they have taken on tasks that are usually performed by other collaboratorspersonnel such as storytelling skills training or coordination of groups the central library of cantabria maintains a stable weekly schedule of storytelling for children which is led by librarians as well as four book clubs and a biweekly film forum skills training in information use technology career development or sociocultural topics is now offered by library staff at the torrejon del rey library for example library staff offer a course on information technologies collections are maximizedreused to develop activities librarians have made conscious efforts to maximize the use of colletions even though they may be dated by developing resources or programs that entail the use of existing bibliographic resources such as new topic reading guides book exhibits or author programming the cantabria central library for example offered the blind date with a book program in which readers were surprised with wrapped works the library uses free resources whether material technological or personnel available free resources are tapped to deliver library services community action libraries engage users in their activities the user community supported and participated in nontraditional library activities such as those of a jobrelated personal or economic nature including providing financial contributions in order for library activities to be implemented that otherwise would not have been offered due to lack of funding the experiences of community action reported that were not related to collection development coalesced into the following five main areas the library expands beyond informational training workshops these included job search workshops and language training libraries have been aware of the need to support their community members in search of employment and have increased these activities during the economic crisis for example since 2010 the regional library of murcia has operated the biblioteca punto de empleo which provides job training information and mentoring the job search tutorial offered by the grupo de trabajo de alfabetización informacional del consejo de cooperación bibliotecaria has been used by different libraries in providing users with advice on job interviews resume writing and job searching there is evidence that these sessions are offered periodically at the public libraries of castilla y león the uned library and the public library of cuenca and are becoming a programming staple in public libraries due to the growth of the unemployment rate in spain collaborations with other agencies and administrations responsible for the promotion of employment were also reported such as the entrepreneurship workshop in which the civican library of pamplona participated the library increases or opens up new space for community group use library spaces are not solely dedicated to library purposes but are being extended to provide space for meetings or activities joint programming popularinterest talks outreach and promotion of initiatives typically the libraries not only provide space but also participate in the organization and dissemination of activities in many cases collaboration is done through friends of the library groups which have been a great support in the years of the economic downturn a notable example is the friends of the casa de las conchas library of the salamanca public library which provided support for cultural activities because the library did not have the necessary funding some university libraries are also offering their space and resources to their communities such as the open space at the reina sofia university library of valladolid or the exhibit equipment loan program offered by the university of extremadura library for notforprofit organizations community members share their knowledge and skills at the library professors and other community members volunteer to present workshops and lectures significant examples are the huelva public library and the civican library whose members have volunteered as storytellers and the villarrubia de los ojos library that offers the what do you know program whereby users give lectures on topics within their expertise similar programs have been developed in the murcia regional library the hellín public libraries the san javier municipal library the cuenca public library and the montequinto municipal library a final example is the tleo program of the peñaranda de bracamonte municipal library in which volunteers visit the homes of people with mobility problems this program is part of a broad range of activities this library coordinates including el club de la nubeteca and the human library the library pursues external and community funding microfinance activities have resulted in libraries receiving generous public support through financial contributions made on public financingcrowdfunding systems local business sponsorships provide another way in which libraries have secured financing for cultural events or services the library is saved by the community the link between user communities and libraries has been demonstrated by their defense of their libraries to the authorities community support extends to reopening libraries the las palomas library which was closed by the city council was reopened after several months of community pressure a local group has selfmanaged the library when it was impossible to maintain the municipal library services a similar situation occurred in the españa neighborhood in valladolid where community members took over the municipal library service outlet that was closed by the city the community neighborhood association collected and organized donations of books and was responsible for the cultural programming of the library social action libraries are sensitive to the problems caused by the recession and are helping people in need by focusing on social issues they are supporting disadvantaged community members and are leading or helping groups at risk of exclusion libraries are collaborating with social service agencies and other sociocultural groups the following four main areas emerged from the social initiatives reported by spanish libraries the library supports food collection and other social action initiatives libraries have facilitated the exchangedonation of food and material needs among users the most significant example which has been replicated in multiple libraries is the regional library of murcia program called biblioteca quitapesares te quitamos las penas y tú se las quitas a otro which collects food and school supplies these initiatives are based on the elimination of fines for overdue materials in exchange for donations of nonperishable food or school supplies in the winter of 20122013 the program collected more than 25 tons of food in spring summer 2013 300 kilos of school supplies were received showing the success of this initiative there are many public libraries that have implemented similar initiatives while examples of university libraries include the university of extremadura library the university of salamancaávila and the university of castillala mancha libraries the library offers its facilities as a social space the library has been used as a meeting space training facility and hygiene area the library is developing as an outletpoint of social assistance information and service fundraising initiatives coordinated by the library are becoming common libraries develop specific programs or work with fundraising programs for the care of the disadvantaged an example is the noain librarys el valor añadido de leer campaign which sold donated books to raise money to support social issues related to the public library community in the academic community university of la rioja librarys 1000 libros solidarios campaign sold duplicate or weededout books from its collection to raise funds for the comprehensive care for immigrant children and youth project there are also many examples of individual or collaborative fundraising campaigns supporting social assistance and relief in other countries including brazil nepal and ethiopia a final example is the civican library which collaborated on the móvil solidario action against hunger campaign that collected discarded phones for reuse or recycling to raise funds for research on diseases or projects combating hunger the library offers services and programs in support of its disadvantaged community members libraries have offered literacy ereading for seniors and spanishlanguage programs for immigrants and refugees the extent to which these programs are offered by volunteers has increased with the economic crisis for example the virgen de la victoria university hospital library in málaga is a library for patients that is supported by volunteers and the university of salamanca library has a volunteer program of students and alumni who collaborate with schools in organizing school libraries political action libraries contest funding cuts and antilibrary policies the findings show libraries and their stakeholders involved in protests against budget cuts imposition of borrowing fees space closures and downsizing of personnel libraries are demanding needed cultural services the examples of how libraries and library professionals have faced the institutional decisions that damage library services are summarized into the following three main areas the library and its stakeholders protest budget cuts and antilibrary policies a variety of activities to protest against library budget cuts have been conducted by libraries and their stakeholders a significant example is the national yellow tide social movement which is fighting against restrictive policies on budgets and cultural rights the collection of signatures has taken place in cordoba seville and cuenca professional associations of these communities published a manifesto on october 23 2013 library day denouncing the situation of public libraries in the region actions taken included a minute of noise in public libraries that day to protest the precarious situation in castillala mancha another symbolic protest of the zeroacquisition budget was developed by the muskiz library whose news section was covered with cobwebs other examples of the various antilibrary legislation protests include asking city councils to obtain approval from the government of spain to exempt libraries from paying a loan fee for items checked out from their collections such requests were made by libraries in arroyo de la luz azuqueca de henares lalin concello foz grado oviedo mieres eskoriatza errentería valley batzan auritzburguete erroibar zaragoza alcaniz the casar torrejon del rey guadalajara las rozas madrid san fernando de henares villamalea villanueva de córdoba castro del río benalúa granada málaga vicar arta and palma de mallorca in fighting this loan fee policy the professional associations fesabid and rebiun developed a draft reform of the copyright act the library and its stakeholders protest against reductions in services branch closures layoffs and space reduction have been fought with demonstrations writings and community demands different libraries participated in the love letters to the library campaign in which users wrote about the importance they attached to libraries neighborhoodcommunity protests have been successful in reopening libraries such as los serrano palace library in ávila the agolada library the jerez de la frontera municipal library and the zaidín library in granada the biblioteca de casapuerta protest was held periodically at the cadiz provincial library with neighborsusers sitting reading outside the library during the times when it should have been open but was closed due to budgetary problems the library works with notforprofit groups in support of culture and education libraries joined social movements and protests to fight against reduced access and funding for culture and education digital action libraries use free or lowcost technologies to deliver services libraries reported providing leadership in technology use in libraries with zero or very low budgets to offer new services for interaction virtual reading groups creating virtual communities on social media coordination of online learning etc these initiatives show libraries as catalysts for their communities through the adoption of technologies and provision of new technologybased services which coalesced into the three main areas below it should be noted that there is no study that objectively concludes that the development of technologybased library services has grown in parallel with the economic crisis or because of it but the truth is that many libraries are offering services and resources and developing programs based on free or lowcost technology tools the library reading groups are organized digitally libraries are using social media and webbased tools to support their reading and literacy activities the online reading club cloud of tears which pioneered cloudbased reading started in december 2012 at the peñaranda de bracamonte municipal library and includes readers from five libraries in badajoz province azuaga cabeza del buey don benito montijo and siruela the library coordinates participates in or supports virtual learning communities examples include online participatory systems for employee training courses on open platforms massive open online courses shared virtual spaces and digital literacy the library coordinatessupports communities using social networks and streamlines library services and information resources on local life libraries are organizing community information and serving as community network managers using digital technologies but their efforts and successes are uneven these digital activities include bulletin boards forums blogs and informationsharing portals to disseminate news activities and resources jobsearch virtual desktops have been created by netvibes zamora public library and the contrueces library in gijon offering both resources and practical guides other examples of the expansion of library services using technologies are virtual exhibits the presence of spanish university libraries in social networks has been studied and appeared in a report from the university of las palmas library culturalheritage action libraries support local culture particularly with free and lowcost technologies experiences are reported whereby the library altruistically shares content with its community coordinates activities to preserve local memory disseminates openaccess documents etc the library offers digital collections to its community whose members in turn provide the materials for local memory preservation projects many of the contributive actions are related to sharing knowledge and documentary heritage and are grouped into the following three main areas the library offers openaccess cultural heritage collections the library emphasizes access to free or lowcost digital content such as local newspapers photographs specialinterest areas and reading guides the library coordinates and participates in projects to preserve local memory the library is working on creating digital collections of local issues history and culture that include collecting and digitizing relevant materials examples include the peñaranda de bracamonte municipal library which digitized local residents personal photo archives the andratx municipal library on the occasion of its eightieth anniversary created a digital version of the local publication andratx published between 1920 and 1971 and the multimedia digital history of the town of agora was developed by the agora library in a coruña using blogs and pinterest examples of librarycommunity collaborations include the sant antonijoan oliver library in barcelona which is collecting oral histories from neighbors about the evolution of the neighborhood and is noted for including its senior voices the amarauna project of the amara library network municipal library in san sebastián which is creating a neighborhood identity from a digital collection of photographs and documents of various types donated by neighbors and the project of the palafrugell library which is organizing a photographic journey using wikipedia a significant experience of digitization is the manes project of the uned library which is creating a digital repository of textbooks from spain portugal and latin america published between 1808 and 1990 the library provides open access to its own edited books or periodicals and to publications from authors who have provided copyright access the creation of participatory spaces to support publication on local issues and digital repositories of openaccess works are new services offered by the library that are based on free technologies libraries are leading in the use of social networks converting them into tools for information communication and interaction with their communities and in turn becoming leaders in their localities economic action libraries adjust or redistribute their budgets limited and uncertain budgets have required the development of collection reduction policies with new selection indicators subscription modifications license renegotiation of electronic resources increase or modification of consortial purchasing procedures etc the reported examples are from publicly funded academic and special libraries that work with very costly information resources the actions reported by libraries regarding budget management are summarized in the following three main areas the library management reviews its budget during the years of the crisis libraries received reduced budgets however in some libraries the situation has been more dire because the budgets promised were not always fully honored resulting in the receipt of even less actual funding than initially allocated libraries are thus frequently reviewing their budgets so that spending adapts to any progressively diminished revenue the library audits its collections the drastic measure of canceling subscriptions has required libraries to review journal subscriptions with actualuse indicators which university libraries have incorporated into their collection development policies in the case of electronic resources such data are readily available and can be combined with expenditure data for use as the basic method to measure performanceefficiency to counterbalance the reduction in subscriptions libraries have created digital repositories of openaccess research works libraries cooperate to leverage resources libraries have engaged in cooperative services increased consortial purchasing and negotiation of licenses for electronic resources as costeffective measures in an economic crisis in the case of university libraries they have always worked in consortium primarily for the acquisition of specialized resources the recession has led to increased cooperation in acquisition in recent years which resulted in a constant exchange of information among consortia members or buying groups and above all a common negotiating position in licensing electronic resources thus university libraries have stopped the constant increase in prices of specialized resources and have even managed to see general reductions in subscription prices resulting in maintaining their collections despite having reduced budgets public libraries have suffered a 36 percent decrease in spending on acquisitions which has been the reason that many spanish public libraries have had to seek the cooperation of their members to maintain a current collection libraries have also streamlined interlibrary loan procedures enabling users to quickly receive works available in their library networks out of necessitymerlovega chu 323 ontological action libraries champion their role in the information society the economic crisis has also led to an identity crisis in the library community it has become necessary to advocate for libraries in society even in times of crisis different groups have produced documents defending the role of the library and professional conferences have been devoted to this topic the actions in defense of the role of the library in times of crisis and a digital society coalesced into the following three main areas professional associations champion the role of the library library professionals have been forced to justify both their work and the existence of libraries through the efforts of spanish library professional associations documents have been produced and disseminated defending the role of the library including those from the collegi oficial de bibliotecaris and documentalistes de catalunya and the murcia regional library the latter adopted on february 19 2010 during its conference the declaration of murcia on the social and educational activities of public libraries in times of crisis of note is the manifesto 12 razones para amar las bibliotecas públicas which is a collective campaign not just to defend the role of libraries but also to reject copyright fees for public library book loans shared support of the need for libraries the public has actively engaged in the library support campaigns and social media initiatives many protests have been staged by the socalled yellow tide a group that chose this color as a symbolic representation of the defense of public libraries other spanish social movements have used colors for their campaigns such as green for the defense of public education or white to advocate for public health in addition to the color recognition a slogan and a logo the latter designed by artist fist have been developed in the fight for libraries libraries are not an expense they are an investment accompanied by a heartshaped book with open pages coverage and examination of the role of the library in periods of crisis a crisis is usually a good time for selfexamination which can take the form of publications or scientific and professional meetings and conferences for example fesabid released its 2011 report estudio fesabid sobre los profesionales de la información prospectiva de una profesión en constante evolución which collected expert opinions on the evolution of libraries including questions on the economic crisis and the future of libraries the economic situation and the damage to libraries have also been addressed at various professional conferences such as the sixth forum of information and documentation specialists of andalusia libraries in times of crisis and the 17th andalusian conference on libraries lessons learned a contributive justice framework for libraries the social actions taken by spanish libraries and their communities are lessons in social justiceor in this case contributive justicethat are not just applicable to the country in question but should be considered in an international context to be practiced globally at all times not just in those of economic exigency the many examples are clear evidence of the value of libraries as a public good and a vital lifeline for the community and that a contributive approach was appropriate in solving the economic challenges encountered by the spanish libraries the need to keep libraries open both as a community space and as an information and technology resource was not even in question the social actions described above revealed the critical areas that need to be addressed or the needed contributions that are essential to the survival of the spanish libraries and possibly libraries in other regions these social actions reveal four lessons learned regarding contributive justice in libraries and their communities these lessons constitute four areas of investment or contribution that make up the following proposed contributive framework they are vital to the sustainability of all libraries and the social opportunities and benefits of communities • communitywide commitment and action the efforts of both librarians and communities separately or jointly reveal the value of libraries on both sides librarians understand that their services are needed by their communities and must continue to fight for support while finding creative ways to sustain services community members recognize their own need for library and information services and have stepped up to partake in the delivery efforts in monetary and nonmonetary ways this symbiosis is affirmed through contibutive action and the synergies that evolve • advocacy communication and promotion should exist on the availability of libraries as a public resource their role as the main public source for individual and community information and engagement and the need for appropriate levels of funding to support them libraries have been taken for granted by those who work in and use them while many who need library services are not familiar with them the value of libraries needs to be expressed to funding agencies in terms of return on investment and stories of individual and community impact ie contributions to social development • public lifeline communities are sustainable when they collectively share in the costs and delivery of services important to their development especially to ensure that the information that can create opportunities is accessible across all economic sectors libraries are the heart of a community the inequality that would occur without them would create a larger digital economic social and ontological divide a contributive approach reduces inequalities of opportunity • identity libraries as the heart of the community are dynamic this identity is not always translated to or understood by the public because in many cases librarians in spain have been a constant presence but with funding cuts they have been able to take action toward claiming their role as a public good librarians are reaching out to each other and to their communities by using social media and other technological tools freely available on the web it is this collective and contributive approach that is solidifying the identity of libraries for themselves and their communities despite economic hardships across spain spanish libraries reveal that the pulse of communities is sustained with functioning libraries the libraries investment in their communities and vice versa the communitys agency in safeguarding an essential public good and the value of grassroots efforts when governments fail to act affirm the role of libraries as social justice institutions and of librarians as change agents spanish libraries found that their resilience exposed an increased opportunity of contributing not just of themselves but also with and by their communities librarians by empowering themselves and their communities found their solutions to the economic crisis from within and without and libraries as a result of contributive justice recognize that they are an assetbased organization appendix list of libraries contributing to the study agolada la biblioteca iba a ser cerrada ávila petición reapertura de biblioteca palacio de los serrano biblioteca central biblioteca central de cantabria biblioteca centro asociado unedasturias biblioteca civican biblioteca de a coruña biblioteca ágora biblioteca de amara biblioteca de andratx biblioteca de casapuerta cádiz biblioteca de castillala mancha biblioteca de contrueces biblioteca de chinchilla biblioteca de ermua bizcakia biblioteca de la rioja biblioteca de la universidad de extremadura biblioteca de las palomas biblioteca de noain biblioteca de orihuela biblioteca de palafrugell biblioteca de sant antonijoan oliver de barcelona biblioteca de torre pacheco biblioteca de torrejón del rey biblioteca de villanueva del pardillo biblioteca de villarrubia de los ojos biblioteca del hospital universitario virgen de la victoria de málaga biblioteca municipal de burgos biblioteca municipal de caldas de reis biblioteca municipal de montequinto biblioteca municipal de peñaranda de bracamonte biblioteca municipal de san javier biblioteca pública arroyo de la miel biblioteca pública de allo biblioteca pública de guadalajara biblioteca pública de huelva biblioteca pública de salamanca biblioteca pública de zamora biblioteca pública del estado en cuenca biblioteca pública municipal de baiona biblioteca regional de murcia biblioteca uned biblioteca universidad de extremadura bibliotecas de badalona bibliotecas de castilla y león

the call for this journal issue notes that social justice in lis services involves achieving actionoriented socially relevant outcomes via informationrelated work there is not a more fitting time and place for such action than in spain where the current economic crisis left more than 6 million 27 percent of the population unemployed as of 2013 it is not just communities that are grappling with the pain of the economic downturn libraries are also suffering from the crisis as a result of budget cuts due to reduced public funding this article presents the case of spanish academic and public libraries that have found solutions to keep themselves open providing services vital to the economic and sociocultural needs of their communities this case is an example of contributive justice as evidenced in the actions taken by spanish libraries and their communities as well as in the manner in which the research data were collected eight libraryrelated actions were found professional community social political digital culturalheritage economic and ontological despite economic hardships all around these spanish examples reveal the impact of libraries as social justice institutions the role of librarians as agents of change and the value of contributive and grassroots efforts when governments fail to provide moreover these contributions to social justice illustrate actions appropriate to a contributive justice framework for libraries as proposed in this article

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introduction ethnic and racial diversity is rapidly increasing within many countries the transformation of united states into a prismatic society constitutes a paradigmatic example of this phenomenon and indeed according to census bureau projections by 2042 nonhispanics whites will amount for less than 50 of the population prismatic societies pose a great challenge for social scientists as intergroups studies have often built on the two groups paradigm yet the methodologies used to analyze the twoparty case are not suited for triads as the latter entails a transformation not simply an extension of the twoparty case for this reason developing quantitative models to understand predict and control multigroups interracial dynamics is a compelling priority to take on this challenge we propose a mathematical approach based on a deterministic model of the lotkavolterra type to study multigroup interactions from a dynamic perspective this mathematical model previously introduced in marasco et al provides a methodology to study the kind and the intensity of the interactions among groups and to forecast future dynamics in a scenario framework we argue that the joint use of the proposed lv model and the scenario methodology offers a key to understand interpret and predict multigroups dynamics in particular we study the dynamical interactions among asians blacks natives and whites within the united states the analysis is structured as follows we start by proposing an aggregate index of socioeconomic status comprising measures of income employment expected life and numerosity of each group for the period 20022013 then we show that these ses indices can assume the form of a logit model and that therefore the corresponding ses functions can be linked to the competitive roles in the lv dynamic framework as shown in marasco et al indeed in our approach the ses functions allow us to highlight and quantitatively measure the interactions among racial groups therefore using the proposed model to study the dynamics of the ses indices allows us determine the kind and the intensity of the interactions among asians blacks natives and whites during the time interval considered last we forecast the evolution of groups ses and how interracial relations will unfold in three stylized scenarios in the first scenario we study what is the magnitude of the policies that would be necessary to prevent whites from losing ses shares in the second scenario we perform a similar analysis but the goal is to ensure that blacks ses shares become at least equal to that of asians in the third scenario we simulate a period of economic expansion we disregard the normative appeal of each scenario as our intention is merely to offer a quantitative measure of the changes required to achieve a given goal or to investigate the impact on ses dynamics of a change in some components of the ses the proposed model is general and applies for any number of racial groups and for any continuous measure of ses therefore while in this article we focus on asians blacks natives and whites for reasons of data comparability the analysis can be replicated including other racialethnic groups similarly it is possible to adopt a different index for groups ses we remark that although formally the ses functions play the role of the utility functions in a logit model our methodology in no way implies that the individuals belonging to a racial group consciously organize to maximize the utility of the group to which they belong instead the analysis only requires three milder conditions to hold first despite being indistinguishable from an anthropological point of view racial groups must be a meaningful unit of analysis from a sociological perspective and in the public policy debate this is confirmed by the countless domains that are relevant to define the ses of an individual in which there are persistent and significant differences among races eg life expectancy and unemployment second given that ses is inherently a relative concept we claim that variations in the ses of one group have an influence on the ses of other groups for instance an individual with a given level of income can be considered upperclass in contexts in which the average income is significantly lower whereas the same level of income could qualify her as lowclass in contexts in which the average income is higher therefore if the income of all racial groups but one significantly increases over time the socioeconomic status of the group that is left behind will worsen even though its income has not decreased similarly despite the fact that the life expectancy of blacks in united states has increased over the last decades the literature considers that blacks suffer from poor health conditions because they live less than asians the fact that blacks have a lower life expectancy than other groups sharing the same environment is an indicator that their socioeconomic status is relatively lower in this dimension the same logic applies to group size the political influence of a racial group is affected by its relative numerosity if anything due to the share of votes that it can cast at the elections for instance in a country with a small population a racial group composed by a few thousands of individuals might have a relevant voice the same group would have a negligible influence in a country with a large population in this vein if the size of one group increases it worsens the relative position of the other groups third we argue that the socioeconomic status is a determinant of the kind of interaction among groups this is corroborated by research showing that racial attitudes shape and are shaped by the ses of the racial groups in other words we build on the assumption that there is a relationship between multiracial dynamics and socioeconomic status the main findings of the paper are the following first we find that the lv model introduced in marasco et al can accurately describe and forecast groups interactions provided that the ses index for each group are rewritten as a logit model indeed the measures of error considered indicate that the model is highly accurate second the kind of interaction among the racial groups changes over time indicating that studies that do not use panel data can only take snapshots of reality third our approach confirms that the interactions among racial groups are influenced by macroeconomic factors in particular we find that during the 2008 financial crisis all racial groups engage in rivalrous interactions and that the intensity of competition is modulated by the severity of the crisis fourth we find that only very drastic interventions can prevent the ses share of whites from declining or allow blacks to enjoy the same ses share of asians last an economic boom only marginally affects ses shares while increasing the level of mutualism within the society the structure of the paper is the following sect 2 covers some preliminary methodological issue and the background literature section 3 illustrates the data and the method the results are presented in sect 4 section 5 concludes and discusses potential extensions of this research 2 preliminary methodological considerations and background literature 21 background literature at a general level this work relates to the literature that analyzes racial groups ses dynamics in an influential article hirschman studies the evolution of the ses of asians blacks hispanics and white men in the united states between 1960 and 1976 his main finding is that the socioeconomic status of high ses minorities tends to converge or even surpass that of the whites whereas disadvantaged minorities constantly lag behind although many decades have passed we find that very similar dynamics still characterize american society other studies concentrate on the evolution of one of the dimensions of ses over time finding that differences across racial lines tend to be stable over time see leicht and references therein we contribute to this literature by studying from a dynamic perspective the interactions among the ses of the various groups two other strands of literature that are relevant to our analysis are studies investigating how the ses of one group influences the attitude of outgroup members toward that group and how the attitudes of the outgroup members toward a group influence the ses of that group taken together and show that the interactions among groups are influenced by their respective ses via attitudes however while there is a general consensus in the literature that racial group ses affects racial interactions scholars disagree on the direction of this effect on the one hand literature on racial group competition and threat argues that minorities with high ses foster negative attitudes in the dominant white group this occurs because as minorities improve their social standing in society whites perceive that they are encroaching their privileged position conversely the group contact hypothesis predicts that higher ses levels of racial minorities can trigger positive attitudes in the majority group in this view an equal social standing facilitates positive intergroup contacts looking at the sesattitudes relationship from the opposite perspective various strands of research investigate impact of attitudes on the allocation of resources among racial groups this literature shows that racial attitudes create differences in key determinants of ses across racial groups eg job positions wages and government assistance to summarize variations in the ses of a racial group can affect the distribution of resources across racial groups this in turn can trigger shifts in ses measures of the various groups within a society another related strand of literature investigates directly how variations in one component of the ses of a group affects the ses of other groups in this regard it is important to distinguish two ways in which these effects can take place on the one hand changes in the socioeconomic standing of a group always have an effect on the ses of the other groups because ses is an inherently relative concept if one group improves its condition while the other remains stable the position of the latter becomes relatively worse on the other hand research on the interactions between racial groups ses highlights that variations in ses measures of a racial group can trigger variations in ses measures of other racial groups in absolute terms for instance variations in the size of minority populations may lead to reductionsincreases in the economic wellbeing of different racial groups in this regard cohen finds a negative relation between concentrations of blacks and their earnings moreover he finds a positive relation between the number of blacks and the earnings of whites therefore there is a relationship between groups ses that goes beyond the mere shift in the relative position of the groups on this background the emergence of a prismatic society complicates the analysis because a multiracial society is a fertile environment for the emergence of nuanced relationships among racial groups and indeed a growing body of literature is investigating social patterns in a multigroups framework the present work contributes to this literature by offering a rigorous mathematical approach to test in a quantitative and replicable way how n racial groups interact and influence each other ses conceptual framework of the analysis an important methodological premise to this study is defining in a clear and detailed way the ses measure because ses is a multidimensional and contextual concept that can be measured using many different indicators in particular traditional measures of ses include education income employmentsometimes called the big threebut also wealth household tenure parental education and so on sesrelated measures are sometimes used as single items or suitably combined and are often operationalized as a single ordinal categorical variable moreover measures of ses can have a different scope and range from a neighborhood to areas as large as states and regions as both single and composite measures of ses have some disadvantages it is widely understood that there cannot be one universally accepted indicator and the debate is still open on which are the most reliable it was noted that the indicators should carry as much relevant information as possible the indicators used should be clearly spelled out including their limitations and the impact of non accounted factors should be explicitly stated we try to follow these guidelines to build our measure of ses in detail we adopt a multidimensions approach that accounts for measures of income employment group numerosity and life expectancy we focus on income and employment because they constitute natural dimensions to study interracial dynamics and the reciprocal impact of the various groups on their respective ses moreover recent studies show that measures of income even considered alone have a high predictive power on relevant outcome variables in addition to develop a more comprehensive indicator of ses we aggregate also information relative to groups political power and health status we account for the former by considering group numerosity because size can positively influence the political strength of a group in a democratic society this is even more so in societies such as the american one in which minorities political turnout is positively correlated with increases in their relative group size we account for the latter by including information on life expectancy which is widely recognized as an indicator of various dimensions of ses eg exposure to pollutants eating habits access to health services exposure to violent crimes etc admittedly our indicator overlooks some important component of ses like education and wealth we do not include these factors due to data availability and because they cannot be aggregated in a straightforward way with the other measures of ses considered for example unlike the variables that we consider education is not a continuous variable and indeed the amount of education is traditionally expressed using categories then in order to include a measure of education in the proposed ses index it would be necessary to build an ad hoc continuous version of the amount of education however we remark that in principle our approach is well suited also when accounting for measures of wealth and education similarly provided that the relevant data is available the analysis can be replicated at a state level or even at a county level while the indicators chosen are far from foreign to the literature we adopt a different strategy to aggregate them instead of obtaining the composite ses measure as a weighted average of their single indicators we opt for a multiplicative form this choice allows us to approximate the behavior of american courts in tort cases when calculating damages awards as noted by avraham and yuracko racebased tables of wage and life expectancy are commonly used to define the compensation owed to a victim of a tort assume that in a car accident a white and a black child of the same age die simplifying to the extreme if these tables are used a court will determine compensation multiplying the predicted wage of each child for his expected worklife because whites generally live longer and have higher wages the parents of the white child will be awarded higher damages this approach has a relevant practical impact on how resources are allocated within the society for instance ceteris paribus for a firm it is cheaper to pollute in a black neighborhood than in a white neighborhood because the expected liability is lower in turn the choice of the firm to locate in a black neighborhood further reduces the ses of the blacks as an increased pollution is likely to decrease life expectancy due to the practical relevance of these considerations we build our ses indicator following the same logic and multiply income expected life and employment rate last we correct the result of this product for the size of the group as standard manipulations allow us to write each ses index as a logit model we perform the quantitative analysis using the class of lv models introduced in marasco et al these models are a powerful tool to study and forecast the interaction among different entities in a given environment at a general level lv models have the advantage of being able to capture every possible kind of interaction for this reason they are widely used in natural sciences and are becoming more and more widespread in a variety of domains in social sciences see modis romano marasco et al and references therein there are two main factors that explain why traditionally lv models have been used more frequently in natural sciences first the most used lv models are autonomous ie the model equations contain only constant coefficients as in tsai and li chiang lin lakka duan et al cerqueti et al thus the kind and the intensity of the interaction is assumed to be constant over time intuitively this is a greater limitation for studies in social sciences than for some studies in natural sciences for example it is very unlikely that sheeps and wolves change the way in which they interact and therefore modeling them respectively as preys and predators for the whole time horizon is a perfectly reasonable choice on the contrary phenomena in social sciences are usually characterized by a high variability of competitive roles for instance an appropriate marketing campaign can turn a firm that used to be a prey of another into a predator similarly we expect that ethnic groups do not have a constant pattern of interaction thus autonomous lv systems are generally not an appropriate choice to model this social dynamics second in most cases the analytical solutions of lv modelsespecially in the nonautonomous caseare not known in a closed form therefore the parameters of the model have to be estimated using expensive numerical fitting procedures this is not always possible in many domains of social sciences that are plagued by data scarcity the lv model presented in marasco et al romano overcomes both problems on the one hand it is a nonautonomous model and therefore the competing entities are allowed to change their competitive roles over time on the other hand the analytic solutions are known and therefore the quantitative analysis is significantly easier and requires less data importantly the analytical solutions of this class of lv models are in the form of a logit model introduced by mcfadden extensively used in every area of social sciences and also in studies analysing socioeconomic status and race therefore besides its properties this model has the additional advantage of being coherent with the mainstream approach to the quantitative study of many social phenomena differently from marasco et al in this paper we can easily design the scenarios since the ses functions are linked in a known way to the components of groups ses scenario method in public policy the scenario method consists in developing a set of hypothetical events set in the future constructed to clarify a possible chain of causal events as well as their decision points in particular scenario planning allows to forecast future dynamics by presenting the crucial elements of a given problem in a systematic and coherent way if appropriately applied it is a powerful tool to approach complex problems characterized by a high degree of uncertainty in a more rational and effective way moreover in settings dominated by uncertainty scenarios are useful for highlighting implications of possible future system discontinuities identifying nature and timing of these implications and projecting consequences of a particular choice or policy decision not surprisingly the literature identifies a correlation between the degree of uncertainty characterizing a given domain and the use of the scenario method as in many policy domains the debate is dominated by the concept of uncertainty health law financial law scenario planning can be a useful tool also for policy makers we contribute to the scenario literature in two ways first many of the scenario applications in the public policy area often remain at a qualitative level we complement this literature by proposing a deterministic modeling approach that translates into deterministic predictions the set of possible narratives second we apply the scenario methodology to a domain that is extremely appropriate for scenario analysis due to its complexity and uncertainty yet in which scenariosto the best of our knowledgehave not been applied before materials and methods data we collect data on life expectancy average income employment rate and total number of residents for four racial groups natives asians blacks and whites in this data set the racial group of asian refer both to asian and pacific islanders natives include american indians eskimo and aleut and all racial groups refer both to hispanics and nonhispanics in particular we obtain data on life expectancy and numerosity from the us bureau of the census the life expectancy l i ðtþ for the iàth racial group r i at time t is obtained as follows l i ðtþ ¼ n f i ðtþ l f i ðtþ þ n m i ðtþ l m i ðtþ n f i ðtþ þ n m i ðtþ ð1þ where n f i ðtþ n m i ðtþ represent the total number of female and male resident respectively whereas l f i ðtþ l m i ðtþ are the corresponding mean life expectancies we denote by n i ðtþ the total number of residents of the iàth racial group r i whereas nðtþ ¼ x 3 i¼0 n i ðtþ is the total number of residents to fill gaps in the dataset containing the annual values of n f i ðtþ l f i ðtþ n m i ðtþ and l m i ðtþ we construct an approximate function that interpolates the available data for each variable in eq then we use this function to find the missing values in particular the fitting procedures are performed by using the following fourier series of order n a 0 þ x n r¼1 a r cos rpt s þ b r sin rpt sð2þ where s ¼ ð2015 à 2002þ þ 1 and n ¼ 2 the data on average income i i per racial group for asians blacks and whites is taken from the website of the us census bureau datahistoricalpeople 1 in particular we take the asians alone blacks alone and whites alone data at current dollar value last the data on employment e i per racial group for asians blacks and whites is obtained from a report of the us bureau of labor statistics all the collected data are reported in fig 1 ses index and logit model supposing that the ses index s i ðtþ at any time t for each groups is a function of the variables l i ðtþ e i ðtþ i i ðtþ n i ðtþ we propose the following analytical form s i ðtþ ¼ l i ðtþ â e i ðtþ â i i ðtþ â ln 1 þ 100n i ðtþnðtþ ð þ mðtþ i ¼ 0 3ð3þ where mðtþ ¼ x 3 i¼0 l i ðtþ â e i ðtþ â i i ðtþ â ln 1 þ 100n i ðtþnðtþ ð þ ½ we note that the function ln 1 þ 100n i ðtþnðtþ ð þ is a weight function to account for the relative size of iàth racial group to highlight the role of each variable in the aggregate indices s i ðtþ we summarize in table 1 all data for the four racial groups in 2002 the ses indices over the period 20022013 are reported in fig 2 in order to apply the lv model proposed in marasco et al to the study of racial groups interactions we need to write each ses index in the form of a logit model as we see in fig 2 the role of the outside good is played by the racial group of natives because of their very low ses share then introducing the positive functions a i ðtþ ¼ l i ðtþ â e i ðtþ â i i ðtþ â ln 1 þ 100n i ðtþnðtþ ð þ ½ i ¼ 0 3ð4þ standard manipulations allow to write eq in the following form s 0 ðtþ ¼ 1 1 þ x 3 j¼1 expðf jðtþþ s i ðtþ ¼ expðf i ðtþþ 1 þ x 3 j¼1 expðf j ðtþþ i ¼ 1 2 3ð5þ where the ses functions f i write f i ðtþ ¼ ln a i ðtþ a 0 ðtþ i ¼ 0 3 we remark that as in the logit models the ses of the iàth racial group increases when its ses function f i ðtþ increases and decreases when the ses function f j ðtþ of any other group increases the first relation captures the fact that the ses of a group is positively influenced by increases in the resources available to the members of the group the second relation derives from the inherently relative nature of ses since the status of one group can be determined only in relation to the one of the other groups positive variations in the ses of one group necessarily negatively affect the ses of the other groups and viceversa moreover due to eqs each ses function f i ðtþ increases when one or more functions l i ðtþ e i ðtþ i i ðtþ n i ðtþ increase and decreases when one or more functions l j ðtþ e j ðtþ i j ðtþ n j ðtþ of any other group increase how ses shares vary in response to variations of one or more ses functions can only be evaluated by numerical simulations the lotkavolterra model in the following we describe in detail the proposed lv model in which the native play the role of the outside good by assigning the natives the role of the outside good we implicitly assume that their strength is too limited to significantly alter social dynamics at a macrolevel if we assume that all the ses functions f i ðtþ i ¼ 1 3 are of class c 2 t 0 þ1 ½ þ ð þit is easy to demonstrate that eq are the unique solution of the following cauchy problem s i ðtþ ¼ g i ðtþs i ðtþ 1 à s i ðtþ ½ à p 3 j¼1j6 ¼i g j ðtþs j ðtþs i ðtþ i ¼ 1 3 s i ðt 0 þ ¼ expðf i t 0 ð þþ 1 þ p 3 j¼1 expðf j t 0 ð þþ 8 t 2 t 0 þ1 ½ þð7þ where the dot denotes the derivative respect to time s i ðtþ 0 represents the ses share of the iàth racial group at time t g i ðtþ ¼ f i ðtþ and s 0 ðtþ ¼ 1 à p 3 i¼1 s i ðtþ eq describes the interaction between the iàth and jàth racial groups by means of their ses indices in a framework of competitive roles varying over time the evolution of the ses share s i ðtþ of the iàth racial group is mathematically determined by two factors the logistic growth rate function g i ðtþ and the competition functions g j ðtþ between the iàth and jàth racial groups last according to eq the maximum capacity related to the saturation value of each s i ðtþ is 1 we remark that at any time the competitive roles are determined by the signs of the functions g i ðtþ hence according to table 2 the lv model is able to capture all the possible kinds of competitive interactions then owing to eq the competitive roles between the iàth and jàth racial groups are determined by the signs of the functions g i ðtþ ¼ f i ðtþ ¼ d dt ln a i ðtþ a 0 ðtþ ¼ a i ðtþ a i ðtþ à a 0 ðtþ a 0 ðtþ i ¼ 1 2 3ð8þ where the functions a i ðtþ are defined in eq to clarify the meaning of the possible forms of interactions let us focus on the two minorities considered asians and blacks if these groups stand in a relationship of mutualism an increase in the ses of one group favors the growth of the other group ses importantly even in presence of mutualism there is no guarantee that when asians gain more ses shares also the ses share of the blacks grows as the beneficial effect of the growth of asians ses on blacks ses must be balanced with other factors an example of mutualism emerging among minorities is the following case there is table 2 the competitive roles between any pair of competitors s i ðtþ and s j ðtþ g i g j type of interation explanation þ þ pure competition the competitors suffer from each others existence þ predatorprey predator benefits from preys whereas preys suffer from predators mutualism symbiosis or a winwin situation 0 commensalism one benefits from the existence of the other while the other remains unaffected þ 0 amensalism one suffers from the existence of the other which is impervious to what is happening 0 0 neutralism no interaction empirical evidence that some asian minorities are discriminated on the work place and that this discrimination also negatively affects their health similar findings have been reported for blacks in our framework these forms of discrimination are bound to affect the ses of both groups because measures related to employment and to health are considered in our ses indicator let us assume that one group becomes more influential in the political arena and some of its representatives persuade the government to pass more effective antidiscrimination rules in this case also the other group will benefit and hence mutualism between the groups could exist competition is the other side of the coin when one group gains the other loses for instance the access to health services in united states is a scarce resource and is largely tied to the economic status if asians improve their economic status they will be able to purchase better insurances and consume a larger share of the pie destined to health care services this could negatively affect the blacks that might experience a further decrease in the share of health care expenditures allocated to them there is amensalism between asians and blacks if an increase in the ses of the asians negatively affect the ses of the blacks whereas the ses of the asians is unaffected by variations in the ses of the blacks instead there is commensalism between asians and blacks if an increase in the ses of the asians positively affect the ses of the blacks whereas the ses of the asians is unaffected by variations in the ses of the blacks it seems reasonable to assume that these interactions emerge when one of the two groups is extremely small and hence it only has a negligible influence on the other as the number of asians blacks and whites is significant we do not expect to observe these forms of interactions predatorprey is a more nuanced interaction in particular it presupposes that an increase in the ses of the predator harms the prey whereas an increase in the ses of the prey benefits the predator last neutralism simply means that the ses of the two groups are completely independent equation allows us to determine a discrete set of values for each ses function starting from historical data on ses shares therefore the indirect determination of the analytical form of these functions is obtained by a fitting procedure using the fourier series of order n ¼ 2 with s ¼ ð2013 à 2002þ þ 1 see eq and fig 3 performance of the lv model on the historical data to evaluate the fitting and forecasting performance of the proposed model we use the mean square error and the mean absolute percentage error fig 3 ses functions over the period 20022013 mse ¼ 1 n x n i¼1 h i à p i ð þ 2 mape ¼ 1 n x n i¼1 h i à p i h i 100 where h i and p i are the historical and predicted values respectively the values of the mse and the mape confirm that the model is highly accurate in describing interracial dynamics we recall that the forecasting accuracy by mean of mape can be classified into four levels 10 10à20 20à50 and 50 we note that lv models have gained in popularity in timeseries forecasting due to their simplicity and ability to characterize a real system by using few data points nevertheless we examine some standard forecasting methods such as those belonging to arima garch and sarima families and compare them with our lv model to highlight the forecasting performances under the constraint of few data indeed due to the paucity of data we focus on arima models for the dynamics of asians and blacks and compare them with lv models using the mannwhitney tests at significance level of 005 2 according to akaike bayesian and schwartzbayes information criteria the ses shares of asians are well described by an arima process of parameters p ¼ 0 d ¼ 1 q ¼ 1 the forecasted data obtained from lv and arima models are statistically indistinguishable as we see in fig 5 both models are consistent with the observed ses shares of asians in the years 2014 and 2015 similarly choosing for the ses shares of blacks the arima process we obtain the behavior in fig 5 although the ses shares of blacks obtained by lv model belong to the upper prediction band also in this case the forecasted data obtained from lv and arima models are statistically indistinguishable we remark that differently from forecasting statistical processes the proposed lv methodology provides information about competitive roles both in the past and in the future moreover the procedures required in a statistical approach to design future scenarios would be extremely complex this is especially true with regards 2 the data on 2014 and 2015 was not available at the time in which the article was written we included this data at a later stage to compare the predictions of our model with the observed dynamics to the possibility of controlling the considered phenomenon and evaluating the effect of any variation in one or more of the elements composing the ses scenario methodology and development although there are different approaches it is frequent to divide the scenario analysis into five main steps following this structure we begin our analysis by identifying the major driving forces and the key variables that are likely to influence how groups interact and their ses we note that the most part of these variables depend on each other each of these driving forces deserves special attention to understand how intergroups dynamics will unfold for instance affirmative action policies have been shown to effectively benefit minorities by fostering their employment in addition affirmative action increases diversity in the workplace thus facilitating interracial contact which is an important determinant of interracial attitudes similarly media play a key role in shaping racial attitudes and stereotypes however for reasons of tractability and data availability we limit our focus to four of these variables in particular we concentrate on measures of income employment rate life expectancy and group numerosity the second step of the scenario analysis consists in developing the scenario logic and the respective story lines during the first two steps the analysis is prevalently qualitative and it is generally conducted via interviews surveys and workshops the third step consists in quantifying the future developments of the main driving forces and the corresponding variables for instance a low numerosity among whites could be quantified in whites representing only 60 of the population in the near future alternatively it can be studied a high numerosity scenario in which the share of the whites is above current levels these measures are then used in the fourth step to 2016a is suited to perform the last three steps of the scenario analysis and especially the fourth one in fact during the fourth phase quantitative methods have a comparative advantage over qualitative ones in providing accurate forecasts moreover we improve on marasco et al because we identify the ses functions and hence scenario simulations can be directly linked to changes in the components of ses using the proposed lv model we analyze the following scenarios businessasusual current trends are expected to continue nondeclining whites scenario instead of declining the ses shares of whites in the forecasted period are stabilized around the value of the last historical observation we calculate the increase in the ses function of whites needed to ensure that their ses shares does not decline and we find that 004ðt à t 0 þ where t 0 represents the year 2013 provides this result in other words as it will be discussed in sect 42 the function 004ðt à t 0 þ allows to derive a measure of the magnitude of the changes that are necessary to achieve a given result we therefore modify the ses function of the whites as follows f sw1 3 ðtþ ¼ f 3 ðtþ þ 004 t à t 0 ð þ 8t 2 t 0 t ½ð9þ where t 0 and t represent the years 2013 and 2018 respectively improving blacks ses scenario the ses shares of blacks in the forecasted period increase at a faster rate than in the bau and becomes higher than that of asians after the year 2016 we calculate by how much the ses function of the blacks should be increased to obtain this result we find that the function 007 t à t 0 ð þensures that the ses share of the blacks becomes higher than that of the asians after the year 2016 3given this result we modify the ses function of blacks as follows f sb1 2 ðtþ ¼ f 2 ðtþ þ 007 t à t 0 ð þ 8t 2 t 0 t ½ ð10þ economic boom scenario in the forecasted period the income and the employment rate of all the groups improve in particular we assume that the changes mirror the losses produced by the economic crisis for instance blacks during the 20072010 economic crisis lost 182 of their income hence we simulate that during the forecasted period the income of the blacks grows at most by 182 more than in the bau then we consider the following ses function f seb 1 ðtþ ¼f 1 ðtþ þ 1 t à t 0 t à t 0 2 f seb 2 ðtþ ¼f 2 ðtþ þ 2 t à t 0 t à t 0 2 8t 2 t 0 t ½ f seb 3 ðtþ ¼f 3 ðtþ þ 3 t à t 0 t à t 0 2 ð11þ where 1 ¼ à00909 2 ¼ à00577 3 ¼ à01178 to highlight how to modify the main variables to obtain the ses functions in eqs and we proceed as follows limiting our attention to eq we assume that the changes in the ses function f 3 are due to the average income i 3 only this is because in normal circumstances life expectancy and group size are relatively inelastic in the short term from eqs and we determine f sw1 3 ðtþ ¼ f 3 ðtþ þ ln i sw1 3 ðtþ i 3 ðtþ 8t 2 t 0 t ½ ð12þ then by comparing eqs and we obtain i sw1 3 ðtþ ¼ i 3 ðtþ exp 004ðt à t 0 þ ð þ 8t 2 t 0 t ½ ð13þ analogously if we assume that the change in the ses function f 3 is due to both the average income i 3 and employment e 3 instead of eq we obtain aðtþbðtþ ¼ exp 004ðt à t 0 þ ð þ 8t 2 t 0 t ½ð14þ where aðtþ ¼ e sw1 3 ðtþe 3 ðtþ bðtþ ¼ i sw1 3 ðtþi 3 ðtþ alternatively owing to eq it is possible to study how future dynamics change on varying the driving variables l i e i i i n i and indeed any change in these variables result in a modification of the ses functions and of the competitive roles as shown in eqs and respectively in particular we show how to modify the income and the employment rate of the four racial groups to obtain the ses functions in eq from eqs to if we assume that the change in the ses functions is only due to the functions e i and i i for i ¼ 1 2 3 we can write f seb i ðtþ à f i ðtþ ¼ ln e seb iðtþ to determine the analytical form of the functions a ei ðtþ â a ii ðtþ a e0 ðtþ â a i0 ðtþ i ¼ 1 2 3 ð17þ we proceed as follows it is assumed a period of economic growth characterized by a specular trend of the economic crisis of the years 20072010 then owing to the historical data of the income and the employment rate of the four groups we have a e0 t ð þ ¼ 10762 a i0 t ð þ ¼ 10865 a e 1 t ð þ ¼ 10444 a i 1 t ð þ ¼ 10223 a e 2 t ð þ ¼ 10840 a i 2 t ð þ ¼ 10182 a e3 t ð þ ¼ 10480 a i3 t ð þ ¼ 09917ð18þ in addition if the effect of economic growth is supposed to result in a gradual change in ses functions we can model these functions by secondorder polynomials then since a e i t 0 ð þ ¼ a i i t 0 ð þ ¼ 1 i ¼ 0 3 we obtain ln a e i ðtþ â a i i ðtþ a e 0 ðtþ â a i 0 ðtþ ¼ a e i t ð þ â a i i t ð þ a e 0 t ð þ â a i 0 t ð þ t à t 0 t à t 0 2 8t 2 t 0 t ½ ð19þ hence eq becomes f seb i ðtþ ¼ f i ðtþ þ i t à t 0 t à t 0 2 8t 2 t 0 t ½ where i ¼ a ei t ð þ â a ii t ð þ a e0 t ð þ â a i0 t ð þ i ¼ 1 2 3 finally from eq we have 1 ¼ à00909 2 ¼ à00577 3 ¼ à01178 the scenarios that we analyze are reported in table 5 results and discussion in this section we present and discuss the historical data and the results of the quantitative analysis performed by means of the proposed lv model all the forecasting in the scenario analysis extends to the year 2018 as a preliminary remark we note that the interactions most frequently observed are mutualism and competition the former implies that an increment in the ses of one group has a positive effect on the ses of the other group whereas the latter means that an increment in the ses of one group has a negative effect on the ses of the other a more detailed description of the competitive roles can be found in the sect material and methods historical data and bau scenario before describing the results we can make some preliminary remarks first the ses of whites is substantially higher than the ses of the other racial groups indicating that they stand in a position of relative dominance yet their dominance is closely related to their numerosity because asians have higher values than whites in all the other indicators because the relative number of whites is expected to decline their relative dominance is likely to weaken moreover asians are eroding ses shares from all the other groups this result is mainly driven by their larger relative improvements in terms of income and employment rates on the contrary blacks have the lowest growth rate in terms of income while their employment level is lower in 2012 than in 2002 the bad performances of blacks in these dimensions are only partially compensated by their improvements in expected life as a result between 2002 and 2013 the gap between asians and blacks increased interestingly in the forecasted future these patterns are expected to partially change an interesting explanation is that blacksbeing the weakest group thrive when there is mutualism in the society whereas they suffer when society is characterized by rivalrous interactions and indeed before the crisis the rate of growth of the ses share of the black population had a positive sign only between 2006 and 2007 incidentally these years are preceded by mutualism between whites and blacks as the model forecasts that groups proceed in mutualism between 2013 and 2017 this might explain why blacks perform well in the forecasted period let us now turn to analyzing the kind and the intensity of the interactions among asians blacks and whites by studying the behavior of the interaction coefficients notably the model captures the simultaneous interaction of all the groups which is an important advantage of lotkavolterra models the most relevant finding is that the groups enter into pure competition roughly at the beginning of the crisis and the interaction coefficients of all the three groups reach their maximum in 2009 during the spannung of the crisis at that moment the groups invert the tendency of the previous years and steadily decrease the intensity of the competition to reach mutualism in 2012 a possible explanation is that negative economic conditions induce groups to compete to appropriate the scarce resources available yet when the intensity of the crisis reaches a certain threshold the fear of potential losses induces the groups to slowly abandon competitive behaviors in favor of more mutualistic interactions we remark that in 2009 the gdp of the united states decreased by 29 whereas in 2008 it only f 3 ðtþ þ 004ðt à t 0 þ sb1 f 1 ðtþ f 2 ðtþ þ 007ðt à t 0 þ f 3 ðtþ seb f 1 ðtþ à 00909 t à t 0 t à t 0 2 f 2 ðtþ à 00577 t à t 0 t à t 0 2 f 3 ðtþ à 01178 t à t 0 t à t 0 2 decreased by 03 therefore the losses to be allocated among the groups in 2009 were significantly larger than in the preceding years this behavior during severe crisis is in line with the well established concept of loss aversion that is individuals fear losses more than they value gains and hence during severe crisis the groups might avoid winlose interactions for fear of being on the losing side let us now move to analyze the single dyads of interaction during the period 20022013 asians and blacks always engage in rivalrous interactions thus disproving the idea that minorities cooperate wittingly or unwittingly to erode the privileges of the dominant majority a possible explanation is that the two groups present drastically different traits as asians are only rarely unemployed have significantly higher incomes and have a higher life expectancy than blacks therefore it is very likely that in the political arena the two groups take diametrically opposite positions on many divisive issues two additional points should be made a similar pattern is observed also between asians and whites as the groups always engage in rivalrous interactions during the period 20032013 this finding is in line with the well known group position theory which predicts that the dominant group reacts in an aggressive manner when exposed to the growing power of a minority that threatens the prevailing hierarchical structure of the society last we turn to blacks whites interaction here we observe the only instance of mutualism in the years preceding the crisis this mutualistic relationship could be interpreted as an attempt to cooperate to prevent asians from eroding other groups ses shares this attempt abruptly ended when the resources available became scarcer during the crisis 42 nondeclining whites scenario in the bau the behavior of ses shares reveals that the dominant position of whites is being eroded by other ethnic groups and especially by asians the only factor that keeps whites ses above that of asians is the relative numerosity of the two groups as united states is rapidly turning into a majorityminority society the relative size of the white population visa vis the other groups is going to shrink thus accelerating the decline of their ses history teaches that when the dominant group feels threatened it can adopt defensive behaviors andor support nationalistic parties according to many the united states are already experiencing a white backlash and the election of president donald trump would be a proof of this the practical relevance of the whitelash is testified by the fact that it is discussed in scientific articles eg in popular media and in university courses yale law school 4 also the taxcut recently proposed by president donald trump can be seen as a signal that the us might be moving in this direction and indeed according to some the proposed taxcut provides relatively small benefits to the middle class while rewarding more the richest although at the moment of writing any comment on the possible tax reform amounts only to speculation a tax reform that benefits the wealthiest would indirectly harm the weaker racial groups and therefore it would contribute to protect the status relatively wealthier groups for this reason in this scenario we study what kind of policies are sufficient to keep whites ses constant in the forecasted period 20132018 in particular as life expectancy and group size are inelastic in the short term we study what changes in employment rates and income level are necessary to prevent whites from losing ses shares in the forecasted future we find that to prevent whites ses from declining their income or occupational level must be increased to reach a 22 with respect to the bau in 2018 see eq acting on employment alone is not a viable strategy becausefor obvious reasonsit cannot be increased by 22 therefore the only two available options are to increase income alone or to simultaneously act on employment and income according to eq in any case even when acting simultaneously on both variables the required changes remain very large net of any ethical consideration on the desirability of this goal the analysis reveals that it is almost impossible to prevent whites from losing ses shares by implementing policies that act on income and employment rate in the shortmedium term if a political party decides to embark on a crusade to preserve the dominant position of whites it must be willing to either work on longterm policies or to take rather extreme measures interestingly we find that in this scenario whites reduce their level of mutualism toward the other groups and by 2018 they engage in rivalrous interactions with both asians and blacks this result is probably dictated by the newfound strength of whites that no longer feel the need of cooperating with other ethnic groups improving the ses of blacks blacks are the weakest group of the three considered this finding is particularly striking if we consider that their number is significantly higher than that of asians therefore it is possible that in the near future there will be political pressure toward an increased equality among racial groups the surge of the black lives matters movement originated in ferguson mo after a police officer killed michael brown is a clear symptom of this pressure the fact that president barack obama set up a dedicated task force testifies that the voice of the black lives matters movement has been heard at the highest political level and might affect future policies moreover the recent increase in congress representatives of colour may ease the implementation of proequality policies in this vein in this scenario we test by how much the income andor the employment rate of the black population should be improved to ensure that their ses reaches that of the asians we remark that blacks are 25 times more numerous than asians and therefore an equal ses implies that asians still perform better on the job market and in terms of life expectancy ensuring that the ses of blacks is equal to that of asians requires increasing their income to reach a 42 with respect to the bau as above a possible alternative is to simultaneously act on income and employment according to eq the required changes remain implausible there are a number of ways to improve employment rate or the average income of blacks among them the most notable are enhancing affirmative action policies targeting discriminatory practices increasing tax rates for high income groups while decreasing tax rates for low income groups etc however these policies generally produce effects that are significantly smaller than the one required to ensure that blacks and asians have the same ses for example there is an extensive literature trying to identify which share of the wage gap between blacks and whites can be explained by racial discrimination the findings of this strand of literature are conflicting as some authors argue that wage differential is mainly driven by a gap in skills between blacks and whites whereas others find that racial discrimination explains 60 of the wage differential a recent article locates in between these extremes and finds that racial discrimination accounts for about 30 of the wage gap assuming that 30 is a reasonable estimate even eliminating all racial discrimination in wage determination would not suffice to allow blacks to enjoy the same ses as asians and indeed the difference between the income of blacks and that of whites in 2013 is equal to 11150 therefore eliminating the part of the gap that is due to discrimination can only increase the income of blacks at best by around 12 it is unlikely that reducing the gap between the income of blacks and that of whites can be achieved by simply increasing the income of the former even though it is not necessarily a zerosumgame it is reasonable to assume that the values would converge with whites average income decreasing and black average income increasing similarly affirmative action policies have been shown to be effective in improving minorities conditions yet the size of the effect that they generate is significantly smaller than what is required by this scenario these findings suggest that to promote equality among racial groups it is mandatory to act on long term variables like education last in this scenario blacks abandon any mutualism in favor of rivalrous interaction with both asians and whites it seems that when the gap between the disadvantaged and the stronger groups decreases below a given threshold the former engages in rivalrous interaction to further improve its condition in society and reach the status of other groups a corollary of this hypothesis would be that to reduce differences among racial groups it is necessary go through periods of social frictions economic boom last we study how a period of economic growth affects the interaction among racial groups and the dynamics of their ses shares differently from the first two scenarios we do not set a target instead we study the impact of a change in two ses variables on ses dynamics therefore from a mathematical perspective this scenario is the other side of the coin of the first two as we intend to portray a period of economic expansion we act on the income and the employement rate of the four groups the reason is twofold on the one hand these components of the ses are conceptually more immediately related to changes in macroeconomic trends on the other hand life expectancy and group size are less elastic in the short term clearly we have no way to predict the magnitude of an economic boom or how the benefits would be allocated between racial groups with precision for this reason we simulate a scenario in which ses dynamics mirror those of the economic crisis for instance asians during the 20072010 economic crisis lost 222 of their income hence we simulate that during the forecasted period the income of the asians grows at most by 222 more than in the bau besides offering a slightly less arbitrary anchor this choice has an interesting property as blacks and natives are the groups the suffered more the crisis in the simulation performed these two groups enjoy larger additional gains from the economic expansions in principle in absolute terms the natives and the blacks might still grow less than asians and whites because we add these value on the base trends predicted by the bau in other words if the base growth of whites income is significantly higher than that of blacks the overall increase in income of the whites might still be larger than that of the blacks thus we do not postulate that during an economic boom the blacks and the natives will necessarily perform better than the asians and the whites instead in line with the economic literature we claim that an economic expansion can contribute to lessening the racial gap and benefit weaker groups both in terms of unemployment rate and in terms of income at a general level we note that the simulated economic expansion has a negligible impact on ses shares whereas it alters the interaction coefficients in a noticeable way this finding is consistent with the first two scenario simulations it confirms that altering ses dynamics in the shortmedium term is extremely hard whereas the kind of intergroup interaction is more malleable more in detail we notice that during the simulated economic boom the ses shares of all the groups remain almost identical the minimal changes observed point to a very small convergence of the ses shares given that blacks and natives perform marginally better than in the bau while the whites perform marginally worse the finding thatalbeit only marginallyan economic expansion can lead to lessening the gap between the strongest and the weakest groups is consistent with the results obtained by the economic literature at the same time we observe that the interaction coefficients of the groups significantly change in the simulated scenario the mutualism among racial groups becomes much stronger than in the bau and the rivalrous interactions disappear completely in other words as the size of the pie increases the groups shift to more symbiotic relationships this seems to be in line with the observation that during the economic crisis all the groups engaged in fierce competition conclusion and research perspectives racial groups interactions are an important component of the dynamics underlying the functioning of many modern societies yet the growing racial diversity within many countries is making their studyespecially from a quantitative perspectiveincreasingly fig 11 scenario sb1 competitive roles of asians blacks and whites continuous and dashed red lines refer to bau and sb1 scenarios respectively complex for example dyadic studies analyzing blackswhites relations are not apt to capture the dynamics characterizing the modern american society in this work after defining a ses index for each racial group and rewriting each of them as a logit model we employ an integrable nonautonomous lv model to analyze quantitatively and from a dynamic perspective the kind and the intensity of the interaction among these groups this approach has a number of advantages first it can capture nuanced forms of interaction like mutualism and commensalism second as the interaction coefficients are explicitly dependent on time it allows to study how the interaction evolves over time third because the solutions of the lv systems are known the analysis is not data demanding and the interaction coefficients of the model do not have to be estimated via expensive numerical methods last when combined with the scenario method this model helps to understand and shape the evolution of social dynamics we apply the model to the study of the interactions in terms of ses among asians blacks native americans and whites in the united states however we remark that our model is general and therefore it is possible to include more groups or to focus on different continuous measures of ses in particular we build an index of ses to study how racial group interactions evolve over time to build this index we aggregate data on life expectancy average income employment rate and group numerosity for each group during the period 20022013 our analysis highlights that racial interactions are inherently dynamic and influenced by macroeconomic factors moreover in a scenario framework we study how the ses of the groups should be altered to achieve the following goals preventing the ses share of whites from declining and ensuring that the ses share of blacks reaches that of asians the main finding is that these goals require changes in groups ses that are hard to achieve via shortterm policies last we investigate the impact of an economic boom on interracial dynamics we find that the ses shares are hardly affected by an economic appendix see table 6 and fig 14

globalization and migratory fluxes are increasing the ethnic and racial diversity within many countries therefore describing social dynamics requires models that are apt to capture multigroups interactions building on the assumption of a relationship between multiracial dynamics and socioeconomic status ses we introduce an aggregate contextual and continuous index of ses accounting for measures of income employment expected life and group numerosity after taking into account that groups ses assumes the form of a logit model we propose a lotkavolterra system to study and forecast the interaction among racial groups last we apply our methodology to describe the racial dynamics in the us society in particular we study the kind and the intensity of asiansblacksnativeswhites interactions in the us between 2002 and 2013 moreover we forecast the evolution of groups ses and how interracial relations will unfold between 2013 and 2018 and in three alternative stylized scenarios

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background in the midst of the recent sociopolitical upheavals in the arab region in particular the syrian crisis research on refugees and warafflicted populations has become of greater interest to the broader scientific community and humanitarian agencies while research in situations of conflict and war is essential to guide programs and services it may not be scientifically rigorous 1 and therefore is rarely followed with publication plans reasons for the inadequate methodological rigor and for not giving publication plans in refereed journals serious attention include the overwhelming need to act swiftly and produce data that would support relief agencies in their humanitarian efforts and help save lives in emergencies additionally the politicized nature of the issues addressed and the sensitivity of the findings to some parties such as in the case of human rights violations may preclude publicizing the findings or sharing them with larger audiences 23 but when research is carried out in such humanitarian contexts responsible ethical conduct may be overlooked 4 5 6 thus posing adverse consequences on the research participants who may be vulnerable marginalized or directly affected by armed conflicts considerations pertaining to the risk and benefits of the research its neutrality and confidentiality particularly in resource poor settings 7 improve participants diversity and representation and enhance the quality of the research its validity and utility 8 whilst guidelines for human subjects research exist in a number of academic disciplines such as the social and medical fields there is yet no single best ethical guideline for conducting research with refugees or waraffected populations in particular a number of ways forward derived from practical research experiences in different humanitarian settings have been suggested to guide fieldwork and research in these contexts 2459 notable strides have been made on the part of international ngos and un agencies to guide humanitarian interventions the red cross movement played an important role in developing codes of conduct for humanitarian aid by declaring four fundamental principles humanity independence neutrality and impartiality 10 more recently hunt and colleagues developed a framework for health professionals working with and alongside local and international actors and providing humanitarian assistance to individuals and communities 11 the arab world has long been beset by continuing armed conflict and political unrest which have caused considerable migration and population movements more recently several countries in the region have witnessed an escalation in the number of waraffected populations both refugees and internally displaced populations as a result of waves of popular uprisings and armed internal conflicts 12 here research practice is in its infancy 13 and is often not regulated by national or institution ethics review boards 14 only a few of the 22 arab countries have highly functioning institutional review boards entrusted with regulating human research conduct this means that there are deficiencies in the knowledge base of researchers and regulators regarding research ethics as well as inadequacies in the application of the principles of research ethics 15 waraffected populations live in extremely vulnerable conditions enduring difficult social economic and political hardships and the need for ethical research guidelines that protect participants and the researcherresearched relationship in these settings becomes even more imperative we examine in this study the extent of reporting ethical research conduct in articles on refugee and waraffected populations in the arab world published between 2000 and 2013 the 2000 to 2013 study period was chosen because the majority of armed conflicts in the region occurred or started in this period including the second palestinian intifada the iraqi invasion and the waves of the arab upheavals starting in tunisia in 2011 and extending to the most devastating syrian crisis 1617 earlier studies reviewing ethical research conduct in the literature have mainly addressed reporting practices in the biomedical field and clinical research and were confined to certain medical journals 18 19 20 or were focused on assessment criteria used for evaluating research ethics review 21 however no previous empirical research has examined the extent to which ethical research conduct is reported in studies among refugees and waraffected populations more specifically this study aimed at mapping the extent of reporting ethical research conduct and factors that may promote or alternatively impede responsible conduct in published studies conducted with refugees and waraffected populations in the arab world the guiding research questions of our study are 1 what is the extent to which three aspects of ethical research conduct are reported in research on idps refugee or other waraffected populations in the arab world 2 do these vary by time and country of study and finally 3 how do reports of ethical conduct vary by study descriptors including participants characteristics study discipline methodology profiles of author collaboration funding source journal type and journal requirement for statement on code of ethics findings from this study contribute to the emerging field of research on research ethics and are essential to relief agencies and researchers in their pursuit of ethically sound research in times of crisis methods search strategy this study followed arksey and omalleys methods and framework of scoping reviews 22 scoping studies are emerging evidencemapping tools that allow the review of a large scope of research output of various methods and quality to assess research gaps and opportunities and highlight areas for further indepth analysis the search strategy was put together by experts in the field of research ethics with an experienced librarian at the american university of beirut and was led by the keywords of interest to the research team an electronic search of eight databases namely pubmed web of science google scholar academic search complete proquest ebsco jstor and mecas was conducted for related articles published between 2000 and 2013 mecas is an index of research policy and scholarly discourse specific for countries and peoples of the middle east central asia and north africa search terms relating to ethics were combined with terms related to refugees and waraffected populations selection criteria the electronic search resulted initially in 5822 records for review these publications were exported to endnote and after duplicate removal 5668 records were retained for screening by title and abstract a total of 5329 records were excluded as they did not meet the inclusion criteria published reports were included if they involved research with human subjects who were idps or refugees if the study population pertained to one of the 22 arab countries of the league of the arab states if they were peer reviewed articles and if they were written in english the remaining 339 publications were screened for full text and 175 publications were further excluded as these did not involve empirical research thus yielding a total of 164 eligible articles included in our analysis work was done in duplicates and in case the researchers did not agree on including or excluding a publication the disagreement was resolved through discussion with the principal investigator charting the data the research team developed a coding sheet based on study objectives and guided by their experience in research ethics the coding sheet included details about the title of the article authors names the country and year of publication and the research characteristics including participants composition and age groups details were also retrieved on the research characteristics namely the discipline methodology as well as on other descriptors pertaining to first author affiliation authors collaboration funding sources national identification records identified through database searching fig 1 flowchart of the screening process regional international un organizations mixed no funding journal type and whether the journal online submission guidelines include a section on code of ethics requiring authors to declare irb approval and the manner of informed consentassent ethical research conduct the main outcome of interest was represented by three criteria namely institutional approval and the body reviewing the research access to the communityresearch site and participants informed consent andor assent details were recorded in a database and transferred later into a statistical package for analyses random checks were conducted for every 20th entry all analysis was conducted using spss and a pvalue of 005 was considered significant results a steady increase in the number of published articles was noted over the study period the majority of these publications came from palestine followed by lebanon sudan and jordan the research participants in these articles included idps and refugees and involved mostly adults or older adults most studies focused on issues related to public health and close to 57 used quantitative research methods nearly half of the articles were published with international coauthors 91 appeared in international journals and the majority were published in journals that require a statement on code of ethics close to 50 of the papers did not mention any funding source among those that did funding was mostly reported to be received from international sources institutional ethics approval to conduct the study was reported in 482 of the articles with irbrec being the granting body in the majority of cases close to 55 of the articles mentioned securing access to the research communitysite and 537 noted obtaining informed consent andor assent from the research participants articles were significantly more likely to indicate access to the community site and to obtain consentor assent from the study population when they reported obtaining institutional approval than those which did not the extent of adherence to the three outcome variables was examined by time and placecountry except for a drop in 201011 an overall increase in the proportion of papers reporting ethical research conduct with time was noted there was no clear differential in the distribution of reported ethical research conduct by country table 3 shows variations in the reporting of ethical research conduct by study descriptors the extent to which institutional approval was reported varied significantly with the composition of the study participants being mostly reported in research that was conducted among idps compared to other types of study participants it was also significantly more likely to be reported when the research was biomedical in nature as compared to public health or social science fields when the research employed quantitative methodologies compared to mixed methods or qualitative approaches and when the paper appeared in a journal requiring declaration of code of ethics in its submission guidelines articles that were least likely to report obtaining institutional approval were those that were soleauthored those that did not mention a funding source and those that were published in national journals similar results were obtained for associations between study descriptors and the likelihood of reporting access to the communityresearch site and seeking consent andor assent from study participants articles from the biomedical field those employing quantitative research methodologies and those published in journals requiring a statement on code of ethics were significantly more likely to report access to the community and seeking informed consent compared to their counterparts additionally studies which reported national or regional sources of funds and those that did not mention funding sources were significantly less likely to report obtaining informed consent from study participants than their counterparts discussion ethical research conduct is a corner stone of research practice particularly when the research participants include populations affected by emergencies or disasters such as wars and political violence this review of reports of ethical research conduct in studies conducted with refugees and waraffected populations is the first of its kind in the relevant literature and provides a benchmark for future research our findings indicate close to sevenfold increase in the number of publications on waraffected populations in the arab region since the beginning of the 21st century with the largest increase being in the past few years following the civil uprisings that started in 2011 close to half of the studies included in our review involved collaborations with international researchers with 20 and 10 of the first authors affiliations being from the us and the uk respectively armed conflicts and humanitarian assistance are increasingly becoming of international relevance and the need for evidence and relevant data to guide humanitarian assistance is mounting overall half of the studies reviewed reported institutional approval and a comparable percentage reported obtaining informed consent and or assent from participants owing to the lack of similar research on refugees and waraffected populations it is difficult to compare our findings to the literature higher proportions of irb approval and patient consent were reported in review studies from the medical field with 71 and 66 respectively being conveyed in clinical papers appearing in anesthesia journals in 2003 18 and 69 and 58 respectively being conveyed in general medical journals in 2006 19 barriers to securing institutional approval are many and vary by time place and the context of the research itself alahmad and colleagues 14 reviewed national research ethics regulation in middle eastern arab countries and note an overall lack of adequate infrastructure and capacity to provide scientific and technical guidance on research ethics in the region and where available are deficient in varying levels additionally the long tedious processes of review may hinder researchers and investigators who are eager to collect data in a timely manner particularly in such contexts of wars and uncertainties where prompt humanitarian or emergency response is much needed this may explain the drop in the reporting of ethical research conduct in 201011 in our study when political upheavals started in the region and were at their peak in several arab counties in our study overall 46 of the papers did not report informed consent and or assent from the research participants although informed consent is at the center of ethical research conduct its emphasis on individual autonomy may arguably be an imperfect means of protection from research related harms limiting informed consent to the individual overlooks the fact that persons make their decisions in relation to or considering others who are significant to them such as family members or people in their social networks this is the case in collectivist societies of the arab world also as mentioned earlier the sociopolitical and the suboptimal humanitarian conditions which people live in such as contexts of armed conflicts influence the decisions they make about themselves and about others taking part in research with some implicit expectations for a compensation for their participation in the study reports of ethical conduct in research in our review have increased over time this may be attributed to the spread of awareness and the gradual attempts to institutionalize research ethics regulation and the increasing requirements of funding agencies and journal editors for ethical oversight 23 adherence was more noted when research was biomedical in nature compared to social research or public health when it followed the quantitative methodology compared to the qualitative when it involved international collaboration and when published in journals that require statements on ethical declarations it was least noted when the research was funded by national sources or published in 141524 our finding that greater attention to ethical guidelines is reported in biomedical research compared to other disciplines is not surprising clinical studies are often likely to be perceived as potentially more harmful than social science research despite the well documented ethically controversial earlier behavioral studies in the usa the debate about whether the traditional orientation of the current ethics regulation adopted by ethics review boards can adequately meet the needs for social science research continues until today 25 given the different epistemological and ontological assumptions between the two standards adopted for the biomedical review may be inappropriate for the social sciences 26 our study findings need to be considered in light of certain limitations although our review covered a wide selection of search engines that aimed to thoroughly capture research output on refugees and waraffected populations in the arab region the search did not include book chapters or output from the grey literature such as reports and publications by ngos and humanitarian agencies yet one may argue that inclusion of the ethical criteria used to guide the research is less likely to be a requirement for nonrefereed publications and hence our findings are likely to be conservative estimates of the extent of deficiencies in the reporting of ethical research practices on the other hand a waiver of informed consent may have been granted in some of the research involving no more than minimal risk or in sensitive research where consent documents may identify its participants in such cases the waiver of informed consent could have been unreported by the authors and hence counted as missing furthermore it is not clear from this study whether irb approval and informed consent were obtained but not reportedparticularly that not all the journals require statements on ethical declaration or whether they were obtained and reported but not adequately exercised in the field the assessment of potential risks and burdens to participants including unintended exploitation unrealistic expectations and stigmatization 27 although being key elements of ethical research conduct and crucial to our understanding of the extent to which ethics in research is adhered to is not achievable in scoping reviews unintended exploitation is particularly a concern in humanitarian crises where study subjects are likely to interpret participation as being linked to provision of assistance and hence may unwillingly consent to participate 28 conclusion in conclusion ethical research conduct appears to be underreported in publications involving refugees and waraffected populations when compared to those conducted with participants in biomedical research with evident variations by study composition of research participants research discipline methodology author collaboration funding sources and journals requirements on ethical declaration the heightened vulnerability of populations caught in conflict the increased engagement of humanitarian agencies in data collection and the lack of local capacities to monitor research ethics are likely to compromise the benefitharm ratio for the research participants and for conducting research in crisis settings 28 research ethics in humanitarian settings need to be seen as much more than a mechanism to obtain ethical approval for research 7 this paper is a call for funding agencies international organizations and relief agencies national researchers and collaborators and journal editors to be vigilant and play a stronger role in promoting and enhancing the practice of ethical research conduct in conflict settings and be transparent in reporting it additional file additional file 1 inclusion and exclusion criteria competing interests the authors declare that they have no competing interests

background ethical research conduct is a cornerstone of research practice particularly when research participants include vulnerable populations this study mapped the extent of reporting ethical research practices in studies conducted among refugees and waraffected populations in the arab world and assessed variations by time country of study and study characteristics methods an electronic search of eight databases resulted in 5668 unique records published between 2000 and 2013 scoping review yielded 164 eligible articles for analyses results ethical research practices including obtaining institutional approval access to the communityresearch site and informed consentassent from the research participants were reported in 482 549 and 537 of the publications respectively institutional approval was significantly more likely to be reported when the research was biomedical in nature compared to public health and social 917 vs 544 and 324 when the study employed quantitative compared to qualitative or mixed methodologies 617 vs 268 and 429 and when the journal required a statement on ethical declarations 574 vs 271 institutional approval was least likely to be reported in papers that were soleauthored 95 when these did not mention a funding source 296 or when published in national journals 0 similar results were obtained for access to the community site and for seeking informed consentassent from study participants conclusions the responsibility of inadequacies in adherence to ethical research conduct in crisis settings is born by a multitude of stakeholders including funding agencies institutional research boards researchers and international relief organizations involved in research as well as journal editors all of whom need to play a more proactive role for enhancing the practice of ethical research conduct in conflict settings

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introduction the covid19 pandemic caused by new coronaviruses represents a major global public health care problem that is causing changes in the current way of life and work in all segments of society the covid19 pandemic is progressively being regarded as a social problem rather than just an infectious disease there are diseases that not only burden the medical system but also instill increased tension in each individual by provoking social stigma 1 health care professionals including nurses around the world have shown exceptional courage and professional morality in responding to the challenge of the pandemic in the international year of nursing and midwifery 23 the entire public including health care professionals are confronted daily with images and reports of a health care system collapse due to the covid19 virus pandemic especially in italy and spain during the first wave of pandemic but also around the world 4 there was fear of infection and the possibility of transmission from family members and friends but also fear of a lack of covid19 protective clothing for the health workforce and equipment to treat patients 5 staff may be concerned about their own risks from exposure to a new pathogen or the risk that they might infect family or friends these concerns can be particularly acute when the etiology and outcomes from a new virus are not well understood 6 data on the large number of sick health care workers in italy and spainespecially doctors and nurses with over 100 deathsfurther added to the unrest and concern among health care staff furthermore the results of research conducted on health care workers who worked with covid19 patients in wuhan china showed that health care workers reported symptoms of anxiety depression and insomnia also in comparison with health care workers who worked with noncovid19 patients nurses that worked on the front lines with covid19 patients showed negative outcomes of mental health 7 another piece of research on the psychological and mental impact of covid19 disease on medical staff and the general population has identified risk factors for anxiety and depression including female gender nurse occupation lower socioeconomic status high risk of covid19 virus infection and social isolation 8 a review of the literature did not find research using a standardized questionnaire to assess the socializing of nurses who worked with coronavirus patients during the first wave of the pandemic the aim of this study was to develop and validate psychometric characteristics of a questionnaire designed to measure nurses experiences working with covid19 patients materials and methods a correlation crosssectional design was used in this study the research was conducted online on a suitable sample of 180 nurses working in the health care system of the republic of croatia with regards to the covid19 virus pandemic the survey was conducted via the google docs platform and was available to all nurses who used the facebook group of nurses and they responded to the questionnaire by clicking on the appropriate link the inclusion criteria were the employment of a nurse in the croatian health care system and providing health care services to the covid19 positive patients from march to june 2020 the exclusion criteria were the employment of a nurse outside the croatian health care system providing health care services to the covid19 negative patients and a positive history of previous psychological problems subjects were of both sexes and aged 2048 years with a mean age of 368 ± 155 years the results analyzed in this study are the part of a broader study of the effect of ward work with patients with covid19 on a nurses mental health in which a series of standardized mental health assessment questionnaires were used all participants gave their informed consent to present the data in the submitted manuscript by accepting the click of a button before taking the online tests participants completed the questionnaire on their own which lasted approximately 5 min only data obtained based on responses to the scale of experiences associated with the pandemic nurses were used in this study participation was voluntary and completely anonymous and the completion rate was 100 instruments a scale named nurses pandemicrelated experiences questionnaire was constructed for the purposes of this research the scale consists of 10 statements examining the different experiences of nurses working in covid19 departments participants were asked to respond on a scale from 1 to 5 the total score of each participant is expressed as the final sum of responses to each statement 9 taking into account the specificity of pandemicrelated professional experiences in comparison with nonpandemic working circumstances the statements were compiled based on a study of literature sources on the most frequent stressors of health care providers during pandemics 10 11 12 13 14 15 the questionnaire was also accompanied by items compiled based on an interview with three experienced nurses who were working in a covid19 department during the first wave of the pandemic about what was most stressful to them nurses expressed their perceptions of feelings behaviors and socializing during the first wave pandemic lockdown in this way an initial list of 10 stressors was obtained the frequencies of which were estimated by 180 nurses who participated in this study in order to examine the psychometric properties of the questionnaire we performed a factor analysis where one item had a saturation less than 05 and was thus excluded from further analysis scree plots were examined and enabled a threefactor model solution the first factor explained 4570 of the variance the second factor explained 1556 of the variance and the third factor explained 1071 of the variance the final version of the questionnaire consists of 9 items the results of factor analysis and reliability measures are explained in detail in the results section the data collected from the questionnaire were entered into microsoft excel spreadsheets according to a previously prepared code plan statistical analysis data were recoded sorted and prepared for analysis using the spss version 260 software package there was no missing data in the dataset for the purpose of data processing descriptive statistics were used to calculate means and standard deviations to identify psychometric properties of the scale the principal axis factoring with promax rotation method was used including scree plots the internal consistency and reliability were measured by mcdonalds ω and cronbachs α the suitability of data for structure detection was verified using kaisermeyerolkin and bartletts tests the kolmogorovsmirnov test was used to examine the normality of distribution as a part of statistical analysis we also checked skewness and kurtosis to determine whether the data were heavytailed or lighttailed relative to a normal distribution the results are presented in tables in the results section the αerror level was set to 005 results factor structure the kaisermeyerolkin statistic proved the satisfying sampling adequacy of the data enabling the factor analysis the bartletts test of sphericity was significant 67677 p 0001 an analysis of the main components with the promax rotation method was performed and a threefactor structure was disclosed the principal axis factoring extraction method was used to determine item saturations by each factor only one item had saturations 050 and was thus excluded from further analysis the total score was recalculated with the remaining 9 items the first factor reflects feelings of stigma and misunderstanding that nurses had while working in a department with covid19 patients this factor was named stigmatization and misunderstanding the second factor describes actual or planned distancingavoidant behaviors of nurses in order to protect significant others this factor was named social distancing the third factor describes nurses fears of infecting oneself or loved ones this factor was named fear of infection descriptive indicators for each statement are shown in table 2 internal consistency the values of the internal reliability of both the items and the factors are shown in table 3 all coefficients range from 081 to 088 for both measures indicating satisfactory internal consistency of the items and extracted factors testing for normality the kolmogorovsmirnov test indicated that the distributions within all three factors were not normally distributed additionally the distributions of the three factors were examined for skewness and kurtosis the skewness of distributions indicate a moderate shift to the left furthermore most kurtosis values are less than zero showing platykurtic distribution with the central peak being lower and broader as well as fewer values close to the mean since most of the values for asymmetry and kurtosis ranged between 2 and 2 it can be considered acceptable in order to prove normal univariate distribution 9 discussion numerous studies have been conducted to investigate public perceptions of health care workers during the covid19 virus pandemic 13578 however insufficient research has been conducted on health care professionals on stigmatization and misunderstanding social distancing and fear regarding the pandemic and their exposure to it the most important result of this study is that the scale of pandemicrelated experiences of our nurses showed good psychometric properties the validation results of the 10particle scale in this paper point to a threemembered structure stigmatization and misunderstanding social distancing fear of infection each of these three factors poses a risk of developing psychological and physical consequences from performing work and providing health care to patients with covid19 stigmatization and misunderstanding being the target of stigmatization places individuals under great pressure stigma is a common phenomenon in the prevalence and spread of infectious diseases it leads to negative emotions among the stigmatized including stress anxiety sadness and even some physical reactions 14 15 16 17 18 stigma leads to a social misunderstanding of risk and extreme fear amongst members of society which is accompanied by a disproportionate allocation of health care resources by politicians and health care professionals 1617 public exposure to dramatic images of deaths caused by the covid19 pandemic from italy and other countries and dramatic news reporting the number of infected and deceased doctors and nurses has led the public to assess personal risk of infection through contact with health care professionals 414 in a survey conducted in 2020 more than a third of respondents thought that health care workers were covid19 positive almost half of respondents said they did not want to be near health care workers caring for covid19positive patients they had unrealistic attitudes about the danger of contact with health care workers and felt that they should even be banned or prevented from contacting their family members in order to prevent the possibility of spreading the infection 8 stigmatization creates an unnecessary burden on the lives of health care professionals and can contribute to the development of mental problems 9 confusion misunderstandings and the presentation of false science by sources deemed to be trustworthy are breeding grounds of stigma as they evoke stereotypes discriminatory behaviors and prejudice 11 12 13 our results are in the line with reports from around the world that doctors and other health care providers have been isolated from loved ones because of anticipated risk of contamination and have also been assaulted physically or emotionally due to fear and stigmatization 14 this makes this already tough situation even more challenging as the increased burden on medical staffs mental health may negatively affect their functioning and resilience 15 16 17 further stigmatization will arouse emotions and trigger the stress response or reaction mechanism due to the global nature of the covid19 pandemic stigmatization has become a psychosocial phenomenon with a larger scope and more influence 18 at present while worldwide public health is facing difficulties studies on the socialemotional burdens caused by stigmatization have reallife significance thus it is important to test the existing theories against the background of this global public health and security crisis 1920 the stigma needs to be addressed rigorously by professionals and health care providers as well as authorities 120 social distancing avoiding socializing or physical distancing is considered an important measure to combat infection health care workers are also obliged to physically distance themselves from their colleagues in order to protect each other causing them to go without the necessary social support especially in these challenging times the results of numerous studies during the covid19 pandemic have shown that health care workers relationships with family members and friends have changed the measures of physical distancing and lock down have led to changes in social functioning turning people towards their immediate family the data obtained support the positive impact of the pandemic on the relations between close family members especially parents and children 18 19 20 21 in 2020 a survey of more than 4000 participants was conducted in jordan and the results suggested that the covid19 pandemic negatively affects the mental health of the jordanian population causing anxiety and depression in a significant portion of the population 22 social relationships and connections allow individuals to regulate their feelings cope with stress and remain resilient during stressful situations in contrast loneliness and social isolation exacerbate stress and often result in negative effects on mental cardiovascular and immune health 23 fear of infection health care professionals working in a highrisk area have a higher risk of exposure to infection the outbreak of the pandemic changed the work scenarios of health care workers they are directly responsible for the process of caring for patients both with and without covid19 must constantly wear personal protective equipment 1021 and lack specific treatment guidelines 24 wuhan showed that 88 of health care workers were exposed to covid19 infection 25 such a high risk of exposure to infection care for patients and fear of exposing their family members and loved ones to infection leads to fear anxiety and stress among health care workers which can result in mental strain and the development of significant psychological problems 26 27 28 a multicenter crosssectional study of more than 1000 chinese health care workers recorded an exceptionally high proportion of depression anxiety and insomnia 27 in a another metaanalysis of 13 studies a total of 33062 respondents confirmed that a large number of health care workers had significant levels of anxiety depression and insomnia during the outbreak of the covid19 pandemic 2829 the prevalence rates of anxiety and depression were about 23 a high proportion of health care workers reported mild symptoms of both depression and anxiety while moderate and severe symptoms were less common 28 29 30 31 fear and anxiety appeared and decreased in the early stages of the outbreak and depression psychophysiological symptoms and symptoms of posttraumatic stress appeared in the second stage and lasted for a long time leading to a more severe picture of the situation 2930 nurses in hospitals have shown higher levels of stress than other health care professionals because they are in direct and intensive contact with patients 31 kang et al estimated the impact of the covid19 pandemic on the mental health of physicians and nurses in wuhan soon after the onset of the pandemic 32 interestingly half of the health care population had received psychological support through materials available online or provided by media one out of three had obtained paperbased psychological counselling and approximately one out of five had received individual or group psychotherapy 3233 those who had been placed in quarantine worked in highrisk facilities or had close contacts affected by sarscov2 were at up to a threefold higher risk of having severe posttraumatic stress symptoms 10 limitations this study has a several limitations the first limitation of this study is related to the relatively small sample size and the fact that it was conducted only in croatia at the end of the first wave of the pandemic when participants were already sensitized and had more information about the pandemic to protect against the spread of infection also it was used only among nurses and no other health care workers the second limitation is related to the online convenient sampling method that was used in this study which could result in a distribution asymmetry we are aware of the limitations of this type of sampling but we would like to emphasize that at the time when the research was conducted strict epidemiological measures of social distancing were present and that was the reason why all research including this one was conducted online on convenience samples the next source of bias is related to the applied methodology that disables determination of the constructive and predictive validity of the questionnaire our primary goal was to verify the applicability of the scale by testing specific stressors in nurses and to identify the factors underlying nurses responses to the questions furthermore as it was noted in the methods section this questionnaire is part of a broader study examining emotional responses of health care professionals working with infected patients during a pandemic in future research in addition to this questionnaire we will also use other standardized scales where the correlation between this scale and similar measures will be examined therefore this research serves as a pilot study aimed to determine the justification for further use of this questionnaire for croatian nurses working with infected patients future research should include all categories of health care workers verify the influence of public stigma on other groups in social public crisis events and deeply explore different types of emotional arousal mechanisms for different groups conclusions this research conducted on nurses has proven that nurses as a profession are extremely prone to the development of burnout syndrome and various behavioral disorders and diseases the covid19 pandemic further burdened nurses and all health care workers fear and avoidance of health care workers during the covid19 virus pandemic is a widespread problem throughout the world but it is still not sufficiently recognized and can therefore have longterm consequences for the health of nurses and the health of other health care professionals families one of the possible reasons for interventions to identify and prevent these problems is the lack of structured scales to measure it the pandemicrelated experiences scale of our nurses has shown good psychometric properties and can be applied in future research as a standardized measurement tool not only for nurses but also other health care workers experiences during the covid19 crisis or while working with other infectious patients data availability statement the data presented in this study are available upon request of the respective author due to the protection of personal data the data are not publicly available author contributions md conceptualized the study design questionnaire and writing va contributed to the results and supervision kd contributed to the drafting and editing of the paper zp conducted supervision and writingreview and editing all authors have read and agreed to the published version of the manuscript informed consent statement informed consent was obtained from all subjects involved in the study

1 background the aim of the present study was to develop and validate the psychometric characteristics of a scale measuring nurses experiences working with covid19 patients 2 methods the participants were 180 croatian nurses who worked in departments with covid19 patients with a mean age of 368 years ranging from 20 to 48 research was conducted from march to june 2020 for the purpose of constructing the scale 10 statements were developed factor analysis was used to determine the factor structure and construct validity of the scale 3 results the scale consisted of nine statements divided into a threefactor structure factor istigmatization and mistrusting four items factor iisocial distancing four items and factor iiifear of infection two items cronbach α was calculated to confirm the reliability of the scale factor iα 080 factor iiα 076 and factor iiiα 070 4 conclusion the nurses pandemicrelated experiences scale showed good psychometric properties and can be applied in future research as a standardized tool for measuring health care workers experience during covid19 or other infectious crises

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introduction there is growing academic interest in how migrants make place around them shaped in complex ways by past and present cultural interactions both local and transnational addressing this in relation to the young children of one prominent group of disadvantaged forced migrants the somalis this study focuses on the development of preschool children born in the uk from a somali background from the perspective of their mothers we have explored first generation migrant mothers experience of children growing up in somalia and in their new home from growing up themselves primarily in somalia and as parents living in the uk and visiting somalia to help understand the physical cultural and psychological worlds that somali children may be developing in we will contextualise this in relation to i the challenges the somali diaspora may face while bringing up children in the west and ii the evolving and interwoven understanding of cognitive science and social geography for young children we will then reflect on how parents and childrens experience of urban environments in the west could impair disadvantaged migrant childrens early language and social development somali people constitute one of the largest diasporas in the world estimated at over 12 million recent studies highlight the challenges somali families encounter during and after forced migration to western countries including the physical and psychological trauma of war persecution hunger and violence osman et al describe challenges postmigration due to poverty insecure immigration status unemployment social isolation and discrimination parents sense of dislocation and powerlessness in the new host culture and its unfamiliar institutions and systems combine with the practical challenges from lack of resources forced migration also has profound consequences for family structure and parenting in somalia the extended family and the wider community play an active part in raising children which is rarely the case in the host culture loss and separation from extended family bring loneliness and isolation and add to difficulty passing on traditional culture to the next generation 1as a result of colonial and historical links the uk has the largest and longestestablished somali community in europe large numbers of refugees began to arrive in the uk in the late 1980s and early 1990s as a result of political instability persecution and violence in somalia while the somali diaspora in the uk is diverse in terms of clan membership and national associations that shape the political and social identities of many somalis overall it is socioeconomically disadvantaged and bears the burden of high unemployment poor living conditions and educational underperformance bristol a port city in the west of the uk with a longstanding somali population has the fourth largest somali community in the uk estimated at 1040000 people 2 somali births have increased 8fold since the late 1980s 3 at least 5 of bristol children are now somali somali preschool children in bristol are significantly underachieving in educational assessments at foundation stage and the gap appears to widen at age 711 and at age 1516 educational outcomes for somali children in other uk cities are comparable to those in bristol somali children born in bristol are also twice as likely as their white peers to be referred to child development and disability services and six times more likely to be referred for consideration of social communication difficulty or autism a systematic review of the mental health of displaced and refugee children identified multiple interconnected factors influencing psychological outcome there has not been an equivalent systematic review of the relationship between migration or refugee status and child development or learning however parental migration history has been associated with lower scores on tests of early measures of learning often interacting with disadvantagedeprivation children born to migrant parents with research prominently including those of somali and other african origin may be at higher risk of cognitive autistic and other neurodevelopmental disorders risk may be particularly high for children of firstgeneration immigrant parents refugee womens reproductive health is also affected by migration while effects on the mental health of refugees reach to their next generation of children healthy cognitive and social development and the brain architecture and neurochemistry that underpin it are powerfully influenced by early experiences there is a growing body of evidence that exposure to biological and psychosocial risks beginning in prenatal life compromises childrens development with multiple cumulative exposures producing widening disparities over time young children in socioeconomically disadvantaged households are at substantially higher risk of intellectual disability with multiple relevant environmental factors high rates of language delay are observed in nurseryage children living in areas of disadvantage play shaped by the physical and sociocultural environment has a crucial role in childrens development as a mode in which children learn and develop capacities of communication symbolic representation selfregulation and thereby a sense of self and other the geography of childrens play has attracted increased interest in recent years play opportunities in urban areas exist for children around the home in the school and public parks and in wider public spaces and spaces left over during the urbanisation process away from parental control playful environments can enhance childrens levels of physical activity and fitness enhance their mental health independence confidence social interaction and socialisation in the west discourses surrounding childrens play have generally been grounded in a developmental perspective focusing on the trajectory to becoming competent adults with adults designing and guiding play environments and activities however these approaches tend to ignore the different sociocultural contexts that shape childrens play around the world with community values beliefs and cultural routines shaping very different ways in which children play and learn in their everyday lives o brien and colleagues in their groundbreaking study sought to map childrens use of and feelings about local urban space comparing childrens experiences in contrasting urban environments girls and children from minority ethnic communities were more restricted in their use of urban space the authors also highlighted the importance of studying the diverse ways children inhabit their cities to assist in the development of social policies to enhance participation for all children childrens experiencing of place in a built environment is inherently relational shaped by and shaping the complex situated embodied and embedded interaction between physical environments neighbourhoods sociocultural technological and economic systems and individual family presences and histories similarly multifaceted conceptualisations link social relationships environment child development wellbeing and resilience including for refugees as a result particular social groups can be encouraged tolerated regulated and sometimes excluded from public space depending on the degree to which they might be deemed in or out of place therefore how neighbourhoods support or hinder childrens development and wellbeing as well as parents collective efficacy4 is an important topic this study seeks to address in relation to migrant families children need a secure base from which to explore and play however perinatal stress and depression are substantially more frequent in disadvantaged populations including refugees and forced migrants with stress and trauma playing an important role parental stress and fear during pregnancy may affect childrens predispositions for example through epigenetics5 andor altered stressresponse system settings as well as impairing early attachments parentchild interaction and child development the experience of safety or fear in a local environment for families with young children and for whole communities may be critical for childrens wellbeing and learning with wide implications for society as a whole in summary the children of disadvantaged migrants in the west are at risk of delayed and disordered early development with multiple factors potentially contributing somali families may exemplify many of these challenges with evidence accumulating of poor developmental and educational outcomes as yet largely unexplored is the relevance of place in this process there are many differences between the physical cultural and psychological environments of rural somalia and urban uk which may have wideranging implications for young childrens experience of play and interaction and their subsequent development this study therefore set out to explore the geography of childhood from the perspective of somali mothers who have resettled in bristol drawing on a lifeworld perspective valuing the phenomenological aspect of understanding child development in its ecological context we collected somali mothers descriptions of childhood play and learning related to place both from growing up themselves primarily in somalia and also as parents observing their own and other children in the uk and on visits to somalia the intention was to understand their experience of what shapes childrens development culturally and geographically the findings illustrate how the physical and social environment of a uk urban context as experienced by migrant somali mothers may act to constrain young childrens development methodologies and methods qualitative semistructured interviews analysed using an interpretative phenomenological approach were used to generate rich description and understanding of the individual lived experience of the participants the semistructured interview schedule was developed to address the following research questions for somali mothers in bristol what is their experience of early childhood in the uk and somalia what do they see as facilitating or restricting childrens early opportunities for play social interaction and development additional prompts were prepared relating to physical social and cultural environments sequencing of questions was flexible to prioritise rapport and follow the respondents interests or concerns the interview guide was revised following the first interview to focus on participants experience of childrens activities and relationships sample sizes using an interpretative phenomenological approach are typically small in order to maintain a commitment to idiography and contextsensitivity6 six somali women participated in a total of five interviews involving respectively two participants jointly and four individual interviews participants were somali women identified by informal contact at community somali ladies lunch meetings having received information about the study in person and in writing and two somali linkworkersinterpreters although somali interpreters were available all participants chose to undertake interviews in english participants gave written consent for interviews to be audio recorded and transcribed verbatim 7analysis was conducted from an interpretative phenomenological epistemology in relation to the research question looking to interpret the meaning and interconnection of themes in the context of participants life world themes were identified by reading each transcript three times the first time identifying and annotating the left margin with general thoughts the second time annotating each section of text with codes and the third time to develop an overview of the codes allocated to identify potential broader themes which were grouped into overarching themes a cut and paste technique was used to place sections of text under the headings of each overarching theme text that related to two or more themes concurrently was duplicated for analysis in relation to each theme after reorganisation the content of each overarching theme was described and both linkages and potential dissonantcontradictory aspects explored and discussed in relation to existing evidence this led to a single final theme being identified that portrayed the unity and diversity of participants experience related to the research question the findings were audited by a researcher experienced in interpretative phenomenological approaches in the excerpts presented in the results section pseudonyms have been allocated to participants specific details and quotes have also been altered to protect confidentiality and identity many participants will have had traumatic experiences in their home country and during the migration process as well as the ongoing challenges they describe in these accounts simple demographic questions can connect people to very distressing experiences of loss or separation for this reason we decided not to ask participants to tell us about their home or family circumstances rather to focus on the questions of our semistructured interview schedule as our starting point in such a small sample to add reflections on individual situations and their accounts would risk making them identifiable within this paper we therefore are unable to place these accounts within individual contexts of participants lives but do not believe this detracts from the coherence plausibility and rigor of the findings in preparing the study methodology during the interviews and the analysis the intention of the researchers was to develop and maintain cultural awareness knowledge sensitivity skills desire and competence this was grounded in a process of reflexivity throughout drawing on personal and clinical experience of the authors discussing assumptions or prejudices identified along the way appreciating that a cohort of individuals do not speak as one homogenous group but as a collection of individuals and attempting to acknowledge account for andor reduce aspects of power imbalance while the interviews were primarily conducted and analysed by a white british woman the semistructured interview schedule reflected advice on relevant and appropriate topics of conversation from the somali coauthors and the findings were developed and refined collaboratively8 members of the research team have professional and academic roles that include work with somali people in bristol in the field of early child development and disability as well as previous roles in other african countries and have drawn on this background to reflect on participants experience in this study findings in this section we present an interpretive analysis of the participants accounts of their experiences of childhood in somalia and the uk by comparing and contrasting their experiences in the two different places and cultures we draw out the features that are likely to inform the design of culturally congruent interventions to support the development of somali refugee children these descriptions are not intended to be phenomenological descriptions of childrens lives in the two different countries rather their aim is to illuminate somali mothers experience of place as an important context for how children of refugees develop in an urban western context the interaction of play and place somalia in somalia mothers described a daily rhythm shaped by the environment rising at sunrise home for a siesta at midday and children returning home to eat and sleep when the call comes from the muezzin9 at sunset men leave early for work women run the home and children can be outside in the mostly warm dry weather children are allowed to roam outside as soon as they can crawl or walk hawa people live in houses like bungalows most of them and there are no flats so you just open the door in the morning as soon as kids start walking they are let outside ruqiyo they children gonna play outside while you need to clean the house and cook the food if they tired they going to come in they going in and out they know when the prayer of the sunset is going every child must come in otherwise they in trouble… participants described play as outdoors free and spontaneous without supervision children using their environment to play and learn creatively and actively commercial toys being limited in availability and durability children created toys themselves made using imagination and recycled materials luul we have to make ourselves the toy we have to make the doll and house and whatever and we play something like hopscotch … sometimes we pretend to be cooking sometimes we pretend to be pregnant ruqiyo kids play by themselves outside… their own game and their own things… they got climbing trees they got sliding for the river bank when the rivers gone… we got a swing we made ourselves to push each other and it was very dangerous and we got tyre and the other one go inside the tyre and you got to roll it … that was absolutely perfect… there are millions of games we used to play so you never ever feel bored… one participant acknowledged that newer technology for people who had them had changed this pattern especially for more affluent families ruqiyo the rich people they live in big houses theyve got loads of thing so their kids dont go outside they just play inside… now loads of people got tv its changed now… they still like playing outside but at the night time everybodys watching tv there is of course a time lapse of a generation between our participants experiences of their own childhoods in somalia and current experience both in the uk and in somalianew technologies will be an important part of this in both countries uk in the uk mothers described multiple constraints combining to limit childrens opportunities for play and interaction with children and adults in small flats in tower blocks with only minimal communal space or shared facilities social interaction for participants and their children seemed difficult due to the limited indoor space to receive visitors and for children to play in this also made it hard to fulfil their duty to welcome visitors as expected in somali culture other constraints included lack of access to outside play spaces the climate and lack of resources parks around tower blocks were seen as generally not being a good place for children to interact and play with lack of money limiting childrens access to preschools and indoor commercial play spaces compared to the rich description of outdoor play in somalia play in the uk was described as limited to parks indoor play barns watching tv and playing with toys in the home zainab most of the houses… are really a bit small… they dont have a garden … everybody gets used to the culture here everybody minding their own business everybody keeping themselves to themselves under one block i think there is a big park and all the blocks share it but it is not close… and sometimes really crowded… you will be just stressed and the kids are fighting nuur its no disrespect but everybody keeps to themselves socialising is really hard when i used to live in a two bedroom flat its hard for other kids or family when they visit theres not enough space… when the weathers improved we meet up in the park there is always a parent supervising… these findings add to our understanding of the interacting roles of family neighbourhood and culture in child development research play and social interaction are key modes in which childrens learning is internalised opportunities for free play may be declining generally in western cultures which may have multiple negative consequences key factors appear to be a decline in the quality and quantity of accessible outdoor public space fears about traffic and strangers and changing patterns of family life migrating from societies in which adults are not directly involved in play but provide a rich and gradually increasing range of expected cultural responsibilities with wholecommunity supervision parents may be challenged to help a child develop in a more individualist cultural environment this would seem especially the case given the multiple other demands and burdens faced by refugee and disadvantaged migrant families elements of nostalgia for a society left behind and the understandable marked difference of a move from rural to urban society may play a part in participants narratives amongst the other social cultural and economic changes they have experienced furthermore accounts of positive experiences in somalia predominated while experiences of war violence and hardship were more difficult to elicit for example one participant chose to speak about distressing personal experiences of violence and loss in somalia after the audio recording device was switched off those whose childhoods were more disrupted by the war or who had experienced stigmatising experiences about which they were reluctant to speak may have been less articulate in the interviews and therefore their accounts potentially featured less in the analysis however these mothers accounts from somalia describe ways in which children grow up communally that are highly meaningful for them as parents they represent cultural assets that they could make more use of in the uk potentially beneficially for their children if more opportunities for interacting communally with other parents were available constructs of neighbourhood collective efficacy10 and of social capital 11 are significant for bringing up children across a range of ethnic and socioeconomic contexts such concepts could also contribute to the design of interventions to improve childrens developmental outcomes more generally in western urban settings development in a cultural context somalia participants described children in somalia being encouraged to develop a range of skills which support their confidence independence and maturity and their ability to communicate and socially connect with others they attributed this to children interacting talking and observingcopying during outside play with other children and with a range of adults as well as being required to help around the house and share in daily tasks and duties from an early age basic responsibilities such as tidying were taught very early while children as young as eight could have responsibilities such as cooking and running the household parents also expected and enforced discipline this was seen as helping children understand their role in the family and in society ayaan the kids are very clever learning by themselves they exploring by themselves they are using their minds all by themselves and then they are copying the other one on the outside there are loads of kids different kids they are going to copy each other… zainab children in somalia develop the talking very early because when they are younger they can go out of the house and interact with adults a lot more so a somali child can talk really properly in somalia the kids are a lot confident… they teach the children to do the house work early early they start with sweeping the veranda like tidying up and all that… when we visit somalia the children there all know how to look after themselves and help their families… my niece is eight and stays with my mum she does everything for her she cooks she cleans although she goes still to school but she manages to do everything as well this occurred within a closeknit community often with extended family living together or nearby which exposes children to adults and children of varying ages participants suggested that families have a large support network where responsibilities and duties are shared and that a family facing difficulties can count on neighbours to support them ruqiyo they children gonna play outside while you need to clean the house and cook the food… grandparents talk to them they tell stories… they teach them outside there are loads of kids different kids they are going to copy each other… nuur normally one family would go shopping for other family… and another person would look after the other children or grandparents or someone… you would know your neighbour if she was sick or not… you should be helping each other i remember… a family who was really struggling and you see the neighbours coming together and they would supply food… emphasis was given to islamic studies from an early age for a somali child with children attending quran school as young as three participants described socialising and play occurring during breaks and after school and children walking together as a group to and from school hawa the children will be sent to those quran classes and they will meet the other kids and they learn the quran there and stay there for a couple of hours and they will play together… when they finish the study the children wont come straight back home but … play around and explore new things and when they feel hungry then theyll come back ayaan some parents can send the child when he is even less than three years go with the other one they listening yeah and copy but five years you must send the child to the quran school however while early learning and selfreliance were valued by the community children who appeared different and unable to live up to the expectations others had of them were not nurtured in the same way by their community participants gave accounts of children with disabilities who were being bullied and excluded from play and other social activities while parents were stigmatised and isolated from the community ruqiyo if someones a bit behind maybe some kids got disability they always left alone they got loads of bullying… we used to call those kids names… you are not welcome if youve got disabilities… because the people thinks bad things about disability they are not supporting you… they need to keep children inside the house and they feel left alone… finally the importance and social value placed on children becoming independent in selfcare and social skills is illustrated in the excerpt below in which a participant highlights the difference between children raised in somalia and her own children who were raised in the uk ruqiyo the little ones they dont need to be trained because they are getting from the older ones… they are going to copy each other i went in africa three years ago and my kids were different the other kids they were going to the toilet by themselves they were eating by themselves they were playing by themselves they were doing everything but mine were absolutely behind they were just waiting for me to do things for them… because that child is going outside and playing and everything in same language but my child im the only one speaking to him before the school and i dont have time to speak all the time because i am busy… according to the participants children growing up in somalia mature and become independent at a young age as a result of being socially connected to older children and adults other than their parents and family talking and listening to others playing copying behaviours and participating in social and religious activities were seen to enable the development of the skills necessary to function as a responsible member of the community the community was seen as facilitating this process through sharing child care responsibilities and providing support however those unable to learn mature and participate in some activities such as children with disabilities were at risk of being rejected and stigmatised by their community uk in the uk participants reported limited social support without their extended family living nearby and limited mutual support between neighbours participants missed having support from close family members especially grandparents to give advice and comfort look after children and impart knowledge of somali traditions and games to children combined with problems around a lack of suitable outside spaces the often inclement weather and a culture in the uk of minding your own business participants found it hard to get to know new people and make friends nearby this limited opportunities to develop trust and mutual support between neighbours zainab maybe your next door neighbours are somali as you but maybe they have nothing to do with you and you dont go to them for help… it depends really on the people now and not the community… it depends on the people knowing each other if i know you i am going to be helpful with you participants described how multiple responsibilities limited their time to play and interact with children especially where fathers worked long hours or lived elsewhere as compensation for not going outside the tv might be put on all day to keep children amused as the excerpts below illustrate ruqiyo it is very bad and very hard when the grand parents are in somalia not here the life is different because the fathers working outside and so the mums doing loads of things for herself cleaning cooking having the kids taking the kids to school to quran so mum in here is very busy she dont have time for the child hawa sometimes here there is a break up and there are a lot of single parents so she might have three or four children and she is alone and she cant cope with that… she does everything… so she just does the most important essential things like feeding them and cleaning them taking to school and the house so she doesnt have the time to sit with them and do play things so just put on the tv and thats it clan conflicts that followed somali families into the uk contributed to dilemmas about the transmission of cultural heritage affecting parents confidence in the coherence of the framework of cultural and behavioural expectations set for their children participants described the importance of family and clan lineage for identity in somalia when people meet potentiallyconnected strangers they will try to establish a common ancestor through recitation of clan lineage due to concerns about interclan violence in the conflict in somalia having ongoing effects in the uk however some participants described children in the uk who may not even be told which clan they belong to or learn their lineage alongside this they described concern at children no longer being taught somali songs and dancing hawa and also our clan yeah they teach all that as well you know you are from that clan… but now our kids here we dont even teach them what clan they are… i wouldnt put a lot of emphasis on somali play that is not very important now you just teach the child how to be safe in a way and songs yeah you sing for them… ruqiyo we came here to run away from clan fighting in somalia… we dont ask each other … we just care about the life we got now… when that person helped you so everybody forget what had happened before and we make it a new life a new thing everything… while learning islamic values and traditions was seen as important for children growing up in the uk participants commented on children missing out on social and communal aspects of that experience due to children not walking together to quran school childrens early learning and development in the uk was seen as constrained by a lack of space and time for play and social connectedness skills development such as dressing and eating independently language acquisition and interpersonal skills were perceived as requiring parental guidance and supervision and thus time as well as material and social resources all of which were in short supply nuur sometimes there are some kids who are a lot more behind because probably they only stay at home or maybe their parents dont take them out more often… they dont know how to share… the importance of cultural context for development and learning is a key message of vygotskys work which has been further developed by rogoff and colleagues to focus attention on cultural practices people undertake together as key vehicles for childrens development though gaining experience confidence and competence much of the variance in developmental outcome of preschool children in the west including for migrants is explained by their parents engagement with child language and learning migrants who set aside their own language and culture from the understandable desire to help children learn the host cultures language as well as trying to leave behind ethnic conflict may inadvertently step further away from a place of confident communication with their children however policies that rely primarily on encouraging migrant parents to use more language individually directly with their children may be poorly attuned to communal cultural practices and limited by the stresses and isolation described so eloquently by our participants a more communalcollective approach helping families meet together could provide more culturallycoordinated opportunities for both communication and interaction as well as more confident parenting and increased wellbeing another reason migrants may set aside their own culture is if they are trying to leave behind ethnic conflict as our participants described salience taboo and dilemmas about clan identity and tradition are familiar from other discussions of somali diaspora experience this is related to the complex dynamics of transnational or diaspora social spaces practices and identity formation after forced migration as highlighted in the previous theme digression from expectations about what constitutes normal behaviour in a society has profound implications for families and individuals while disability neurological and mental health difficulties can elicit responses such as fear and stigma in any society they also interact powerfully with the experience of ethnic or racial discrimination individual migrant communities own beliefs and practices can play an important part a common mechanism for the effect of stigma may be loneliness and social isolation perceptions of safety and danger influencing opportunities and social connectedness somalia participants accounts suggested that the environment in somalia is experienced as safe for children to play and explore outdoors because neighbours are familiar and trusted and there are few hazards children have been allowed to play outside unsupervised in most areas even against the background of the civil war participants described how adults confidently take on responsibility to set boundaries and ensure safety of any children around them while older children keep watch on younger ones as well as organising their activities zainab as soon as they start walking properly they are let outside the house they would be safe to play outside… because all the community know each other my two and a half years old niece got lost out with my mum a neighbour of my mum recognised her and they told her elder sister and they get her so it is still safe while the armed conflict had decreased perceptions of safety it did not disrupt participants overall sense of an environment facilitating play and social experience participants from northern somaliasomaliland where the war had been bloody and disruptive but relatively shortlived described the somalia they knew as generally safe for children in the past and present although they were wary of the impact of refugees from other ethnic groups participants from the south and especially from mogadishu were more wary of danger but still considered the environment as safe enough for outdoor play ruqiyo in somalia i have grown up in a war but when i was five years old it was quite safe… but now it is not like that there is gun fire and everything its not safe but the kids are still safe to play outside you are not thinking your child is going to get lost and you are not thinking someone is going to steal it because the child not going far and he got friends to play with… grandparents look after the safety of the child as well ayaan i think still they play outside but it is not safe like before because everywhere is shelling guns and fighting… nuur …the refugees come as the civil war is still happening in the south… not somalis but other cultures a few incident have happened on the news people are trafficking kids children for organ enhancement you have to be really on your toes now these accounts report mixed perceptions of safety and danger in a somali context the civil war resulted in differing experiences of violence depending on the geographical area in which the participants lived however even against the background of the civil war the environment in somalia was experienced as safe for children to play and explore outdoors uk the participants described a sense of lack of safety in the uk this was related to concerns about traffic as well as fears of abuse or abduction participants no longer felt able to continue the practice of letting children play outside and walk to school and quran classes without being accompanied by an adult adult supervision was required for all activities outside the home putting more pressure on parents time and energy the excerpts below clearly illustrate the participants concern about the safety of their children hawa here you cant just open the door because the children might go missing or something bad might happen to them so when the new mothers arrive they are told make sure you keep an eye on the kids so they have to behave differently and they teach their children dont trust everybody… zainab …yeah and paedophiles and all that you think that it might happen to your child so you might as well keep them in your house unless youve got really the time to… stay with them in the park so you dont feel safe to leave them by themselves even as seven or eight years old… they might get bullied… because some community thinks because they have been longer than the somali community here then they have more right… they could just bully the kids because hes not that confident or something bit shy or slow whatever reason echoes of the conflict in somalia were still present with differing perceptions of how people here were dealing with them luul we still look after each other but not like somalia… a somali family they dont want to go far from the somali community … theyre scared… we always want to be close but even somali are fighting tribe tribe tribe… participants reported how all these constraints contributed to a very significant sense of isolation for some families zainab maybe their mum does not speak that good english and so theyre a bit isolated ruqiyo so when they came here they scared… some people have no idea what is going on where they live they just inside the house so they keep the child until two three years olds and then they let the child go to the nursery… and they feel they cant speak the language theres no use to go outside… they dont know the language and maybe their husband work like a life in a cage these accounts indicate how fear and a lack of social connectedness can lead to social isolation expressed by one participant as like a life in a cageat once safe from the war in the home country and its devastating consequences of civil order and the availability of economic and material resources jobs and education but also trapped in an unfamiliar environment that holds other dangers social isolation and loneliness are consistent risk factors for mortality when experienced by mothers during pregnancy and with young children they could represent critical risk factors for adverse child developmental outcomes through the epigenetic stressresponse attachment and interactional mechanisms referred to in the introduction feelings of social isolation and loneliness increase a sense of vulnerability and vigilance towards threats as well as a broad range of other psychological processes for example isolation can impact on parents decisionmaking around the tensions between risk and opportunity for their children babies born after pregnancies where their mothers have felt stressed and socially isolated or excluded could we speculate also have a sense of vulnerability and vigilance towards threats which could make the route to secure attachment and confident interaction with their parents and others even more challenging minority ethnic children are disproportionately more likely to live in deprived areas and to be socially excluded with ethnicity racism and family isolation having substantial impact on access to and experience of play neighbourhood ties and mutual trust are important features geography may have an important role in segregating or integrating people of different ages and cultures with consequence for perceptions of risk and safety as well as for transmission of cultural traditions the challenge may be to move from philosophies and politics of protection and inequality to those of resilience and connectedness by building childfriendly communities and by changing public policy and practice overarching theme the role of freedom and constraint in early child development in our interpretation the two different geographical contexts in somalia and the uk afforded different freedoms and imposed different constraints potentially affecting early child development we use the term freedom to refer to the physical existential social cultural and spiritual dimensions of the two places that offer choice and range for activities through which children can develop and learn the term constraint describes those dimensions limiting opportunities and presenting barriers but also those defining the structures and limits for culturallyacceptable activities within a society constraints may therefore support confident creative activities and identities 12freedom in relation to life in somalia meant a life lived predominantly in outside spaces in warm weather where there is communal responsibility for childrens safety without fear of strangers or physical dangers constraints were related to the somewhat rigid social structures and daily routines childrens early responsibilities difference such as disability leading to social exclusion and isolation and the civil unrest and violence participants described the environment in somalia creating a structure of shared understanding expectation support and responsibility this interconnection of support and constraint created a sense of safety and freedom that allowed children to play interact and mature this highly positive view is summed up in this participants description of the environment in which children in somalia are nurtured and raised ruqiyo sometimes neighbours are family as well… grandparents talk to them they tell stories they look after the safety of the child as well know where the child is going helping them to explore by themselves yeah they teach them… they are welcome to go every house if they want to… the doors are open… all the neighbours going to watch them… they could speak very early they know everything in contrast the extended interview excerpt below gives an indication of this participants distress that can accompany raising children in an urban environment in an unfamiliar country and culture especially without material and social resources nuur if i was better off i would take my child to preschool because she will learn ill take her to playgroup and then learn from there… i think each mum has her own struggle with the kids… it will have an effect on the child because instead of spending time with the child you are thinking of tomorrow like how get ready or get ready for the house or helping one child if one child is sick even yourself if you are sick i think it would be hard for somali mum if her english wasnt that good and she doesnt know how to communicate with the school if she need help… sometimes asking for help you feel like weakness as well weakness in the community you thinking you are not coping the thing is sometimes shes putting herself so much stress not to be weak if i am crying because i am stressed out about the kids that seems like im weak… i mean it is really hard it is really hard this and other participants accounts of childhood in the urban environment they inhabited suggested that in the uk they perceived few if any of the freedoms of the life they left behind in somalia while the uk provided sanctuary and safety from war with access to an education system which they observed encouraging children to develop creativity and imagination and to health and welfare systems providing services free of charge and an attitude of inclusion towards those with disabilities they experienced new problems and dangers for children such constraints related to lack of material resources small living spaces in highrise tower blocks with few communal spaces in which to socialise outdoor activities curtailed by the lack of good places to play fears for childrens safety and the climate a lack of social connections with family and community and loss of cultural traditions together with the loss of the familiar and supportive cultural environment in somalia and wider stress and isolation experienced in the uk as a whole their experience of the uk environment was highly constraining to child play interaction and development conclusions this study focused on uk born children from a somali background exploring their mothers perspective on experiences of childhood in order to learn about opportunities and barriers for somali childrens early development we report highly contrasting accounts of childhood in somalia and in the uk that provide insight into the difficulties somali mothers and their young children may face in the uk our participants saw housing environment and community in somalia enabling social interaction creating a structure of connection safety and responsibility within which children are free to play and learn in contrast in the uk multiple stressors including lack of knowledge and language skills limited financial and material resources conflicting cultural expectations lack of social support and fear of traffic or abuse appeared to constrain childrens play and interaction with others and might contribute to social isolation their accounts suggested that children growing up in somalia mature more quickly as a result of their environment developing independence confidence and social skills more quickly than children growing up in the uk although children with disabilities are likely to be stigmatized we argue that these findings represent a detailed context for the way disadvantage can impair early child development  lack of freedom to play and interact with children of all ages and adults other than their parents may be a key mechanism for social disadvantage impairing childrens outcomes somali parents in western urban settings such as the uk may need to ensure they find places where they and their children can meet other families even if they are feeling stressed this could help recreate their sense of community support potentially to be experienced as their own village in this new urban environment we would encourage somalis as a group to engage further with local services to help them understand the specific strengths and needs of somali families and to campaign for local environmental improvements so they feel it is safe for their children to play and interact early childhood interventions are highly effective and costeffective have become a national priority for the national health service and for research in the uk and are increasingly central to social policy in other european countries the findings of this study could help tailor such interventions to improve refugee child developmental outcomes drawing on locallyand culturallycongruent practices and networks and attending to the role of the local environment interventions should attend to creating safer places for play and interaction as well as to engaging and enabling families within a cultural context that reduces isolation and supports confident and culturally congruent parenting similar approaches to developing and adapting interventions and modifying the environment may also be relevant to young children and families from other refugee and disadvantaged migrant backgrounds we believe these findings have policy implications to assist in tailoring the nhs healthy child programme for refugee families contribute to the evidence base for early years education policy and provision and to refine policy guidance and practice for urban design housing and neighbourhood development spending for example relating to communal space in shared housing developments design of childrens play facilities and traffic flow alteration it would also seem very much consistent with the uns sustainable development goal 11 make cities and human settlements inclusive safe resilient and sustainable by 2030 with a small number of participants from a single community these narratives cannot attempt to represent somali women in bristol let alone the range of somali experience in the uk the sample size is typical for an interpretative approach this account does not argue that these are the only conclusions that could be drawn from these interviews somali fathers would be expected to have different experience and would be a valuable source for further exploration however we have attempted to present a coherent and persuasive interpretation of these mothers experience which we believe offer useful points of theoretical generalisation not as contemporaneous experiences of the two countries but as vivid expressions of critically important context for early child development in an urban western environment in conclusion therefore we believe that this small study makes an important contribution to understanding the experience of refugees from somalia and potentially other disadvantaged migrants as they move from a predominantly rural communal collective society to urban more individualist environments it may also help make sense of the increasing evidence of delayed and disordered development in the children of refugees and disadvantaged migrants from nonwestern countries public health policies and interventions need to take account of the interrelationships between geography and the migrant communities arriving into urban areas our study suggests that fostering environments in which communal childrearing practices can be developed or continued would help reduce isolation and promoting child development further exploration of neighbourhood geography as experienced and shaped by parents and children would seem an important part of improving early child development in the westboth for refugees and forced migrants and for the population as a whole

migration to a different culture may affect opportunities for play and social interaction essential for childrens developing cognitive and social skills we asked somali migrant women about experiences of childhood both while growing up themselves and subsequent observations in somalia and the uk in somalia they described a supportive connected community and safe environment enabling children to play and learn together in the uk by contrast multiple local stressors constrained childrens opportunities to play and interact understanding and improving neighbourhood geography as experienced and shaped by parents and children would seem important for promoting early child development in refugee families

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background pregnancy is a period when physiological nutrient demands are considerably increased this period imposes the need for considerable extra calorie and nutrient requirements therefore a balanced and adequate diet is of paramount importance during pregnancy and lactation to meet the increased needs of the mother and to prevent nutritional stress 1 nevertheless diet restrictions due to the mistaken belief or food taboos during the critical period of pregnancy may compromise the womans ability to meet the increased demands of the essential nutrients hence putting the woman at an increased risk of adverse pregnancy outcomes 2 the practice of food taboo is widespread in developing countries while there is a variation in the type of food considered as taboo and also the reasons attached to the taboos vary from society to society for instance in a study in south africa the most common foods that were avoided were meat and fish potatoes fruits beans eggs butternut and pumpkin which are a good sources of in essential nutrients the reasons for avoidance of the food items were associated with pregnancy outcome labor and to avoid an undesirable body appearance for the baby 3 studies in ethiopia also revealed that food items avoided were linseed honey sugarcane milk yoghurt cheese fatty meat eggs fruits and vegetables and reasons mentioned for the avoidance of these food items were it get plastered on the fetal head makes fatty baby and difficult delivery fear of abortion evil eye fetal abnormalities 45 even though adequate dietary intake during pregnancy could be affected by many factors including affordability and accessibility food taboo has been recognized as one of the factors contributing to maternal undernutrition in pregnancy especially in rural settings 67 food taboos are closely associated with dietary intakes of pregnant women underscoring the need for assessing food taboos and related misconceptions during pregnancy to design appropriate interventions at national regional and local levels however studies in ethiopia particularly that involve several actors that can influence food consumption like health workers the elderly women and health extension workers as well as husbands of pregnant women are rare if not nonexistent hence this study used focus group discussions with pregnant women and their husbands as well as key informant indepth interviews with various actors to explore maternal dietary habits food taboos and misconceptions which influences the dietary intake of pregnant women in rural ethiopia methods study setting a community based qualitative crosssectional study was conducted in eight rural kebeles selected from four districts of illu aba bor zone southwest ethiopia the zone is one of the twentyone zones in oromia regional state the zonal town mettu is found at a distance of 600kms from the capital of ethiopia to the southwest direction there are 14 districts in the zone with a total population of 933 345 where 467553 are males the dominant means of livelihood in the zone is agriculture and cereals such as maize sorghum millet and legumes like beans and peas are the commonly grown crops fruits and vegetables also grow in the area and coffee is the main cash crop of the zone study design and participants an exploratory study was conducted from may to june 2019 using a qualitative method mainly focus group discussions and indepth interviews of key informants these qualitative methods were used to best explore the food taboos and dietary habits since they are sensitive issues and it is necessary to uncover the why and the how behind such practices to thoroughly investigate the cultural and community factors related to food taboos during the prenatal period four health care providers four health extension workers and four elders a total of 12 key informants were interviewed eight fgds having 810 purposively selected participants were conducted the number of indepth interviews and fgds were determined based on the level of information saturation which was determined by transcribing the discussions of each days session purposive sampling was used to select the kii and fgd participants the criteria for fgd eligibility required that women should be pregnant able to understand and speak the local language and give consent and husbands of a pregnant woman who is also able to understand and speak the local language and give consent homogeneity was maintained by sex and education the criteria for kii participants selections were being health care workers health extension workers and the elderly the conduct and reporting of this study are compiled using the guidelines outlined in the consolidated criteria for reporting qualitative research 8 all details are provided in the additional file 1 data collection methods and tools piloted interview guide questions were used for both the fgds and idis all the participants were approached facetoface and none of them declined to participate to the study the fgds were held with pregnant women and their husbands separately so that they can express their opinions without fear of being arbitrated by their respective partners the kiis were conducted with health care workers health extension workers and the elderly both the fgds and indepth interviews were held at the nearby health posts and health centers during the kiis the participants were encouraged to take an active role in establishing the flow of the interview all questions used in the fgds and kiis were openended and new questions arising from the responses from the respondents as participants were able to build on each others ideas and comments redundancy of responses was considered to be saturated and was removed every evening after transcribing the days work and preliminary analysis new questions were added whenever an information gap was identified the data collection team was composed of the principal investigator and a research assistant who had tertiary level qualifications the principal investigator is a phd student the research assistant was a bsc holder in public health and trained before the actual data collection period before the commencement of the study the research assistant did not have a relationship with the participants however participants were notified of the reasons for conducting the research in the study area the principal investigator and one recordernotetaker facilitated each focus group discussion and key informant indepth interviews with the participants the data were audiorecorded and to assure triangulation of the data with the record the team took note including memos of participants behavior and contextual aspects the focus group discussions took a minimum of an hour and half whereas the indepth interviews took a minimum of half an hour trustworthiness the quality of qualitative research is assured by meeting standards of trustworthiness through addressing credibility and transferability 9 to satisfy credibility participants from different districts and different backgrounds were included additionally focus group discusions indepth interviews and field notes were used in the analysis of the data the study provided descriptions of the setting sample size and sampling procedure eligibility criteria interview processes and findings to strengthen the transferability to different contexts validity and reliability were ensured by triangulation of the data gathered from the interviews with the information obtained at the fgd and then after sharing the results with the attendants data analyses the taperecorded fgds supported by handwritten field notes were transcribed verbatim and analyzed manually using the principle of systemic text condensation 10 transcripts were reviewed repeatedly to gain a thorough sense of the overall content in the texts to identify central meaningful units in the material condense the content through colorcoding of the text and finally create categories that contain the condensed meaning of the main themes in the material the data were then organized into themes sections of the discussions were quoted verbatim and a few were modified to enhanced readability the results were presented using narratives using the verbatim of the study participants as illustrations to substantiate major assertions quotes were translated from the local language to the english language phases of the thematic analysis of the qualitative data is indicated in table 1 below results background characteristics of the study participants a total of seventynine respondents participated in the eight fgds and twelve kiis the participants comprise twentysix pregnant women twentyfour men four health professionals four health extension workers four elderly the participants represented a wide age range and the educational status of the respondents ranged from no formal education to secondary school and above from a thorough review and readings of the scripts the following three themes were identified beliefs and practice of food taboos in the community food items held as taboos and reasons attached to it reasons nderlying the adherence to the food taboos and misconceptions beliefs and practice of food taboos in the community the respondents were asked whether they were aware of any foods that are culturally prohibited during pregnancy differing opinions were noted regarding the practice of food taboos some pregnant women their husbands and mothersinlaw believed that some foods should be avoided during pregnancy to protect and support maternal health a kii participant motherinlaw said …when they have morning sickness they cannot eat oily foods restriction of oily foods is practiced early in pregnancy to reduce the likelihood and severity of morning sickness similarly another motherinlaw explained the following corroborating what was said earlier … intake of oily foods may be limited throughout pregnancy and that in general pregnant women dont eat as much oily food fgd participant pregnant mother also stated …pregnant women should be careful and avoid certain foods particularly towards the last trimester our community strongly believes that what a pregnant woman eats in the last months of her pregnancy goes directly to the womb to feed the baby thus some foods can hurt the fetus… in contrast the health care workers and health extension workers believed that food taboos are becoming an old story one kii participant said …i do not think many people still believe that pregnant women need to avoid some foods… except few women that live in faroff areas … similarly another kii participant detailed … ihhhhh though in the former times there was the restriction of foods like egg milk and milk products due to the belief that it makes the fetus big and gets attached to the fetal body… nowadays there is no such practice in our community… another kii participant also stated table 1 phases of the thematic analysis of the qualitative data illu aba bor zone southwest ethiopia 2019 phase description transcription of data the audiotape interviews supported by handwritten notes were transcribed verbatim familiarization with the data familiarization with the whole interview was made by listening to the audio recording andor reading the transcripts and contextual or reflective notes that were recorded generating initial codes the transcripts were read carefully line by line applying a paraphrase or label to describe what has been interpreted in the passage as important searching for themes dts reviewed and grouped codes according to the similarity of the topic and started to form potential themes theme names that captured all codes included within the theme were developed reviewing themes the themes were checked with the coded data extracts and assessed in terms of how well they represented the entire data set defining and naming themes the names and definitions of each theme were refined and a short description of each theme was developed by the principal investigator producing report a full report of the analysis was written by dts with the use of the most appropriate extracts and relating to the original research question the report was read and reviewed by all authors …most of our community members are now questioning the reason behind these taboos and the need for adherence so the practice is not widely observed in the district another kii participant stated the following substantiating the same opinion educated people are not strongly upholding the taboo and beliefs… foods held as taboos and reasons attached to it pregnant women their husbands and mothersinlaw believed that certain foods should be avoided during pregnancy fgds across participant groups pointed to restriction of high carbohydrate foods particularly sugarcane the consumption of this food was perceived to be associated with having bigger babies which is believed to lead to difficult labor and delivery fgd participant and husband of pregnant mentioned …our community strongly believes that if a pregnant woman eats sugarcane she may have a big baby which endangers her life by making labor difficult but i doubt the effect … similarly fgd participant pregnant women stated …if you eat these kinds of foods or meals you will have difficulty during birth consumption of a lot of sugar during pregnancy leads to an increase in weight and a risky delivery as the increase in weight during pregnancy makes the baby very big… similarly the discussants reported that foods like fruits specifically banana and avocado and some types of vegetables like cabbage pumpkin and taro are considered as taboo for pregnant women particularly as the gestational age advances the reason attached to the taboo of these foods as stated by the discussants is that cabbage may cause abdominal cramps to the baby when born whereas pumpkin banana avocado and taro locally named godare are believed to pass to the fetus in the womb and get plastered to the head of the fetus in explaining this instance a mother in law kii participant stated …if a pregnant woman consumes banana avocado and taro particularly as the gestational age advances it can pass to the womb and get attached to the babys body while cabbage causes abdominal cramp to the fetus after birth … likewise fgd participant husband of a pregnant woman uttered … i heard some people saying that pregnant women should not consume pumpkin but i do not know the reason… by the same token the consumption of dairy products and eggs during pregnancy is considered harmful to the fetus and the mother one of the fgd participant pregnant women said …it is believed that pregnant women should avoid consuming dairy products like yogurt and cheese particularly in the last weeks of her gestation this is because dairy products can pass to the womb and attach to the babys body… one of the respondents had the following to say which reaffirms the assertions of the other discussants stated above …a pregnant woman shouldnt eat some foods such as eggs this is because the fetus will become very big and the mother will have difficult labor and delivery reasons underlying the adherence to the food taboos the underlying reasons for adherence to the food taboos from explanations provided by study participants were grouped into three broad categories cultural influence social context and beliefs of the pregnant women themselves cultural influences the majority of the study participants viewed the existence of traditional practices and beliefs about foods held as taboos are inherent in the community they stated the reasons for their practice of food taboos stem from cultural influences one fgd participant husband of pregnant women stated the following to elaborate the matter … our community strongly believes that if a pregnant woman consumes foods that are held as taboo she may have a big baby which makes labor difficult and endanger her life … social context the pressure from important others surrounding the pregnant women is a critical driver of the adherence to the food taboos the discussant expressed that husbands and mothersinlaw impose cultural and traditional beliefs on pregnant women one fgd discussant also mentioned peer influence to substantiate this state affair a kii participant motherinlaw stated …pregnant women should avoid foods like banana avocado and taro …if she consumes particularly as the gestational age advances it can pass to the fetus in the womb and gets attached to the babys body … similarly one pregnant woman indicated … it is believed that some foods can pass to the fetus in the womb and plastered on the fetal body… and women laugh at each other if a woman gives birth to a baby full of the white substance on the body…that is why we follow the food restrictions… attitudes and beliefs of the individual pregnant women this study revealed that recipients of the cultural practices pregnant women were without an understanding of why they do what they do however some of the discussants believed that consumption of the foods held as taboo may hurt the fetus a pregnant woman mentioned … if you eat certain kinds of foods or meals you will have difficulty during birth … similarly another pregnant woman fgd participant stated … it is believed that consumption of the tabooed food may cause damage to the fetus and … i do not want my baby hurt that is why i avoid the foods held as taboo… the reasons for the food taboos are deeply embedded in the persons believes and attitudes of the pregnant women who are nested within the influence of the social environment surrounding her and the traditional beliefs and values of the society in general the interrelationships between drivers at the different levels are illustrated in fig 1 discussion the study found out that one or more foods are avoided during pregnancy as a result of food taboos this finding is supported by many studies reported elsewhere where women would adhere to different food taboos and beliefs 5 11 12 13 14 the foods items most frequently avoided during pregnancy were dairy products like milk cheese and yogurt fruits like bananas avocado eggs vegetables like cabbage pumpkin taro and sugarcane most of the foods that were reported as taboo are rich sources of essential micronutrients which are crucial for maternal health and child growth and development findings from the current study support others in which food taboos during pregnancy were found to be more elaborate nutritionally significant and differ only in the type and reasons attached to avoidance of the food type 45 15 16 17 the main reasons for the restriction of the food items held as taboo in this study were the fear that the food will be plastered on the fetal head and having a big baby which make labor and delivery difficult this finding is supported by findings from a study in shashmane and addis ababa that state the reasons for adhering to pregnancyrelated food taboos and myths to be a large baby and difficult birthing and food sticking on the fetal head 412 a study in accra ghana also showed that pregnant women were restricted from consuming certain foods to check their health control the weight of the expectant mother and unborn child and ensure there is a safe delivery which is consistent with our study finding 6 the study revealed that sugarcane is commonly restricted during pregnancy because it is believed to causes excessive weight gain and difficult deliveries a similar finding was reported from a study in arsi zone where the discussants considered consumption of sugarcane to be associated with having bigger babies which is believed to lead to a difficult delivery 5 similarly a study in ghana showed that consumption of sugary foods makes fetus large 17 the study further revealed the community belies the fact that if pregnant women consume fruits like bananas or avocado and vegetables such as pumpkin and taro particularly towards the last weeks of her pregnancy it passes to the fetus in the womb and plastered onto the head of the fetus this finding is supported by the report from ghana and east gojam ethiopia in which consumption of bananas during pregnancy is believed to be attached to the head of the fetus 1117 another type of food considered taboo in the study area was the consumption of eggs during pregnancy because it is believed that it makes the fetus large contributing to a difficult delivery this finding is again supported by the findings from the study in ghana and kenya that showed consumption of eggs makes the fetus large 1718 this finding is again supported by the study finding from nigeria where consumption of eggs is prohibited during pregnancy because it is feared that the children may develop bad habits after birth 16 the difference supports the literature that indicates there is no single reason but several reasons for the belief and adherence to food taboos 19 consumption of milk and milk products during pregnancy was also considered taboo in the study area the reason for the restriction of the food type is that it passes to the fetus and gets plastered onto the head of the fetus and makes the baby big our study finding is supported by the study finding from kenya which states the reason for the restriction of milk during pregnancy is due to the belief that it makes the baby bigger 18 similarly a study in abala district of afar region ethiopia also identified that consumption of milk and yogurt is considered taboo and the reason attached to the food held as taboo was to prevent the fetus from getting large and reduce the risk of long labor 15 another food type considered taboo during pregnancy was the consumption of leafy vegetables like cabbage which are considered to hurt the fetus and pregnant women this finding is similar to the study report from arsi zone central ethiopia that showed if a pregnant woman eats leafy vegetables especially after 8 months of gestation the leaf passes to the womb and attaches to the babys head and forms what they called particles 5 the study further identified that the explanations underlying adherence to food taboos provided by study participants were cultural influence traditions beliefs and values in the society this finding is consistent with the finding from the study in tamilnadu state which showed that women were dutybound to avoid specific food items due to cultural and traditional views 14 similarly another study in accra ghana supports this finding that the main reason for belief and adherence to food taboo was culture 6 another reason for the adherence to the food taboos was the social environment influence from mothersinlaw and peers this finding agrees with the finding from a study in west bengel in which fig 1 the interrelationships between drivers at the different levels underlying reasons for the adherence to the food taboos and misconceptions during pregnancy in rural communities of illu aba bor zone south west ethiopia the majority of the respondents pointed that their mother motherinlaw other senior female members and female neighbors were the advisors of those taboos 13 attitude and beliefs of the pregnant women themselves towards the food taboos is another reason for the adherence to the food taboos similarly a qualitative study conducted in addis ababa points that the underlying reasons for the adherence to pregnancyrelated food taboos and myths were largely traditionally held beliefs and misconceptions 12 the findings have strong practical implications after several years of implementing the national nutrition program national maternal and infant and young child feeding guidelines and deployment of both urban and rural health extension workers the finding of pregnant women who practice food taboos indicates the necessity for revamping the implementation to the grassroots level especially the fact that this practice is backed by the pressure from the social environment and is deeply embedded in the traditional believes of the society heralds the need for galvanizing more public health interventions to optimize the dietary practices of pregnant women in the study area the following limitations need to be considered when interpreting the findings of this study although the kiis and fgds were conducted with great care the extent of overreporting or underreporting of positive or negative behaviors may not be known moreover purposive sampling was used to select the key informants and focus group discussant thus the findings should not be generalized to the entire study population and beyond but should be taken as an indication that taboos and misconceptions are still present among a number of the studied subjects conclusions this exploratory study revealed that pregnant mothers in the study area are influenced by food taboos based on cultural perceptions and beliefs with the fear of increasing body weight of the fetus which can result in either the mother facing problems during childbirth or the child will be born with ill health the most common foods prohibited as taboo were milk and milk products and eggs some vegetables like cabbage and pumpkin taro banana from fruits and sugarcane omitting those food staff from the requirement during pregnancy will have a longterm impact on the mother and fetus making maternal and child that is for the mother and underweight during delivery of the infant and easily susceptible to disease during childhood based on the finding of the study we recommend nutritional counseling with emphasis during antnatal care and post natal service is imperative at the same time a comprehensive nutrition education involving significant others is recommended abbreviations fgd focus group discussion hew health extension worker kii key informant indepth interview mch mother and child health prft pregnancyrelated food taboos and myths additional file 2 authors contributions dt1 conceived the idea for the study and discussed it with dt2 and tb dt1 dt2 and tb designed the study and developed the analysis parameters dt1 collected the data dt1 dt2 and tb were involved in the analysis and interpretation of the findings dt1 produced the initial draft of the paper and dt2 and tb provided feedback and contributions to various sections all authors critically reviewed and approved the final content competing interests the authors declare no potential conflicts of interest concerning the research authorship andor publication of this article

background poor maternal nutrition adversely affects pregnancy and birth outcomes in many societies there are dietary restrictions due to misconceptions or food taboos during pregnancy which consequently results in the depletion of important nutrients these cultural malpractices and beliefs can influence the dietary intake of pregnant women which subsequently affects the birth outcome the study aimed at exploring the extent of food taboos and misconceptions during pregnancy in rural communities of illu aba bor zone southwest ethiopia methods a qualitative study was conducted using an indepth interviews of key informants and focus group discussions among purposively selected pregnant women and their husbands health care workers health extension workers and elderly people data were transcribed verbatim thematized colorcoded and analyzed manually using the thematic framework method result thorough reading and review of the transcripts generated three major themes the primary theme was the belief and practice of taboos related to the intake of certain food items during pregnancy pregnant women their husbands and mothersinlaw believed that certain foods should be avoided during pregnancy the second theme was foods that were held as taboo and the reason attached to it the most common food items held as taboo were related to the consumption of vegetables like cabbage pumpkin milk and milk products sugar cane fruits like bananas and avocado and egg the main reasons to avoid these foods were beliefs that it can be plastered on the fetal head making fatty baby which is difficult for delivery the third theme was the reasons underlying adherence to food taboos which is deeply embedded in the persons believes and attitudes of the pregnant women who were nested within the influence of the social environment surrounding them and the traditional beliefs and values of the society in general

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background cardiovascular disease is a leading cause of death globally 12 hypertension is a major risk factor for cvd 3 once rare in ssa hypertension and its related complications are increasingly common in the region 4 treatment with medication and behavioral changes can greatly reduce blood pressure and the risk of cvdrelated mortality among people with hypertension 5 in ssa cvd prevention is a recent development 6 and hypertension detection treatment and control rates are generally low 7 the absence of affordable communitybased primary care services has been identified as a major obstacle to effective hypertension treatment in the region 8 but several countries in ssa are now developing programs that provide such services 910 hypertension is a chronic condition that requires lifelong adherence to pharmacotherapy and healthy behaviors for many patients longtime adherence to hypertension treatment is a problem 11 12 13 14 15 16 there is evidence that hypertension care is more effective if it includes educational interventions that address barriers to adherence 121718 theoretical frameworks underlying various models for patient education propose that in order to be effective education should be patientcentered and tailored to patients views about the condition and the treatment 17 18 19 in high income countries where access to affordable care is generally available many studies have investigated patients perspectives on adherence to hypertension treatment in different populations 13 20 21 22 a recent systematic review of 53 of those studies indicated that common patientrelated factors for nonadherence to antihypertensive medication across countries and ethnic groups include patients beliefs that medication is unnecessary when symptoms of hypertension or stress disappear a dislike of medications fear of addiction and the experience of side effects 22 data from such studies have provided content for educational interventions to improve adherence and health outcomes in patients with hypertension in the usa and europe 23 24 25 nonadherence to hypertension treatment can have serious consequences for the patients in terms of lost opportunities for health improvements and for the health care systems in terms of wasted financial and human resources new programs that provide universal primary care coverage are emerging in ssa 26 so far few studies in the region have investigated perceptions of hypertension treatment among patients who are covered by health insurance 27 hence it is important to fill this gap 28 nigeria is one of the countries in ssa where initiatives are being taken to introduce private or public community based health insurance plans 29 the estimated prevalence rates of hypertension in nigeria are 193 for rural areas 366 for semiurban areas 42 for urban areas and from 124 to348 for the country as a whole 29 30 31 32 studies of patients perceptions of hypertension treatment have been carried out in several settings and communities in nigeria 1516 33 34 35 36 but not among patients who were covered by health insurance understandably many of these studies concluded that patients perceived financial constraints as the major reason for not adhering to treatment 163738 the present study was conducted in the context a subsidized community based health insurance program that covers the costs of primary and limited secondary health care and medications for low income residents of rural communities in kwara state the 9th poorest among nigerias 36 states a recent populationbased study that was conducted in kwara reported hypertension awareness treatment and control rates of 8 5 and 3 respectively 29 as a first stage of a larger project 39 we conducted a qualitative study among hypertensive patients who participated in the community based health insurance program in kwara state to explore their views on hypertension management the specific research questions of the study were as follows 1 what are patients views on factors that may inhibit or facilitate adherence to prescribed medications and 2 what are patients views on factors that may inhibit or facilitate adherence to behavioral recommendations methods we used a qualitative research design and individual interviews with openended questions to explore patients perceptions on inhibitors and facilitators for adhering to hypertension treatment 40 setting and participants for this study we recruited patients who had enrolled in the hygeia community health care plan and were treated for hypertension at ogo oluwa hospital which is located in bacita a small rural town in kwara state nigeria the hygeia community health care plan now called the kwara state community health program is financed by an international development organizationthe health insurance fund 4142 this health care plan was launched in 2007 to provide subsidized community based health insurance for lowand middle income groups in western nigeria and northcentral nigeria the insurance package covers primary and limited secondary care including hypertension treatment ogo oluwa hospital is one of the first clinics in kwara state that joined the hygeia community health care plan it is a large busy private hospital that has offered primary and secondary care to people from the bacita area for over 25 years in the 1990s bacita was a busy commercial center that hosted the then thriving but later moribund stateowned nigeria sugar company the original population of bacita is nupe but the sugar company attracted other nigerians of various ethnic origins particularly the yoruba although the sugar company went out of business a substantial majority of the economic migrants of the time settled permanently in the bacita area therefore yoruba is now widely spoken alongside the native nupe currently considered a poor community the predominant livelihood activities of the inhabitants are farming petty trading artisanship hunting and fishing ogo oluwa hospital is owned and managed by an experienced general practitioner assisted at that time by about 2 other doctors 10 nurses 3 pharmacy staff 4 laboratory staff and 4 records staff at the start of this study about 400 of the hospitals patients were treated for hypertension and attended clinics on a monthly or bimonthly basis most of them had joined the hygeia community health care plan about twothirds resided within the town at an average distance of 10 to 20 minutes travel time to the hospital the remaining third were living in some distantly located surrounding villages the inclusion criteria for this study were as follows having hygeia community health care plan diagnosed with hypertension in treatment for hypertension at ogo oluwa hospital for ≥ 12 months having been prescribed antihypertensive medication for ≥ 12 months aged 18 years or over and being prepared to give verbal informed consent since pregnancy induced hypertension has a different course and etiology pregnant or lactating hypertensive females were excluded from participation in this study we also sought equal participation of men and women in qualitative interview studies data or thematic saturation is a criterion for determining sample size 4344 this means that the number of respondents is sufficient if interviews with new respondents do not yield new themes fifteen interviews is generally enough to achieve saturation 4344 on the basis of these considerations and the inclusion criteria we selected a purposeful sample of 40 patients from the case file records of ogo oluwa hospital and invited them to the study none of the invited patients declined patients who agreed to participate were reminded about the appointment some days prior to date of interview at the beginning of each interview session patients were asked to give audiorecorded informed consent and were assured of confidentiality travel expenses incurred for study visits outside usual clinic days were reimbursed interview guide and data collection to explore patients perceptions of hypertension treatment we developed a semistructured interview guide the guide built on instruments that were used in previous qualitative interview studies of patient perceptions of hypertension 1345 and it was adapted to the specific context and purpose of this study the interview guide was edited in english and translated into yoruba and nupe by native speakers eight main topic areas of the interview guide that referred to hypertension treatment were knowledge and personal views about hypertension access to care the role of health insurance sources of information about hypertension views on medications views of behavioral adaptations satisfaction with care and general views on cvd prevention information on the sociodemographic characteristics of the participants was collected through closeended questions information on the participants recent health related outcomes was collected from the respondents case file records data collection and analysis are continuous and simultaneous iterative processes in qualitative studies 46 in this study we held a first set of 30 interviews between july and october 2010 and a second set of 10 interviews between november and december 2010 the specific aim of the last set of interviews was to explore a number of emerging themes that were identified through the analysis of the first 30 interviews the researcher conducted the interviews at ogo oluwa hospital he is not from the study area and he did not know the participants prior to the interview he made his profession researcher with a medical background known to the participants each of the first set of interviews lasted 120 minutes on average and the second set lasted about 60 minutes each all interviews were recorded transcribed and translated into english by the researcher and an assistant data analysis the interview transcripts were analyzed using steps and coding procedures of the method of qualitative data analysis that was developed by strauss and colleagues 47 briefly this inductive method begins with the assignment of a series of open codes to the transcripts of individual interviews which are then grouped into clusters in order to make them more workable from these concepts broader categories and subcategories are generated through a process of constant comparison or verification the ultimate outcome is a databased matrix of concepts and categories which serve as an input for developing theoretical or conceptual frameworks we imported all interview transcripts into maxqda and we used this qualitative data analysis software to support consistent data analysis processing ordering and comparison of the results at different stages 48 underneath we provide some more detail about the process of data analysis that was adopted in the present study first in each of the interview transcripts sections containing information on respondents ideas on hypertension and hypertension treatment were identified and inductively coded similar codes were assigned to text fragments that reflected the same idea these coding activities yielded a codebook that included all the codes that were created during the analysis of the individual interview transcripts to conclude this stage we reviewed the code book to eliminate duplicates and to inspect if the remaining codes captured similar concepts so that they could be grouped together the goal was to establish a smaller set of mutually exclusive conceptual codes that expressed the meaning of the underlying codes without loss of the original content the identified concepts and underlying text fragments were then scrutinized and grouped under four major themes referring to our research questions inhibitors and facilitators of adherence to medication and behavioral recommendations subsequently thematic coding procedures were used to group the concepts under each of the four major themes into categories and subcategories results of these multilevel coding procedures were summarized into matrices trustworthiness the researcher selected the sections of the interview transcripts that served as an input for the data analysis to increase reliability and trustworthiness of the analysis the following steps were taken to establish a consistent open coding procedure two members of the research team coded fragments of 15 interviews independently results were compared and if differences occurred they were resolved through discussion and by going back to the original data to establish the list of conceptual codes two members of the team independently reviewed the code book and created relevant concepts differences of opinion with respect to the clustering of codes or the naming of concepts were resolved by discussion and by going back to the original data the categorization of concepts under the main themes was done by aoo and supervised by jah who made sure that every decision was plausible and could be justified the preliminary results of the data analysis were based on 30 interviews overlooking these results aoo and jah acknowledged that some additional interviews were needed to further confirm or explore some of the themes and concepts that had emerged from this preliminary analysis so that thematic saturation could be reached examples of such themes were related to the perceived role of religion on adherence to medication and patients ideas about local practices that can inhibit or enhance healthy eating habits and physical exercise based on the analysis of the last set of interviews some new conceptual codes were added to the original list where appropriate the researcher returned to the transcripts of the first set of interviews to check if any of these new codes could also be applied here thematic coding was done by aoo and jah they reviewed the conceptual coding trees for each of the four major themes and independently categorized those concepts into categories and subcategories differences in opinion were resolved by discussions and by checking the underlying data at several occasions other members of the research team asked critical questions as regards the categorization of the concepts and this led to some adaptations in the final ordering and presentation of the categories and sub categories and consequently the results the final results of the analyses that are presented in the tables in this paper were reviewed by all authors ethics this study is part of a larger project that aims to develop and evaluate cardiovascular health education program for insured patients with hypertension in rural nigeria 39 ethical approval was obtained on 30th march 2010 from university of ilorin teaching hospital prior to the start of the study in july guidelines for quality assurance of qualitative research in health from the academic medical center were used to ensure appropriate conduct of the study 49 coreq criteria for reporting qualitative interviews were used as a guideline for reporting this study 50 results we interviewed 40 patients half of them had controlled bpsystolic bp 140 mmhg and diastolic bp 90 mmhg and the other half uncontrolled bpsystolic bp ≥ 140 mmhg andor diastolic bp ≥ 90 mmhg most were older than 50 years all were rural dwellers 80 earned less than 5 usd per day and 70 had none or only primary school education almost all lived in poor housing conditions and most were farmers artisans or traders all were religious 625 practiced christianity and 375 practiced islam factors inhibiting and facilitating medication adherence some patients said they did not always take their medications according to prescription frequently mentioned patterns of selfregulation included reducing the daily dosage skipping medications under specific circumstances and discontinuing medications for several days or weeks none had stopped using medications all together patients accounts of factors that inhibited them from using their pills as prescribed could be classified into five main categories 1 healthcare related factors the way in which hypertension care was organized was perceived as one inhibitory factor for medication adherence in general patients at ogo oluwa hospital are required to attend hypertension clinic once a month for followup and medication refills the hypertension clinic is always held at fixed hours on fridays other obligations such as attending muslim praying hours work household chores or being on a trip out of town will sometimes prevent patients from meeting their appointments at these fixed hours the distance to the clinic was also mentioned as a reason for missing appointments highlighting the resultant financial challenge a 50 year old woman with uncontrolled hypertension id6 saidvisiting regularly is problematic for me in the sense that the clinic is far from my residence and travel cost is prohibitive i spend 500 naira to get here and another 500 naira to go back home long waiting times at the clinic were also cited as a reason for missing appointments asked how regularly he attends clinic a 72 year old man with uncontrolled hypertension id27 repliedvisiting is difficult for me because of the many hours spent in clinic which could be used on my business in fact i once stopped coming for about 2 months when i realized my hypertension was under control sometimes the pharmacy is out of stock for particular drugs and not all prescribed medications can be dispensed a 50 year old woman with controlled hypertension id11 respondedsometimes the pharmacy doesnt have all the drugs prescribed so they write it in paper for me to buy or come back to collect them oftentimes days after being without pills to use 2 patient related factors patients own views such as the idea that hypertension is a transient curable condition also emerged as a consideration for deviating from the prescribed medication responding to a question on how long she expects to continue to use hypertension medication a 64 year old woman with uncontrolled hypertension id13 repliedsurely hypertension can be cured one cannot continue to use drugs all days of ones life with prayers in no time it will go n refers to the number of respondents whose perceptions contribute to the corresponding concepts for success for the operators of the program the program manages my hypertension well and makes me healthier and stronger to work for my daily bread the easy approachability of the doctor was also perceived as facilitating factor for medication adherence a female participant with uncontrolled hypertension id3 respondedlast january when i was about to travel i approached my doctor and told him that i will be away for 2 months requesting enough drugs stock to last the period this he willingly did so i always take my drugs whether traveling or not another a 61 year old man with controlled hypertension id22 respondedduring the last fasting season i approached my doctor 2 weeks earlier to seek advice on how to use my drugs he decided to withdraw my thrice a day pill and replace this with a twice a day pill and later reverted back to the thrice a day drug after the monthlong fasting 2 patient related factors responses grouped under this category show that knowledge and fear of complications of hypertension may motivate patients to comply with their medications a 60 year old man with controlled hypertension id24 statedhypertension is something that brings death in different forms one can be working and suddenly fall down and slump or become paralyzed it is called kosibale okanin yoruba meaning theres no peace of mind another patient id29 similarly alluded to the danger of hypertension thushypertension is dangerous and can kill suddenly it shows no mercy 3 medication related factors many patients said they comply with their medications because they firmly believe orthodox western medicines are effective especially when compared with alternative traditional medicines a 70 year old man with uncontrolled hypertension id29 responded i am into herbs and i have used them severally in the past but they did not work like the white mans medicine 4 social support some patients view reminders and monitoring by family members and support from peers with same condition as important factors that motivate compliance asked how carefully she uses her medicines a 56 year old woman with controlled hypertension id37 replied i dont miss my pills if i do my children will be annoyed with me they monitor me closely to be sure i take my drugs regularly every day 5 religious factors many patients said prayer supported them in using and in improving the beneficial effect of their medications moreover additional health education from religious leaders was also deemed important by some a 62 year old man with controlled hypertension id25 said i have received enlightenment about hypertension from some radio programs and from my church too they are useful advices and i usually followed them factors inhibiting and facilitating adherence to behavioral recommendations managing hypertension requires a healthy behavior including limited use of salt weight reduction or maintenance n refers to the number of respondents whose perceptions contribute to the corresponding concepts exercise cessation of smoking and limited use of alcohol and other stimulants table 4 illustrates factors which inhibit achieving such healthy behaviors in the eyes of our respondents 1 salt while most participants said they had been informed by their doctor that they need to be prudent with the use of salt our data also suggest that some patients were aware of the impact of salt n refers to the number of respondents whose perceptions contribute to the corresponding concepts reduce salt in the study region adding salt and salt substitutesseasoning agents like maggi ajinomoto etc has become standard practice while cooking the consumption of canned foods often salty is also increasingly common in the region the previously fairly common cultural habit of drinking salted water in attempts to treat undiagnosed abdominal discomfort of all sorts was practiced by some respondents a 50 year old woman with uncontrolled hypertension id6 statedit is more or less customary for people to cook food with salt in this region… and for some people who may sometimes have stomach upset tradition demands that one should pour salt into a cup of water and drink to treat the ailment i used to do this too but being better aware have now stopped the practice 2 weight control participants mentioned a number of local or cultural practices that may prevent people from losing weight including the cultural perceptions that large body sizes are associated with wealth comfort or beauty that weight loss is associated with disease and that weight is an unchangeable family trait a 50 year old woman with uncontrolled hypertension id3 respondedpeople often see being fat as synonymous with affluence comfort and peace of mind they also sometimes associate fatness in a woman with beauty some of us women prefer to be fat or robust believing that by so doing we will be more attractive to our husbands and men generally some men too prefer to be plump so they will be liked by women a 63 year old man with controlled hypertension id30 saidin this region people often link weight loss to disease particularly if the slimming down is getting too much suggesting that such might be due to disease at other times they suggest that slim people are very miserly and would rather not spend money to eat well and get robust highlighting the perceived link with inheritance a 55 year old woman with uncontrolled hypertension id16 respondedmy friends and neighbors often say i was too fat but im not bothered about such comments as i believe i inherited the trait from my mother we are usually fat in my family local food practices may also inhibit weight control some participants highlighted the difficulty in avoiding some of the main fattening ingredients of local popular dishes such as cassava groundnut oil palm oil and meat the first three ingredients are commonly grown by farmers in the community while meat is widely available due to popular goat breeding practice in the community whereby owning and breeding goats is a pastime that many families engage in 3 exercise perceived inhibitors of exercising include local practices and lack of information prevailing local or cultural views that exercise is needless or useless dangerous or incompatible with advancing age may prevent people from being physically active exercise is sometimes regarded by people as an activity for unserious fellows the unengaged or the miserly that rather walk habitually than pay for transportation costs to destinations an elderly male patient with controlled hypertension id30 respondedwhen people see me walking to exercise they often slight me and make derogatory comments that one is greedy and would rather walk long distances than spend money on transportation asked further how people see exercising or sporting activities he repliedsome people see those who exercise as unserious people sports like playing football are only engaged by youths not elderly people like me several respondents said they were not aware or informed about positive effects of exercise on bp or easy ways to exercise insufficient knowledge makes some patients view exercise as dangerous for their hypertension some others are simply unfamiliar with practicable exercises 4 tobacco and stimulants besides cigarettes and alcohol other locally accessible stimulants like snuff and kola nuts are also used by some people in the region some patients perceive positive effects from using these substances as illustrated in the following n refers to the number of respondents whose perceptions contribute to the corresponding concepts with salt before now the availability of substitutes for salt in local markets was similarly viewed as a facilitator finally social support particularly the familys willingness to eat low salt meals was identified as an important motivator for reducing salt as one respondent a 50 year old woman with controlled hypertension id11 puts ityes i was able to make use of the advice we now reduce the quantity of salt added to common family pot food generally thereafter those in the family that desire more salt in their food can add extra salt to their portion after dishing 2 weight control the perceived facilitators of weight control related mostly to local practices some people said the changing local and cultural perceptions on linkages between weight wealth beauty and health are an important condition to facilitate weight control being too fat is sometimes viewed as being tantamount to ugliness and physical unfitness or sluggishness when asked what peoples comments on fatness are a 65 year old man with controlled hypertension id23 repliedpeople will say look at him big for nothing yet he will not be able to enjoy breathing worse still his bigness really has nothing to do with wealth another respondent id26 saidbeauty is a good thing that sometimes goes with bigness but some people are ugly looking when fat the ample availability of affordable healthy foods from local vegetable farmers and fishermen was equally seen as an important motivator for changing ones diet and for weight control discussion in this study we explored perspectives on treatment adherence among patients who received hypertension care in the context of a community based health insurance program in rural nigeria results suggest that having free access to previously unaffordable high quality care from a healthcare center headed by a physician who was highly respected in the community and to western medication were perceived as important facilitators for being adherent to medications as was the perception that hypertension is a serious condition similarly the performance of prayers support from family members and other patients with hypertension and counseling from religious institutions were seen as factors reinforcing adequate medication use interestingly compared to results from similar qualitative studies on hypertension in western countries 22 the patients in this study regarded modern white mans medications more positively and seemed to be less likely to alter the prescription according to their own insights this finding seems credible in the light of a number of other nigerian studies in a qualitative study of explanatory models of hypertension among patients in a lagos hospital it was found that patients lacked the desire to be active participants in their health care decisions while they believed that the doctor knew what was best for their care 33 another study from urban western nigeria also found that patients were motivated to comply with treatment because they had access to western prescription medications 36 the nigerian antihypertensive adherence trial demonstrated that medication adherence was very high among those participants who did not drop out of the study the authors concluded that this is in line with the general experience that patients with no or little prior contact with organized modern medical care will readily adhere to recommended therapy 38 at the same time however certain characteristics of the way care was organized could still hinder medication adherence the most important being travel costs associated with clinic visits for those patients living far from the clinic clinic operating hours waiting times and the under dispensing of prescribed medications in addition patients idea that hypertension is a temporary condition for which medications may no longer be required once symptoms disappear was an inhibiting factor for taking medications regularly or a reason for omitting clinic visits while the practice of faith healing or the use of herbal drugs might inhibit the use of prescription drugs in their own case participants said they would use these remedies only to supplement antihypertensive medications and not as a substitute interestingly lack of social support from the patients immediate environment was rarely mentioned as an inhibitor for using medications these findings are plausible in the light of other studies that have also identified travel costs long waiting times clinic operating hours and limited knowledge by patients as factors limiting medication use 1633 while most respondents said they were aware that healthy behaviors could have a positive influence on their health and bp adopting a healthy lifestyle seemed to be a greater challenge to them than taking their medications local practices and norms held by people in the community were identified as important inhibiting factors for behavioral changes including use of salt for food preservation negative cultural images associated with decreased body size and physical activity and perceived benefits of using palm wine kola nuts tobacco and snuff anthropologists have noted that a resistance to change local food and eating practices and body images is common among people throughout the world as these are often seen as an important component of an individuals cultural identity 51 yet our study offers also some insight into the factors that may facilitate healthier behaviors and tackle the inhibitors these include sufficient knowledge or understanding of how healthy behaviors may affect hypertension and support from family or religion but most importantly the awareness that healthier behaviors will not require profound changes of ones usual daily life by using open interviews the strength of this study is that its builds on direct experiences of the patients we interviewed a sufficient number of patients to achieve thematic saturation which is a criterion for sample size and internal validity in qualitative studies 43 the iterative approach taken in this study 44 and specifically the decision to collect additional data on the basis of themes that were unclear from the preliminary analysis of data from the first set of interviews added value to the results we learned from these additional interviews that our informants attached significant importance to a traditional rural african way of life and when probed they were readily able to describe how this way of life not only provides inhibitors but also opportunities for adhering to the behavioral recommendations they were given by their doctor for example the interviews provided much detail on what affordable food products are available in local markets to compose healthy meals and how peoples normal daily activities offer ample opportunities for getting exercise the additional interviews also provided further insight into reasons for medication adherence it became clear that some patients felt particularly motivated or obliged to adhere to their medications because they perceived their health insurance and consequently their access to good treatment as blessings from god but at the same time religious practices could sometimes pose practical barriers to medication adherence in line with quality criteria of qualitative research 50 we undertook several efforts to reduce individual biases in the analysis and to strengthen the trustworthiness and credibility of the findings eg by using maxqda software to ensure consistency of analytic procedures and by involving two or more members of the research team at crucial stages of the analysis the study also has limitations the participants consisted of insured hypertensive rural dwelling low income nigerians reachable through telephone who had continued to visit the clinic for treatment for at least one year consequently our findings do not capture ideas from other groups of patients for example within the context of a community based health insurance program it would also be relevant to further investigate views on treatment adherence among patients who dropped out of treatment despite the fact that they had access to good care in terms of data collection and analysis our possibility to verify what patients told us against other sources was limited ethical considerations prevented us from interviewing significant others to crosscheck information from participants similarly since the interviews were conducted in local languages and transcribed in english it is not impossible that some deeper meanings participants intended to convey might be lost in the process of translation poor adherence to treatment has been identified as one of the most important modifiable barriers to bp control in patients with hypertension 141952 overlooking the accounts of the patients who participated in this study it becomes clear that adherence can be affected by multiple spheres of influence including public policy institutional and organizational factors environmental factors social and cultural norms and practices social networks and intrapersonal factors this provides support for social ecological approaches to health promotion 53 these approaches assume that single interventions such as the provision of free access to care are generally not sufficient to promote healthier behaviors and that a mixture of interventions aimed at different levels is needed to accomplish this the framework of inhibitors and facilitators to adherence that emerged from this study suggests that in the case of the community based health insurance program in kwara state a number of additional interventions may be needed to remove barriers that patients face in adhering to their treatment first more attention could be paid to patient education the findings suggest that patients with difficulty in managing their medications may benefit from further counseling or education about the nature of hypertension why medications need to be taken regularly what they may discuss with their doctor to make regular medication use easier how they may deal with specific social cultural or religious impediments encountered in taking their medications and with the logistic challenges faced in getting refills on time in addition patients who experience challenges in managing behavioral changes may benefit from further counseling or education about the positive influence of salt reduction weight control healthy diet and exercise on bp and health and on how existing dietary and physical activityrelated local practices may help them in implementing behavioral changes community education may be one possible solution to avoid limited human resources and financial problems which patient education can pose to the already charged health care clinics this type of education has been effectively used in the usa 54 it can be delivered to groups of patients at the health care center or in other community settings the patients are familiar with such as schools churches or mosques the education must be delivered by people who are known trusted culturally competent and fluent in the language of the target community these educators need not be health professionals but they do need to be prepared for their role such preparation can be provided through careful training programs which can be offered by the health care center secondly it must be acknowledged that not all the patientperceived barriers to adherence that were identified in this study can be tackled by education alone solutions will also have to be found at the level of the health care facility or the insurance program for instance in order to address some of the logistic obstacles patients face with the monthly clinic visits conclusion this qualitative study of patients perspectives on adherence to prescribed treatment reveals that hypertensive patients in an ssa setting who receive affordable care may still face challenges in adhering effectively to their prescribed hypertension treatment more than just health insurance is required to enable adherence to treatment local communities in rural africa may present specific barriers but also opportunities for adhering to medications and to healthier behaviors with more insight into the specific inhibitors and facilitators perceived or experienced by patients actionable community based educational interventions can be designed to strengthen adherence however some barriers cannot be tackled through patient education alone and should be addressed by interventions at the level of health care services and payment systems key messages 1 despite affordability of carea feature of community based health insurance programs and insured care in general hypertensive patients in ssa settings may still face other challenges in adhering effectively to prescribed treatment more than just health insurance is required to improve adherence and treatment outcomes 2 using information from exploration of patients perspectives on adherence to prescribed treatment this study suggests that local communities in low resource settings may offer specific barriers but also opportunities for adhering to medications and to healthier behaviors 3 adherence counseling and education for patients may benefit from addressing the identified specific inhibitors and facilitators perceived or experienced by patients additional files additional file 1 interview guide used for quickii study qualitative interviews with hypertensive patients additional file 2 examples of coding steps and matrix for facilitators of treatment adherence abbreviations bp blood pressure cvd cardiovascular disease id identity maxqda max qualitative data analysis ssa sub saharan africa competing interests the authors declare that they have no competing interests authors contributions aoo drafted the manuscript conducts the study and participated in the design reporting analysis and revision jah jl ks and mh participated in the original designing of the study jah revised commented and made substantial input to several drafts of the manuscript ao ca cs go hw jah jl ks mh oab and ta reviewed the manuscript jah and ks participated in data quality improvement and analysis cs hw jah and ks participated in review of the data procedures and content of the study ka pa and ta provided logistic supports ao cs jah jl and ks are members of the supervisory board all authors read and approved the final manuscript

background universal health care coverage has been identified as a promising strategy for improving hypertension treatment and control rates in sub saharan africa ssa yet even when quality care is accessible poor adherence can compromise treatment outcomes to provide information for adherence support interventions this study explored what low income patients who received hypertension care in the context of a community based health insurance program in nigeria perceive as inhibitors and facilitators for adhering to pharmacotherapy and healthy behaviorswe conducted a qualitative interview study with 40 insured hypertensive patients who had received hypertension care for 1 year in a rural primary care hospital in kwara state nigeria supported by maxqda software interview transcripts were inductively coded codes were then grouped into concepts and thematic categories leading to matrices for inhibitors and facilitators of treatment adherence results important patientidentified facilitators of medication adherence included affordability of care through health insurance trust in orthodox western medicines trust in doctor dreaded dangers of hypertension and use of prayer to support efficacy of pills inhibitors of medication adherence included inconvenient clinic operating hours long waiting times underdispensing of prescriptions sideeffects of pills faith motivated changes of medication regimen herbal supplementationsubstitution of pills and ignorance that regular use is needed local practices and norms were identified as important inhibitors to the uptake of healthier behaviors eg use of salt for food preservation negative cultural images associated with decreased body size and physical activity important factors facilitating such behaviors were the awareness that salt substitutes and products for composing healthier meals were cheaply available at local markets and that exercise could be integrated in peoples daily activities eg farming yam pounding and household chores conclusions with a better understanding of patient perceived inhibitors and facilitators of adherence to hypertension treatment this study provides information for patient education and health system level interventions that can be designed to improve compliance trial registration isrctn47894401

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introduction globalization is currently the cause of economic competition between countries resulting in uncontrolled exploitation of natural resources 1 as a result of uncontrolled development various issues of environmental damage have emerged which are a very real threat to human life various environmental damage problems faced by humans include deforestation climate change extinction of flora and fauna diversity due to pesticide contamination damage to aquatic and forest ecosystems 2 the problem of environmental damage has become part of the reality of human life in the 21st century so that it requires awareness concern and human participation in preserving the environment 3 the cause of environmental damage is an error in ichelss managing the environment that is not oriented towards sustainability and the existence of an ecological crisis namely the relationship between humans and nature that is bad so as to create environmental problems 4 environmental problems are currently one of the global citizenship issues syaifullah et al 5 revealed that there are five global citizenship issues that are problems and challenges faced by countries in the world namely economic inequality technological advances access to information conflicts of interest between developed and developing countries which resulted in damage to ecosystems forest deforestation and uncontrolled population explosion environmental damage has always been the impact of problems caused by human actions at this time based on a study conducted by shaw oikawa 6 states that humans are currently facing environmental crises such as pollution that occurs in water and air depletion of the ozone layer massive deforestation of tropical rainforests global warming a crisis in biodiversity and socioeconomic problems as a result of environmental problems environmental destructive behavior is the main factor that causes the environmental crisis dermawan 7 categorizes environmental destructive behavior in three categories namely increasing population exploitation of nature such as forests and seas and pollution contained in water soil and air the impact of the issue of environmental damage must be addressed immediately at this time an effort is needed to control various issues of environmental damage for a better life in the future 8 controlling the issue of environmental damage is not only the burden and responsibility of the government but all citizens in it it requires the participation of all citizens in managing the environment 9 efforts to preserve environmental management by citizens are not only limited to formal education but can be through citizen communities or community civics that are engaged in environmental issues 10 in civic education it is known as the concept of ecological citizenship which is an idea about emphasizing citizens rights to a healthy and proper environment which means that it requires participation between citizens communities and governments to ensure a proper environment 11 the emergence of the idea of the ecological citizenship movement is also a civic virtue that expects no strings attached unlimited territory and noncontractual so it can be understood that ecological citizenship focuses on acting virtuously towards the environment for the common good 12 regarding the situation in indonesia efforts to deal with environmental damage through civic education are limited to school education only even though in reality doi 1018502kssv9i214904 ichelss environmental damage is done by adult citizens who are no longer in school so it is necessary to handle it still well through the community in the sociocultural domain namely corporate civic engagement or which is understood as job creation based on handling public issues and community civic education which can be understood as community civic education 12 environmental damage control in the community will be more successful if it is based on existing local wisdom sendi indigenous people as part of indigenous communities in indonesia sendi indigenous people have local wisdom in managing customary institutions have their own government structure and customary law system 13 in the context of preserving the environment the sendi indigenous community has various regulations regarding the management and utilization of the environment such as the tradition of basuhan cutting trees that are limited to a certain time preserving and preserving springs called kucur tabut 14 the existence of disasters that have occurred the sendi indigenous community seeks to carry out a better life with the principle of sustainability this research seeks to reveal the existence of the sendi indigenous community who seeks to care for their environment after the disaster method the reason for choosing a case study strategy in this research is based on yins perspective 15 that case study research usually focuses on how and why questions has limited time in controlling the phenomenon under study and focuses on contemporary result and discussion the intensity of disasters due to the ecological crisis is caused by the lack of public awareness in protecting the environment so there is a need for awareness in managing the environment with the concept of sustainability and the existence of local wisdom is one of the main factors in resolving the ecological crisis the sendi indigenous community lives in the area where two gurung slopes meet namely mount welirang and mount arjuno and has a local identity called sengkalaning sendi environmental problems that currently occur based on a study conducted by usaid 16 found that the topography of pacet village pacet subdistrict mojokerto regency as the place where the sendi indigenous community lives is in a high disasterprone location in landslides and flash floods as a result of climate change the data obtained that during the period 20022016 hydrometerological disasters occurred factors causing disasters such as landslides and flash floods in that period were due to the conversion of forest and agricultural land into various tourist attractions and restaurants that did not comply with the principles of life of the indigenous people of the joints based on the unrest and concerns of the indigenous people of the joints against disasters that could recur the idea emerged to form an ecological movement based on the local wisdom of the joints local wisdom in managing the environment is a direct application of civic ecology 17 the sendi indigenous community has various activities in preserving the environment in the context of preventing and overcoming hydrometeorological disasters that have occurred in the location where they live the activities they carry out are guided by existing local wisdom if further understood local wisdom in indonesia is centered on food drinks natural resource management literary works and sculptures 18 sengkalaning diri as the identity of the sendi indigenous people relating to relationships with nature and fellow humans and god 14 in relation to nature the indigenous people of sendi have traditions such as basuhan ngangsu banyu aras and babakan kucur tabut according to an interview conducted with ki demang supardi local wisdom cannot be transferred but can be inherited through exemplary methods and the adequacy of a conducive or safe environment 20 the traditions carried out by the sendi indigenous people are a form of inheritance that is taught to their generation through the exemplary method related to the inherited tradition it is the urgency of ecological awareness that is poured into real activities by citizens to foster loyalty to nature 21 various traditions that have been carried out are one form of effort to strengthen ecological citizenship carried out by indigenous leaders in the form of traditions that have been mentioned the response obtained by strengthening environmental awareness has a positive value and the enthusiasm of the sendi indigenous people in managing the environment is much better because of the encouragement and consultation of residents who feel the environment is much better than before besides that there is cooperation carried out by the leaders of the sendi indigenous people who are related to environmental conservation activities through various traditions such as walhi east java and pplh this is done to provide an understanding of the importance of managing a good environment so that the relationship between humans and nature goes well and does not result in the emergence of various disasters that harm humans themselves in addition the sendi indigenous community formed a tourism manager as a result of the development and utilization of environmental potential that can be used to attract tourists and contribute to the economy of the sendi indigenous community which is still in accordance with existing local wisdom activities carried out by sendi integrated educational tourism as an existing tourism manager provide strengthening of environmental awareness to visitors who come to do tourism activities in the destinations provided the visitors are given education about what local wisdom exists in the sendi indigenous community especially those related to environmental management such as when cutting down trees it must be replaced with a number of felled trees the use of predetermined traditional clothing commonly referred to as ageman and building houses where residents live with the characteristic of having a sustainable doi 1018502kssv9i214904 ichelss concept because development is very environmentally friendly when related to the study conducted by dash 22 states that ecological citizenship contains moral virtues that guide humans to do good to nature and the environment through a form of solidarity with the earth when viewed from the perspective of ecological citizenship by dash what is done by the manager of sendi integrated educational tourism is part of one of the life choices of the sendi indigenous people to manage the environment for a decent life based on sustainability and local wisdom this is also in line with fahlevis opinion 23 which states that in managing the environment one must look at the conditions that surround humans in their activities meaning that the environment around where people live in their activities is a top priority in protecting and managing the environment tourism management efforts through integrated educational tourism managed by the sendi indigenous community have a very good impact on their lives this is based on the results of interviews with subari as kasinoman and chairman of the sendi integrated educational tourism management the joint indigenous community is very much helped by the existence of integrated educational tourism which has a good impact on the economic sector and the environment because in terms of the economy we initially only depended on agriculture and plantations but we realized that there was potential that we could develop into tourism but still in accordance with our wisdom in managing the environment interview dated may 13 2023 the form of activities carried out by sendi integrated educational tourism based on local wisdom in the sendi indigenous community contributes to environmental protection by involving all components as part of a strategy to strengthen ecological citizenship and has a very good impact on community members and nonmembers this can be seen from the increase in capability in managing the environment properly and participation which was initially lacking has increased due to the involvement of all components in the sendi indigenous community however this does not mean that there are no obstacles in implementing strengthening ecological citizenship through existing forms of activities in managing the environment based on local wisdom there are obstacles in managing the environment including internal and external factors from internal factors there are problems in the form of lack of community compatibility in supporting new programs that do not have a direct economic impact this is a challenge in itself that is very hampering for the strengthening of ecological citizenship carried out by its administrators to members of the sendi indigenous community besides that the impact of lack of compatibility doi 1018502kssv9i214904 ichelss in social life requires the existence of socialization activities getuk tular to be able to arouse the solidarity of community members another internal factor is the economic needs of the community which mostly depends on agricultural products plantations and trade in the tourism area developed by the sendi customary society because of economic pressure some people are forced to carry out cooperation activities that are not in accordance with existing local wisdom such as renting out their land to be used as a food stall which should not be allowed to carry out rental activities with parties outside the sendi customary society when viewed from dobsons opinion 12 behavioral factors are dominant factors in internal obstacles deviant behavior due to economic pressure and selfishness has an impact on solidarity in managing the environment the obstacles from external factors are caused by land ownership issues that still have no meeting point between the sendi indigenous people and perhutani which began in 1999 this is based on the history of land ownership and forests in the area where they live until in 2007 there was an arrest of mr toni as a customary uncle who was accused of carrying out unlicensed activities in the pine production forest owned by perhutani in addition this conflict led to a conflict that was trying to be resolved through recognition of the existence of the sendi indigenous community through the making of regional regulation no 4 of 2018 which was used to establish a preparatory customary village and was also finally revoked because it conflicted with the village law which must have a minimum of 6000 residents to form a new village government the impact of land status issues and recognition has an influence in providing strengthening of ecological citizenship in the implementation of various traditions one of which is the tradition of ngansgu banyu aras which in its implementation was once disputed by perhutani because it is located in a production forest area and a limited area where other people are not allowed to enter without special permission from perhutani conclusion as a community that has a residential location in a disasterprone area it is necessary to provide awareness in strengthening ecological citizenship by the sendi indigenous

environmental degradation is currently causing many hydrometeorological disasters ecological citizenship as part of the concept of civic education has the aim of forming smart citizens with environmental character this study analyzes the form of strategies to strengthen ecological citizenship in sendi indigenous peoples of mojokerto regency along with the obstacles and challenges they face in strengthening environmental awareness based on local wisdom the study uses qualitative research methods with a case study design data were collected through direct observation in the environment where the joint indigenous community lives interviews with kasepuhan pamengku adat and members of the sendi indigenous people and documentation data were analyzed using interactive data analysis methods it was found that the sendi indigenous people have a strategy to strengthen ecological citizenship based on local wisdom namely sengkalaning sendi which regulates relationships with nature and the environment in collaboration with various stakeholders and ngos such as walhi and pplh the obstacles encountered by the sendi indigenous people are mainly internal and external factors

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introduction each year thousands of african americans experience morbidity and mortality from several chronic diseases national studies continue to demonstrate that african americans are at greater risk than nonhispanic whites for developing most forms of cancer 1 and cardiovascular diseases 2 health promotion programs developed to address the specific needs of this population include communitybased programs that provide education and training on strategies for eating a healthy diet and being more physically active 34 in addition to evaluating the effects of these programs on health behaviors and other outcomes it is important to determine the extent to which programs reach the intended audiences and whether or not participation differs based on sociodemographic factors and other variables when programs are offered in specific settings such as churches or in partnership with other types of sponsoring organizations the population reached can be estimated by knowing the membership and characteristics of the organization or clientele 5 however when programs are developed and offered to african americans using nonrandom communitybased approaches it may be more difficult to estimate their reach because exposure to recruitment initiatives is unknown in these instances it is useful to determine the extent to which program participants are demographically representative of the target community and to evaluate rates of program participation in 2007 we conducted an exploratory study to evaluate the feasibility of offering an integrated risk counseling program for cancer and cardiovascular disease to african american men and women who were residents of an urban community in a large metropolitan city this research was conducted as part of the west philadelphia consortium to address disparities which is an academiccommunity partnership consisting of four communitybased organizations in philadelphia pa and academic researchers and staff from the university of pennsylvania consistent with the principles of communitybased participatory research 67 the partnership was developed to facilitate collaboration between community and academic members on research efforts to address the health priorities and concerns of community residents as such community and academic members of the partnership shared responsibility for developing the intervention and monitoring accrual to the study collaboration on these issues and strategic direction for the partnership was achieved through regular meetings of the executive committee which consisted of academic and community representatives the intervention was developed to increase motivation for eating a healthier diet and increasing physical activity among african american residents in west and southwest philadelphia we focused on this community for several reasons first focusing on a specific geographic community is in line with the principles of cbpr 7 also since the university of pennsylvania is located in west philadelphia we believed that it was important to implement our research and develop programs in a setting that would build on the activities at an important resource for health care in the west and southwest philadelphia community finally several of the census tracts in west and southwest philadelphia have been designated as health professional shortage areas according to the 2000 census of the more than 200 000 residents in west and southwest philadelphia more than 70 are african american andor black and within this population 41 are men and 59 are women in addition 40 are in the labor force and 27 live below poverty 8 the purpose of the present study was to evaluate rates of participation in an integrated risk counseling program that was developed through the partnership because recent reports suggest that among african americans decisions to participate in health promotion programs offered in research settings might be influenced by factors such as the amount of community support for participation sociodemographic factors psychological variables and risk factors for disease 910 we evaluated the relationship between participation in the program and sociodemographic factors health beliefs and intentions to make behavioral changes we also assessed the representativeness of our sample in comparison to the demographic composition of our target community because we used nonrandom methods to recruit individuals to participate in the intervention materials and methods study population this study was conducted at the university of pennsylvania and was approved by the institutional african american participation representativeness communitybased participatory research review board participants were adult african american men and women who were residents in an urban community in philadelphia to be eligible for participation individuals had to be at least 18 years of age and be a current resident in west or southwest philadelphia individuals who had a personal history of cancer and those who had ever had a heart attack stroke or heart disease were not eligible for participation in the study because our interest was in assessing motivation for behavior change for the primary prevention of these conditions procedures participant recruitment and eligibility participants were recruited into the study through selfreferrals from newspaper advertisements flyers and health fairs from july 2007 through november 2007 advertisements were placed in free regional and community newspapers these advertisements described the study as a research program that would provide information about risk factors for cancer and cardiovascular disease and strategies for improving ones health participants were also told about the study by community members of the partnership and also by individuals who had completed the risk counseling program regardless of how people learned about the study those who were interested in participating were instructed to call the study line for additional information following selfreferral a screening interview was completed to determine eligibility those who were eligible to participate in risk counseling completed a baseline telephone interview the interview was a 30minute structured questionnaire that obtained information on sociodemographics height and weight perceived risk of developing cancer and cardiovascular disease selfefficacy for diet and physical activity and motivation to eat healthier and exercise more prior receipt of advice to lose weight was also assessed during the baseline these interviews were conducted by research assistants at the university of pennsylvania following provision of verbal consent at the end of the interview individuals were invited to participate in risk counseling intervention risk counseling consisted of participating in a group session during which individuals received information about the occurrence of cancer and cardiovascular disease in african americans risk factors for these diseases and strategies for reducing their risk using a multimedia format the program was developed by members of the partnership to address the health priorities and concerns of african american residents that were identified through a multiphase needs assessment that included focus groups key informant interviews and community health survey and used the health belief model as the conceptual framework 11 to facilitate the process of developing the intervention we formed an intervention development subcommittee that consisted of academic and community members of the partnership the ids met regularly to develop the objectives for the intervention develop its content and strategies to increase behavioral motivations and develop methods for evaluating the effects of the intervention as part of risk counseling participants completed activities that were designed to highlight the connection between risk factors for cancer and cardiovascular disease for instance following a video presentation about risk factors for cardiovascular disease 12 the facilitator led a discussion about risk factors for cancer during which individuals were asked to describe risk factors for this disease participants then completed a group exercise in which they identified risk factors that were common to both cancer and cardiovascular disease elements from motivational interviewing 13 were also included in the protocol to increase motivation to make behavioral change specifically participants completed a values clarification exercise and were asked to indicate how motivated and confident they were to make changes in their diet and physical activity practices an experienced health educator facilitated the risk counseling sessions and each session lasted about 23 hours all the counseling sessions were held during a weekday evening at the university of pennsylvania using a group format eight sessions c h halbert et al were held during the study period and the average number of participants in each session was 13 written informed consent was obtained prior to the provision of counseling those who completed counseling received an incentive of 20 and 15 was also provided to compensate individuals for travelrelated expenses measures sociodemographics gender age marital status education level employment status and income were obtained by selfreport during the baseline telephone interview we recoded marital status education employment and income into dichotomous variables based on the distribution of responses body mass index we obtained height and weight by selfreport during the baseline telephone interview and calculated body mass index using the formula weight 2 3 703 risk perceptions we used items from previous research to evaluate perceived risk of developing cancer and cardiovascular disease 14 specifically participants were asked to indicate how likely it was that they would develop specific forms of these diseases compared with other individuals of their age in this report we focused on perceived risks of developing colon cancer and having a heart attack selfefficacy we used instruments from previous research to evaluate perceptions of confidence to eat a healthy diet and to be more physically active specifically dietary selfefficacy was assessed in terms of perceived confidence to eat fruit and vegetables under a variety of circumstances 15 similarly the selfefficacy for physical activity scale 16 asked participants to indicate how confident they were that they could be physically active under various conditions both instruments had good internal consistency behavioral motivations we developed items to evaluate motivations for behavioral change specifically participants were asked to indicate how likely it was that they would try to eat healthier and exercise more during the next month as a part of the baseline telephone interview participation and representativeness variables as in prior reports 10 we assessed participation in the program in terms of the proportion of individuals found to be eligible who completed a risk counseling session participation in the program involved completing one risk counseling session individuals who completed counseling were categorized as program acceptors and those who declined to participate in the program or did not complete the session after accepting the invitation were categorized as nonparticipants the representativeness of the program participants was determined based on the extent to which our program participants were similar to african american residents in west and southwest philadelphia in terms of sociodemographic characteristics data analysis first we generated descriptive statistics to characterize participants in terms of sociodemographic factors and participation in risk counseling in order to determine whether participants in our sample were representative of the target community we conducted exact onesample hypothesis tests specifically we compared the prevalence of key sociodemographic variables african american participation representativeness communitybased participatory research from our study sample with those for these characteristics among african american residents in the seven zip codes for west and southwest philadelphia using exact binomial methods information on sociodemographic characteristics was computed from data in the 2000 census 8 specifically we extracted data for gender education and employment from the total population of african american andor black residents who were at least 18 years of age and created dichotomous variables for these characteristics that were conceptually similar to those that were obtained during the baseline telephone interview information on marital status was not available specifically for african americans therefore we used the percent married for all residents in west and southwest philadelphia we then conducted chi square tests of association to evaluate the relationship between participation in risk counseling and sociodemographic characteristics perceived risk variables selfefficacy and behavioral motivations all statistical tests were performed at the alpha 005 level and were two sided results a total of 285 individuals selfreferred for participation in the study most of the individuals who participated in risk counseling were recruited from newspaper advertisements that were placed in a free regional circular table i shows the bivariate analysis of participation in risk counseling there were no differences in participation in terms of gender marital status education income perceived risk or motivation variables there were also no differences between participants and nonparticipants in bmi or selfefficacy however individuals who were unemployed were significantly more likely to participate in risk counseling compared with those who were employed table iii shows the characteristics of our study sample compared with african american residents in west and southwest philadelphia consistent with the characteristics of community residents our sample included more females than males and the proportion of men and women who participated in risk counseling was consistent with the percentage of male and female residents in addition a comparable proportion of risk counseling participants were not married relative to community residents however our sample included a greater proportion of individuals who only had a high school education relative to community residents discussion the purpose of this study was to evaluate whether participation in a health promotion program that was offered as part of an academiccommunity partnership for cancer and cardiovascular disease differed based on sociodemographic factors and psychological variables in a communitybased sample of african american men and women we also evaluated the extent to which our sample was demographically representative of our target community although a benefit of cbpr is that it may increase the relevancy of studies and overcome barriers to participation such as mistrust 67 the rate for participating in the risk counseling intervention c h halbert et al offered in the present study was modest however our participation rates were greater than those reported in other research that did not use a cbpr framework for instance only about 50 of african american women participated in a cancer risk counseling program that was offered as part of a genetic counseling research protocol 10 and attendance at a breast health and weight loss intervention ranged from 41 to 55 among african american women 17 we did not find differences between participants and nonparticipants based on bmi or psychological factors and participation in the program did not differ based on gender martial status education or income however individuals who were unemployed were significantly more likely to participate in risk counseling compared with those who were employed this could be because individuals who are not working have greater african american participation representativeness communitybased participatory research availability the counseling sessions were offered during a weekday evening thus it may be important to offer health promotion programs at other times such as on weekends and at other locations in the community in order to provide greater opportunities for participation among individuals who are employed alternatively individuals who were unemployed may have been more receptive to the financial incentive that was provided following completion of risk counseling previous reports have shown that financial incentives are effective at increasing response rates among female residents in minority zip codes 18 similarly giving potential participants a prepaid incentive along with promising an additional amount for retention led to equal enrollment rates among gender and racial groups in a study that evaluated enrollment in an online program for heath behavior 19 it is important to note that differences in participation based on employment status did not affect the representativeness of the sample for this variable this suggests that differences in participation based on sociodemographic factors may not necessarily affect the representativeness of the sample with a few exceptions our sample was comparable to community residents in terms of sociodemographic factors we found that a greater proportion of our sample only had a high school education compared with the proportion of community residents who only had this amount of formal education this finding could be the result of using nonrandom methods to recruit participants and may be a reflection of the characteristics of individuals who read free circulars attend health fairs or are responsive to flyers posted in community locations although we did not compare participation in the program based on recruitment source our findings suggest that it is important to use recruitment strategies and sources that are likely to reach potential participants who are diverse in terms of sociodemographic characteristics and comparing the effects of these approaches in future research 20 in considering the results of this study some limitations should be noted first our participation rates may not be comparable to those in health promotion programs that involve multiple visits and have more complex study procedures in addition we provided a financial incentive for participating in risk counseling nevertheless our study provides novel insight on the outcomes of using nonrandom communitybased approaches to recruit african americans in a specific community context because of the challenges associated with recruiting african americans to participate in health promotion research investigators are likely to use a number of different strategies to reach accrual goals these approaches are likely to have some benefits as well as limitations our findings demonstrate that census data reflect information on the percent married for all residents in west and southwest philadelphia we determined the percent not married based on this information according to census data 34 of residents in west and southwest philadelphia are married using this information we determined that 66 were not married p value for the exact binomial test is the probability that observed risk counseling prevalence is equal to the prevalence in community residents the target population c h halbert et al nonrandom methods are likely to yield a sample that is mostly representative of the larger community from which it was drawn furthermore there is not likely to be systematic participation bias based on most sociodemographic or psychological factors future studies should identify strategies that are most effective in terms of recruiting representative samples and those that yield a high participation rate conflict of interest statement none declared

when using communitybased participatory methods to develop health promotion programs for specific communities it is important to determine if participation differs based on sociodemographics and the extent to which program participants are demographically representative of the target community especially when nonrandom recruitment methods are used we evaluated rates of participating in a health promotion program among african american residents in an urban community and determined if program participants were representative of community residents in terms of sociodemographic factors while participation in the program was modest participation did not differ based on psychological factors or body mass index however individuals who were unemployed were significantly more likely to participate in the program compared with those who were employed our sample included a greater proportion of individuals who only had a high school education compared with community residents but was similar to community residents in terms of gender marital status and employment

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introduction in recent years sugar has supplanted fat as public enemy number one in public health campaigns against a range of noncommunicable diseases for example in 2015 the world health organisation identified sugar as a key factor in ncdrelated deaths with high intakes of free sugars i associated with poor dietary quality obesity and risk of ncds free sugars the report explains contribute to the overall energy density of diets and may promote a positive energy balance as well as contributing to widespread dental disease globally the 2015 report by public health england sugar reduction the evidence for action reprises this theme claiming that consuming too much sugar and too many foods and drinks high in sugar can lead to weight gain which in turn increases the risk of heart disease type ii diabetes stroke and some cancers it is also linked to tooth decay obesity looms large in these warnings as a disease as a cause of other diseases and as a visible proxy for health status the who recommended a reduction of the intake of free sugars to below 10 of total energy intake with a conditional recommendation of a reduction to 5 following the recommendation of the uk scientific advisory committee on nutrition phe opted for the 5 target noting that this is a significant reduction from current mean intakes of 1215 sugar figures in these documents as a specific and urgent public health threat about which something must be donean urgency which echoes the familiar justificatory rhetorics of the war on obesity and which mayes describes in his analysis of the concept of lifestyle as activating a range of strategies to protect and secure the population as the phe report notes this is the first time sacn has made a recommendation to minimise consumption of a specific food and its importance must not be underestimated the expectations for the benefits of sugar reduction are high including the reduction of the burden of disease and its associated health care costs and quality of life improvement it is also anticipated to reduce inequalities since the lowest income groups suffer the highest burden of sugarrelated diseases and have the highest intakes of sugar in their diets a claim that reinforces the linking of social disadvantage with behaviours rather than structural inequalities in the rush to intervene the report reminds us emphatically any significant progress to reduce sugar intakes would yield benefits this policylevel focus on sugar provides the backdrop for a burgeoning field of antisugar advocacy and advice for example the public health programme change4life funded by the uks department of health urges readers to be sugar smart listing a series of food smart swaps and tips for reducing sugar intake as well as links to a tracker app that enables users to scan in bar codes to calculate sugar content action on sugar comprised of health professionals and other related experts serves as an information and advocacy hub particularly in relation to food industry regulation and hosts an annual sugar awareness week and sugarwise advocates for increased low or nosugar options tax reductions for low sugar foods and offers a branded certification for products low in free sugars these interventions are oriented towards the reduction of total sugar consumption in line with the phe recommendations but they also provide the context for the dramatic proliferation of popular texts websites and business ventures oriented towards abstention from sugar drawing on a range of published sources this paper explores what it means to give up sugar in this moment of antisugar urgency this is not intended to be an exhaustive analysis of the extensive genre of sugar abstention narratives but rather using high profile texts as exemplars the paper aims to draw out the key themes and explore their implications in the wider context of the attack on sugar as such the texts focused on here are the most commonly visible at the time of writing as identified via online searches and the crossreferencing of key texts and antisugar advocates between narratives the analysis takes a discourse analytic approach treating texts as actively doing rather than describing and asking what those texts are trying to achieve and how based on this analysis the paper explores what it means to give up sugar in this moment of antisugar urgency by focusing on three intersecting but divergent modes of sugar abstention evangelical experimental and charitable through an analysis of these three modes of abstention this paper argues that sugar is far from only being a source of empty calories and its consumption or abstention is never simply a question of objectively knowable health instead drawing on insights from critical nutrition studies and fat studies both of which raise critical questions about normative understandings of foodbody relations sugar emerges as an overdetermined node for social and medical anxieties about 21 st century health bodies and consumption furthermore it is a site of privileged selfactualisation through which some can demonstrate bodily discipline and deserving citizenship and accrue social and economic capital while others are excluded and rendered abject this highlights the ways in sugar abstention is not only embedded in social inequalities but actively reproduces them the next section of this paper interrogates the extent to which the attack on sugar can be understood as a new departure arguing that it is both inextricable from the more established demonization of fat and its conventional nutritional wisdoms and a crisis of its time this status as both continuous and novel creates the conditions for the selfentrepreneurial potential of giving up sugar the remainder of the paper looks in turn at the three abstention narratives drawing out points of intersection and divergence before addressing the inequalities upon which sugar abstinence is premised whats new about the rush to sugar the focus on sugar marks a shift from the prevailing wisdoms of the 1960s onwards and consolidated through the work of researchers like ancel keys that it is fat and particularly in its saturated formthat underpins the increase in costly health conditions that are deemed to be hampering productivity and stretching health services to their very limits however the accusatory turn to sugar is not a consecutive shift from one food enemy to the next but rather gains purchase through a series of nutritional and health continuities firstly sugar never completely escaped suspicion during the lowfat hype and the empty calories of sugary foods have consistently been understood popularly and by health professionals as potentially contributing to obesity conversely mainstream dietary advice even while treating sugar as an urgent threat maintains a commitment to limiting the consumption of fat and especially in its saturated form this was exemplified by the response in 2016 to the national obesity forums release of the report eat fat cut the carbs and avoid snacking to reverse obesity and type 2 diabetes following the evangelical logics of the lowcarbohydrate highfat movement the report argued controversially that prevailing dietary wisdoms are the product of flawed science and the corruptive influence of the food industry that saturated fat consumption is not related to heart disease that full fat dairy may protect against obesity and that the optimum sugar consumption for health is zero a british medical journal editorial described the report as oversimplistic and flawed in its assumptions and use of evidence while public health england and the british dietetic association respectively denounced it in the media as irresponsible and extremely dangerous in its forgiving approach to saturated fat sugar and fat then exist in relation to each other rather than as consecutive threats to health they also continue to occupy the same antiobesity territory characterised by an imprecise hostility to fatness as a threat to individual and populationlevel health and as constituting an urgent need for action which places responsibility on individual choices and behaviours rather than structural change a second continuity lies in the embeddedness of the antisugar movement in the established nutritionist paradigm relying on a reductive focus on the nutrient composition of foods as the means for understanding their healthfulness as well as by a reductive interpretation of the role of these nutrients in bodily health in particular the contemporary attack on sugar reflects what scrinis calls the era of goodandbad nutritionism this is exemplified by the focus on fat that gained momentum in the 1960s and marks a shift from the concerns around malnutrition that drove 19 th and early 20 th century efforts to quantify the nutritional content of food towards anxieties around overconsumption this led to nutritional binaries of good and bad foods resulting in a focus in dietary messages on what not to eat these single nutrient proscriptions as with all nutritionism are based on the decontextualization simplification and exaggeration of the role of nutrient in determining bodily health to the exclusion of questions of food quality or the combination of foods with which the problematized nutrient is consumed this is particularly true in the case of sugar which is rarely consumed in isolation and yet is the focus of a sustained singlenutrientfocused reduction campaign despite the continuities evident in the rush to sugar it is also a crisis of its time this is particularly evident in relation to changing understandings of the body characterised by the emergence and dominance of scientific practices technologies and theories that conceptualize and conduct the surveillance of the human life at the molecular level according to rose the molecularisation of the body marks a departure from molar conceptualisations of the body at the scale of limbs organs tissues flows of blood hormones and so forth looking instead towards molecules such as dna to define human difference and to inform futureoriented understandings of bodies at risk and in need of healthmaximising intervention this is not to argue that biomedicine and health care no longer operate on the molar scale indeed according to rose this is how most people continue to imagine and act upon their bodies this is particularly the case for obesity for example where internal and external body fat clogged arteries and damaged organs serve under the clinical gaze as the visible evidence of healthdamaging effects of bodily excess however obesity is also increasingly conceptualised as a metabolic disorder that is as a disorder of the biological processes by which bodies metabolize nutrients derived from food and which can only be diagnosed via an aggregation of clinical and laboratory measurements the turn to sugar aligns with this molecularisation unlike the action of fat which is easily imagined settling on the body as fat in visible ways sugar is understood as acting in the body in ways that are largely invisible to human observation without the mediation of technologies of measurement and their associated biomarkers this invisibility also exacerbates the invidiousness of the risk that attaches so easily to the consumption of sugar anybody can be at risk and not know it as popular antisugar author robert lustig warns menacingly you think you are safe you are so screwed and you dont even know it this invisible threat to health is also compounded by the invisibility of sugar itself which is conceptualised within antisugar rhetorics as hidden in everyday processed foods and requiring constant vigilance the compulsion to understand and manage risks to health lies at the heart of the moralisation of health that crawford described as healthism and he argues that the early 21 st century has seen an intensification of this health consciousness and the moral imperative to achieve health and manage risk the ubiquity of mass media the commercialisation of health products and services the expansion of professional health promotion increased awareness of environmental hazards and the growth of technologies for detecting risk factors all converge to aggravate insecurities around health at the same time this reinforces the ideological conviction that health can be accomplished through the exercise of individual responsibility and selfcontrol this combination of competing and coincident nutritionist conceptualisations of food and health the molecularisation of the body the proliferation of risk and the intensification of the imperative to health consciousness collectively provide fertile ground for concerns about sugar in ways that make giving it up meaningful in contemporary society both the continuities and novel intensifications in the contemporary attack on sugar exemplify what hayesconroy and hayesconroy call hegemonic nutrition this is a repressive approach which is characterised by attempts to standardise and quantify the foodbody relationship for distillation into universalised dietary prescriptions a reliance upon reductionist understandings of nourishment the decontextualisation of food and its consumption and a commitment to a hierarchical knowledge system that privileges expert knowledge these attributes also reflect the persistent reproduction of health as a transparent universal good and of obesity as selfevidently incompatible with health in ways that erase not only the complex social and cultural configuration of both health and obesity but also their potent moral charge this paper explores what goes missing and to what effect when sugar is so closely defined by normative discourses of health and nutrition in doing so the aim is not to arbitrate between different degrees or strategies of sugar reduction but rather following hayesconroy and hayesconroys challenge to hegemonic nutrition to change the rules of the game and who is playing them giving up sugar the act of giving up sugar begins from the understanding that it is simultaneously bad and alluring that its allure is part of its badness and that giving up sugar will be both challenging and elicit rewards images of illicit drug addiction abound it is pure white and deadly but compellingly soothing and pleasurable this image is bolstered by sugars association with other potentially addictive substances such as alcohol and caffeine and the familiar experience of craving more of a sugary food gives further commonsense weight to the metaphor while there is some evidence from animal studies that rodents can become sugar dependent the jury is out on whether sugar is addictive for humans westwater fletcher et al for example argue that studies of the neurochemical effects of sugar do not support the case for sugar addiction and even the most determined to connect sugar with addiction particularly in an antiobesity context acknowledge the limitations of this approach nevertheless sugar addiction remains a very popular and powerful idea particularly in lay understandings which in turn reinforces the framing of giving up sugar as a heroic act of healthful overcoming and good citizenship however as exemplified by the three modes of sugar abstention discussed below the act of giving up sugar can take multiple forms incorporating diverse chronologies and intensities of abstention and differing understandings of what counts as sugar and the threats that it poses this in turn generates diverse selfentrepreneurial possibilities and exclusionary effects evangelical abstention the most vociferous of these modes is what i have labelled evangelic abstention this refers to the active and often impassioned promotion of sugar abstention usually via commercial products and services through the mobilisation of a dietary philosophy and practice that gleans its authority from the strategic deployment of personal experience scientific and medical discourse and the rhetorics of antiobesity and addiction the thriving market in lowcarbohydrate and paleoinspired diets exemplifies this mode of abstention these diets do not constitute a unitary programme with each struggling to articulate a unique approach to secure a larger portion of the market nevertheless they share a contempt for the fat body and they repudiate not only free sugars but also carbohydrates more generally as metabolically destructive and unsuited to how we are meant to eat instead they look nostalgically back to an illdefined preagricultural paleolithic huntergatherer era where humans thrived on diets high in animal protein and fats they mobilise the rhetorics and authority of science to articulate an angry critique of conventional highcarbohydrate lowfat nutritional advice which they hold as culpable for rising obesity rates and its presumed health consequences there is also a burgeoning field of abstention evangelists who focus their attentions specifically on sugar these texts typically expound a personal narrative of dietary conversion set out their dietary philosophy and then offer a howto section including psychological strategies and menu plans with the intention of converting readers to the sugarfree path these are often also gateway texts to paywallprotected online resources services and communities for acolytes these authors distance themselves from the lowcarbohydrate and paleoinspired diets as unnecessarily restrictive while sharing considerable common ground in terms of the evangelical strategies that they employ appeals to science and the display of scientific competence are fundamental to evangelical abstention laying claim to an authoritative platform from which to challenge mainstream dietary advice these appeals operate not as a critique of science per se but of what they see as a corrupt and flawed scienceinpractice subject to the corruptive influences and desires of politics and big business in their study of the swedish lchf movement gunnarsson and elam describe advocates as inventive popularisers of science who have succeeded to some degree in turning a conventional tool of incumbent scientific authority into a weapon to be turned back against this authority as jauho observes in his study of lowcarb dieters narratives of science these are invitations to a social construction of competencediscursive moves which not only legitimate a dissenting position but also construct an identity through the appropriation of the symbolic cultural capital afforded by the command of the scientific idiom to be an antisugar evangelist then is to engage in this critical work albeit selectively for example the core claims of the war on obesity that equate fatness with illhealth are never subject to the same degree of interrogation to the exclusion of the extensive fat studies literature challenging those assumptions this prized scientific literacy is facilitated by two different kinds of key translators the first group are predominantly white male scientists who speak with professional authority and offer up digestible accounts that are intended both to persuade and to enable individuals to become lay experts in their own right these are exemplified by science writer gary taubes sports and nutrition scientist tim noakes nutrition and exercise physiologist loren cordain and paediatric endocrinologist robert lustig these figures take pride in their status as dietary heretics and iconoclasts who challenge mainstream nutritional science with science itself with texts repeatedly returning to tales of persistence in the face of professional exclusion and persecution opposition only affirms their world view and is mobilised as evidence of the validity of their courageous truthtelling for example in 2013 noakes published an article in the south african medical journal based on selfreported weight loss among new lchf dieters presented as a series of case studies the paper attracted vociferous criticism for its lack of scientific rigour but for noakes this simply served as confirmation arguing if i was totally wrong nobody would have made much of a fuss the second kind of antisugar translator comes in the form of nonscientists who position themselves as autodidacts and entrepreneurs often across an array of selfimprovement platforms this is exemplified by david gillespie whose website describes him as author speaker entrepreneur and journalist and wellness entrepreneur sarah wilson gillespie is a former corporate lawyer and cofounder of a software company and has written books on food education and the psychology of the workplace his website quotes a courier mail description of him as a polymath an oldfashioned renaissance man who finds few things dull and everything else interesting his selfnarrative then is not one of established scientific expertise but as a truthseeker and mythbuster in sweet poison which is credited on his website as driving the contemporary wave of sugar awareness in australia he takes pride in being one of those people who cant leave a problem alone educating himself about the science in his quest for understanding he describes himself as having to look up every second word in the journals he ploughed through in preparing for the role of persuasive intermediary concluding i wont bore you with the detail of all the false starts and blind alleys but here is what i discovered in the absence of professional scientific expertise his role as evangelical translator gains endorsement from experiential knowledge based on his own significant weight loss after giving up sugar in the same vein wilson proudly declares that she is not a whitecoated scientist and offers a similar narrative of selfentrepreneurial seeking to that of gillespie i interviewed dozens of experts around the world and did my own research as a qualified health coach i experimented using myself as a guinea pig and eventually assembled a stack of scientifically tested techniques that really worked then i got serious and committed i chose there is significant overlap between evangelical and experimental abstention narratives antisugar evangelists and particularly those whose lack of scientific credentials requires them to draw more heavily on experiential accounts to authorise their position commonly open with narratives of selftransformation born out of experimentation for example gillespie describes trying numerous diets including paleoinspired plans without sustained success before losing 40 kilos by giving up sugar and sarah wilsons account of the i quit sugar brand locates its origins in a twoweek experimental sugar abstention intended as material for a newspaper column conversely the recipes and tips for sugarfree living that conventionally append experimental abstention narratives are implicitly evangelical however there are two key differences between evangelical and experimental narratives firstly for the evangelists the experimental period provides the foundational narrative for the subsequent explanations advice and recipes that constitute the main body of their books websites and commercial services however for the experimental abstainers the period of abstention itself is the primary focus gillespie makes this explicit in his foreword to schaubs year of no sugar describing his own book sweet poison as a translation of the science rather than an experiential account schaubs book he argues is the diary i wish i had kept the second key difference lies in their relationship to narratives of science published experimental abstainers such as nicole mowbray and eve schaub not only occupy positions outside of conventional scientific authority but also take pride in it and make only passing efforts to grasp translate and communicate the nutritional science consequently while popular antisugar science translations such as robert lustigs youtube lecture sugar the bitter truth which has been viewed over 7 million times are common touchstones in experimental narratives and serve as proxy expertise the problem of sugar is assumed and the authors primary authority is derived instead from their everyman status and their accumulated experiential knowledge for example journalist mowbray describes herself in her memoir sweet nothing as a normal woman in my early thirties and the back cover of schaubs year of no sugar describes the experiment as being about a real american family the implication is clear and is made explicit in mowbrays concluding evangelical sentence if i can do this anyone can charitable abstention both the evangelical and experimental abstainers narratives are oriented towards permanent behaviour change either through ongoing strict avoidance of sugar or in a moderated version once released from the rigours of the experimental period for example schaub concludes by describing herself as transitioning postexperiment to being a sugar avoider rather than a sugarphobe and carpenter following her familys 30day sugar free challenge concludes that although she is committed to reducing the amount of sugar consumed by her children she is certainly not going to be a militant antisugar mother she is sugaraware rather than permanently sugarfree charitable abstention on the other hand refers to purposefully provisional periods of abstinence that can be traded for sponsorship for example in february 2017 cancer research uk hosted a sugar free february fundraiser and in march 2017 the british heart foundation launched its dechox challenge where participants were invited to publicly renounce chocolate in exchange for donations this latter is not explicitly about sugar but the campaigns survival kit includes a how much sugar section with teaspoons of sugar arrayed next to common chocolate foods making it clear where the problem of chocolate lies charitable abstention is founded on the premise that sugar is both difficult to resist and bad and that giving up sugar constitutes a form of laudable suffering and a demonstration of willpower that warrants reward as the sugar free february fundraising information sheet declares scrapping the sweet stuff for a whole month is no easy task so dont be shy about asking friends family and workmates for sponsorship you deserve it the programmes lack any significant explanation of the threats to health posed by sugar that are evident in other modes of sugar abstention but the selfsacrificial act of charitable sugar abstention remains potently coded as an investment in healthboth for the abstaining individual and for the future patients who will benefit from research as the dechox website asserts your dechox saves lives and the sugar free february website promises not only will you make a huge difference to your health but youll also help fund lifesaving research to beat cancer sooner this creates a winwin scenario whereby sociallysanctioned investment in the self through activities coded as healthy operates as a means of caring for others serving as an exchange that in its ideal form creates beneficial outcomes for all parties this is not to argue that participants are not altruistically motivated in their charitable endeavours or that their donations are not meaningful to the recipients of those funds instead charitable abstention from sugar should be understood as always more than altruism or creative altruism in titmuss terms facilitating selfactualisation alongside benefits to unknown others significantly charitable abstention can only be realised through other forms of consumption through which compassion and selfdiscipline can be displayed for example through the purchase of branded goods or the display of social media badges or downloadable posters the sugar free february fundraising information sheet even advises hosting a night where you let your friends indulge themselves and they donate to support your steely determination the playfulness of this performance of nonconsuming consumption highlights the ways in which charitable abstention does not require any fundamental rejection of sugar and instead sugar is being mobilised as a vehicle for displays of sponsorshipearning sacrifice and suffering it is the socially legible act of healthful giving up that is the site of selfentrepreneurial work rather than sugar per se this is illustrated by the other abstention campaigns running alongside those involving sugar for example cancer research uk also hosts an annual alcoholfree january dryathlon where participants can become dryathletes in exchange for sponsorship the inequalities of giving up sugar these three modes of sugar abstention differ in philosophy chronology and intensity but all share the conviction whether explicitly or implicitly that sugar is bad and that to give it up is a positive act they also share the conviction that to give up sugar says something about the kind of person that you are evangelical abstainers lay claim to qualities of scientific literacy and independence of thought alongside the good citizenship of selfcare experimental abstainers learn through experience and demonstrate determination and the willingness to exercise control over their lives and health and charitable abstainers show compassion while investing normatively in the self in contrast to the familiar rhetorics of emptiness that attach to sugar these entrepreneurial projects of selfhood highlight the ways in which sugar is laden with meaning and significance and provide a means through which the embodied individual can be known however these abstention narratives are premised on what guthman calls a neoliberal antipolitics and the price of selfactualisation is the erasure of the vast social environmental and economic inequalities that underpin both the consumption of sugar and the act of giving it up the white middleclassness of the world of sugar abstention is fundamental to this depoliticisation its primary advocates are scientists journalists and entrepreneurs already occupying powerful platforms from which to speak and be heard with lower social positioning and nonwhiteness acting as signifiers of poor choices and as sites for coercive state interventions this is demonstrated in lustigs landmark popular antisugar text fat chance the hidden truth about sugar obesity and disease sixteen of the books chapters open with short illustrative case studies of children six of which focus on nonwhite children the ethnicity of the nonwhite children is noted in the case studies alongside potent markers of their social status for example the book opens with the case of juan a 100pound sixyearold latino boy whose mother is a nonenglishspeaking farm worker from salinas california whiteness is not explicitly marked sally is a beautiful thirteenyear old girl but more significantly while the nonwhite cases report incidences of poor parenting and illinformed food choices obesogenic medical conditions such as hypothalamic tumours genetic defects and abnormally high insulin release account for 6 out of the 10 white childrens narratives furthermore while all but one of the white children achieve positive outcomes only one nonwhite cases achieves resolution even in this case while the white childrens successes are the result of successful medical interventions and informed parentallyenacted lifestyle changes salvation for 11yearold africanamerican deshawn only comes after child protective services become involved forcing his mother to face up to her own sugar addiction with mothers figuring as the primary carers in the case studies an implied model of good and bad dietary citizenship emerges along racialized classed and gendered lines and the selfactualising potential of sugar abstinence that is enjoyed by popular antisugar advocates is beyond their reach the middleclassness of giving up sugar is also evident in the nonsugar dietary recommendations with a focus on locallyproduced and homecooked whole food this reflects a wider trend in the alternative food movement and presumes not only the accessibility and affordability of a wholefood sugarfree diet but also the time and capacity to shop for and prepare food this is exemplified in the documentary film the big fat fix which makes the case for the lchf diet in the film cardiologist aseem malhotra and irish exprofessional athlete donal oneill feature in a lengthy segment filmed in oneills adopted home of cape town in south africa where we see them shopping for and consuming grassfed meats artisanal cheeses and organic olive oils in a strikingly white middle class social milieu and without any acknowledgement of the multiple privileges that facilitate that consumption in contrast mowbrays experimental abstention narrative acknowledges the time and financial costs involved in maintaining her new albeit relentlessly middleclass sugarfree lifestyle declaring that now my life needed planning and recalling that my bank balance was groaning under the strain of all the fresh produce i was loading up on however towards the end of the book amidst an evangelising account of the sugarfree life as an opportunity to expand food horizonsbuckwheat groats cocoa nibs emerald green richbuttery tasting queen olives the size of walnuts she denies the added expenses as an obstacle if you cant afford organic meat buy free range if you cant afford free range buy what you can afford the privileged economies of shifting from organic to free range overlook the lived realities of food poverty and instead render a healthy diet the product of simple household economy evans et al note the same assertion at work in a strategy document for the uks change4life which refutes the myth of cost as a barrier to healthy eating with the claim that you just need to be clever about it this framing reduces diet to a matter of informed choice and clever management effecting a depoliticisation of the production and consumption of food in the case of sugar this positions those assumed to consume high levels of sugary food and drinks as feckless citizens always marked by gender race and class obscuring the social inequalities that underpin practices coded as unhealthy including sugar consumption this includes the erasure of greater health risks that might make sugar consumption the lesser evil in the face of more immediate threats to health such as hunger or violence for example otto describes the case of a native alaskan woman who was putting soda in her babys bottle despite extensive health campaigns to the contrary the soda quieted the baby explained the mother because if he cries when his uncles come in theyll beat him these inequalities open up a gulf between those who can give up sugar as part of a profitable project of selfactualisation and those whose abstention must be coerced this is exemplified by calls in the us to prevent recipients of supplemental assistance nutritional programme from using their food stamps to buy sugary drinks even though research shows that their soda purchases are in line with those of nonsnap households the focus on sugar as the primary threat to health in these campaigns renders invisible issues that targeted disadvantaged groups themselves might identify as priorities for their own wellbeing such as employment or racism the social rewards of sugar abstention then are a privileged preserve and the social significance of giving up sugar lies in its display of informed voluntariness and the demonstrable exercise of selfcontrol enacted in direct opposition to those who must be nudged or coerced into abstention or reduction crawford argues that selfcontrol is a pillar of middle class identity employed as a shield against downward mobility operating as the foundation of dividing practices that attempt to achieve immunity not only from threatening disease but endangering others health he argues is the language of class and this is exemplified by sugar abstention which draws a classed boundary between the good citizenship of the abstainer and the perilous overconsumption of the chaotic consumer of sugar this is premised on the exclusion of the social and environmental inequalities that delimit access to healthful food and foodways in favour of the individualised acts of informed selfcontrol through which the good sugardenying citizen is fashioned conclusion this paper has explored the ways in which sugar has become a 21 st century dietary nemesis with its empty calories and deleterious metabolic effects held culpable for a panoply of expensive and debilitating noncommunicable diseases the rise of antisugar campaigns at the global and national levels and the sedimenting of antisugar sentiment in the public domain has created fertile ground for the burgeoning genre of popular sugar abstention narratives by focusing on three different modes of sugar abstentionevangelical experimental and charitablethis paper has explored the ways in which far from being empty sugar is laden with social meaning emerging as an overdetermined node for contemporary anxieties about health consumption and selfhood and a privileged site of identity production and selfentrepreneurship that far exceeds any perceived health benefits the social benefits of sugar abstention have been shown not only to accrue to those already occupying privileged social positions but also to actively reproduce those social hierarchies by dislocating the act of giving up sugar from the social economic and environmental inequalities in which it is embedded this dislocation can be understood as the combined outcome of the nutritionism inherent in the positing of a singlenutrient solution to complex health and social problems and of healthisms conflation of practices of selfcare with good citizenship and empowerment this framing enables those who are already privileged to capitalise on that privilege through selforiented projects of consumption and displays of informed selfcontrol in ways that have been rendered legible by the demonisation of sugar in health policy and practice this simultaneously reproduces class boundaries in ways that render invisible the vast inequalities in access to food health care and safe healthful environments that characterise the lives of those who are excluded from the selfentrepreneurial possibilities of sugar abstention selfcongratulatory accounts of giving up sugar therefore operate both as the display of privilege and the means of its reproduction and entrenchment as guthman argues in relation to the alternative food movement it is this selfcongratulatory aspect that is perhaps most consequential for social justice since it limits what is put on the table politically with this warning in mind this paper signals the need to resist the rush to intervention and instead to think more inclusively not only about what can be brought to the table but also who is invited to join or indeed initiate those discussions this it is also an invitation to dethrone health from its position of false neutrality by thinking critically about the way it is mobilised in the attack on sugar and to what means and ends to leave the task of articulating the problem of sugar to those already best positioned to accrue capital through its repudiation is to risk exacerbating health and social inequalities rather than ameliorating them i this terminology follows the 2002 joint who fap expert consultation on diet nutrition and the preventions of chronic diseases free sugars includes all monosaccharides and disaccharides added to foods by the manufacturer cook or consumer plus sugars naturally present in honey syrups and fruit juices

sugar is increasingly supplanting fat as public enemy number one in public health campaigns and calls for significant reductions in consumption have provided fertile ground for the proliferation of popular texts and services advocating sugar abstention this paper explores three modes of popular sugar abstention evangelical experimental and charitable these vary in chronology philosophy and the intensity of abstention but all serve as sites of identity production and selfentrepreneurship for those able to advocate for and engage with them the paper argues that these abstention narratives are not only premised on the exercise of social privilege but that they also necessarily reproduce and sediment those social hierarchies this is achieved through a combination of nutritionism and healthism dislocating sugar and its consumption from the vast social economic and environmental inequalities within which both the consumption of sugar and the act of giving it up is made meaningful

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introduction the outbreak of coronavirus disease has undoubtedly raised worldwide concerns on march 11 the world health organization officially declared covid19 as a pandemic pointing to the sustained risk of further global spread as the new epicenter of the covid19 there had been 4405932 cases and 150283 deaths in the us by july 30 2020 according to the centers for disease control and prevention they accounted for 262 and 227 of the global statistics as the covid19 pandemic progresses social distancing one of the nonpharmacological control measures to reduce persontoperson contact has emerged as an effective measure to restrain the spread of infections studies discovered that the considerable mobility reduction following the implementation of social distancing measures is greatly responsible for the reduction of the transmission of sarscov2 the virus that caused the covid19 pandemic however the disproportionate responses in mobility due to the different socioeconomic status reflects the longstanding disparities in health outcomes and potentially leave more vulnerable populations uniquely exposed to the covid19 pandemic the investigation of inequality and disease is not new in literature as many pieces of epidemiological evidence that prove a robust relationship between social inequality and health outcomes have been found income particularly as one of the major factors in socioeconomic status is responsible for the noticeable disparities in the exposure of many diseases for the covid19 pandemic barnetthowell and mobarak found that the epidemiological and economic benefits of social distancing are much smaller in poorer countries as the poor place relatively greater value on their livelihood concerns compared to contracting covid19 a recent study by nayak et al links the socioeconomic vulnerability with mortality rates in us counties they find that counties with higher social vulnerability are experiencing greater mortality rates by investigating the role of income inequality in moderating the effectiveness of social distancing measures chiou and tucker find that highincome earners are more likely to selfisolate at home and the evidence further suggests that the presence of highspeed internet plays an important role what makes things worse is that the existing incomeinduced disparities in the responses of covid19 tend to be exaggerated by the recognized shortcomings of the us protection measures potentially causing longterm negative outcomes for the lowincome populations despite the above efforts multisource and multiscale evidence is still needed to understand whetherhow the wealthy and the poor populations respond to the covid19 pandemic differently existing research has suggested that the disproportionate exposures to the risk from the covid19 between the lowerincome and upperincome groups can be properly measured using the human mobility data given the close relationship between human mobility and the transmission of sarscov2 since the outbreak of covid19 many mobility data sources have been made available to facilitate rapid monitoring in human mobility most notably google mobility report derived from google maps and apple mobility report derived from apple maps in addition to the mobility data collected from cellphone navigation applications mobile network operators start to collaborate with local authorities and the federal government to estimate the impact of mobilityreducing related measures one notable effort is by descartes labs a platform that has opensourced the daily mobility statistics in the us collected via mobile devices as a more harmonized and less privacyconcerning data source social media data are also favored by many scholars to study the mobility dynamics during the covid19 pandemic given the existence of publicly available mobility datasets from various sources understanding their similarities and dissimilarities is in great need owing to the multifaceted nature of human mobility however neither cellular records navigation applications nor social media can solely represent human mobility as a whole instead they reflect human mobility from varying yet valuable perspectives linking these perspectives with economic disparities contributes to a better understanding of the mobility dynamics of groups with different socioeconomic status in response to the covid19 pandemic in this study we aim to examine 1 the similarity and dissimilarity of mobility from various sources and 2 the luxury nature of social distancing in the us during the covid19 pandemic by highlighting the disparities in mobility dynamics from lowerincome and upperincome groups we collect and compute mobility data from a variety of sources including google and apple mobility reports descartes labs mobility and twitter to quantify the general degree of mobility changes at the county level we designed a responsive index via the time series of mobility change percentage using the sources above specifically we attempt to answer whether a consensus can be reached from various mobility sources that the lowerand upperincome groups present contrasting mobility dynamics during the pandemic eventually leading to disproportionate exposures that disfavor the lowerincome group our study extends the increasing amount of literature in understanding disparities via big mobility data the findings of this study help us gain knowledge of not only the similarities and dissimilarities in multisource mobility data but also the wealth disparity in tandem with the implementation of social distancing greatly benefiting epidemic modeling and policymaking for better mitigation of future pandemics mobility datasets and preprosessing we collect and compute four opensource mobility datasets that cover the us which include 1 mobility records from descartes labs using commercially available mobile device dataset 2 apple mobility reports mainly from apple maps 3 google community mobility reports mainly from google maps and 4 twitterbased mobility from geotagged tweets the finest spatial level of the mobility data from descartes labs apple and google is the us county level given that the us national emergency was announced on march 13 and the majority of the us states started to react aggressively after midmarch we present the daily mobility change percentage from march 1 2020 to june 30 2020 we believe that this fourmonth period well covers different epidemic phases in the us thus providing valuable knowledge of how people react to the covid19 pandemic by adjusting their travel behaviors accordingly although the four mobility datasets in this study differ from each other in terms of data quantity data quality and baseline calculations we apply several preprocessing steps to make them more comparable to ensure that data records are sufficient enough to generate reliable and stable time series of mobility changes we only map the time series for counties with more than 100 days of mobility records to fill the missing data we apply a simple linear interpolation under the assumption that mobility changes linearly between two consecutive available records mobility data from descartes labs the mobility dataset from descartes labs a predictive intelligence company that makes dataagnostic platforms for largescale analysis is opensourced at github and updated daily the data cover a total of 2668 counties among them 2612 counties have mobility records in more than 100 days from march 1 to june 30 the data are derived from a collection of mobile devices reporting consistently throughout the day the distance measured in this dataset is the daily maximum distance of a certain user ie the maximum distance between a users initial location of a day and other locations within the same day the countylevel mobility baseline is defined as the median of the maximum distance of all users in a certain county on weekdays from february 17 2020 to march 7 2020 the mobility change percentage is further calculated by comparing daily mobility to the baseline due to the data quality issues mobility data on april 20 and may 29 are not released to facilitate a smooth time series mapping we generate mobility change percentage on these two missing days for all available counties by averaging the values of the corresponding days in the preceding week and following week that is the mobility change percentage for april 20 is the average value of mobility change percentages on april 13 and april 27 and may 29 is the average of may 22 and june 5 apple mobility reports the raw mobility reports from apple cover major cities and a total of 63 countries and regions unlike descartes labs mobility data that measure the travel distance apple mobility reports are generated by counting the number of requests made to apple maps for directions despite the difference in measurement the daily changes in the number of requests from navigation services like apple maps still offer valuable insights into peoples mobility changes in response to the covid19 pandemic although apple provides mobility records in three different categories that include transit walking and driving only driving is available for the us at the county level apple mobility reports cover 2070 us counties and all the counties have mobility records in more than 100 days in the designated period however data for may 11 and may 12 are not available following the same procedure in the descarte labs mobility we generate mobility data of the two missing days by averaging the corresponding days in the preceding week and the following week in addition apple defines the mobility from january 13 as the baseline value to make it comparable with descartes labs mobility we compute a new baseline value from february 17 to march 7 and use it to adjust the mobility in the entire apple mobility dataset google mobility reports google mobility reports use aggregated anonymized data to chart movement trends over time across six different categories in retail and recreation groceries and pharmacies parks transit stations workplaces and residential although a total of 2794 us counties are covered our investigation reveals that the quantity of the records varies greatly across categories with workplaces having the most records and other categories insufficient for deriving stable time series therefore we select mobility in the category of workplaces for further analysis google defines the baseline of the dataset as the median value for the corresponding day of the week during the 5week period january 3 to february 6 to make it comparable with other datasets we adjust the google mobility records by computing a new baseline value from february 17 to march 7 within 2794 counties covered by the dataset 2110 counties have records in more than 100 days from march 1 to june 30 and are therefore selected to derive the mobility time series twitterbased mobility we have collected about 197 million geotagged tweets in a time period from january 1 2020 to june 30 2020 from over 29 million unique twitter users in the us using the official twitter streaming application programming interface following the work by huang et al we compute two types of distances 1 singleday distance that reveals daily travel patterns and 2 crossday displacement that reveals users displacement between two consecutive days we then calculate a weighted distance of each county by integrating these two distances 𝑑 𝑤 𝑑 𝑠 ×𝑢 𝑠 𝑑 𝑐 ×𝑢 𝑐 𝑢 𝑠 𝑢 𝑐 where 𝑢 𝑠 and 𝑢 𝑐 denote the user counts for the calculation of 𝑑 𝑠 and 𝑑 𝑐 in each county respectively by considering both singleday and crossday distance the weighted distance is expected to reflect the overall mobility dynamics from twitter our investigation suggests that a stable time series can be achieved when the daily user count for the distance calculation reaches 30 within the 2981 counties covered by the twitter dataset 565 counties are qualified for the time series mapping as their daily user counts are greater than or equal to 30 for more than 100 days between march 1 and june 30 following the baseline settings of the aforementioned mobility datasets we compute the mobility change percentage by setting the baseline between february 17 to march 7 methods conceptualization of responsive index the time series of the mobility change percentage from the various mobility sources generally quantify the level of reaction in response to the covid19 pandemic a reduction in mobility denotes the positive response while an increase in mobility denotes otherwise the strength of the response is assumed to be proportional to the degree in mobility changes we use baseline mobility to divide the responsiveness into positive and negative space different from the mobilitybased responsiveness in huang et al we calculate the ratios respectively in positive response and negative response to confine our 𝑅𝐼 into a range of 11 figure 1 describes the concept of the responsive index using time series in mobility change percentage we first smooth the time series using a onedimensional gaussian filter to remove the noises so that the general trend of mobility changes is revealed the baseline divides the space into two parts positive response with reduced mobility and negative response with increased mobility the area between the baseline and the smooth time series is denoted as 𝛼 while space excepts 𝛼 is denoted as 𝛽 in figure 1 where the former ratio quantifies the strength of the positive response and the latter ratio quantifies the strength of the negative response the 𝑅𝐼 we propose is the difference between the two ratios given that figure 1 for the illustration purpose confines the mobility change in a range from 100 to 100 we have 𝑆 𝑃 𝛼 1 𝑆 𝑃 𝛼 2 𝑆 𝑃 𝛼 3 𝑆 𝑃 𝛽 𝑆 𝑁 𝛼 1 𝑆 𝑁 𝛼 2 𝑆 𝑁 𝛼 3 𝑆 𝑁 𝛼 4 𝑆 𝑁 𝛽 in this study however the mobility change percentage is unrestricted from 0 to 100 in the calculation of 𝑅𝐼 generally the 𝑅𝐼 can be calculated via the following equation 𝑅𝐼 ∑ 𝑆 𝑃 𝛼 𝑖 𝑖 ∑ 𝑆 𝑃 𝛼 𝑖 𝑆 𝑃 𝛽 𝑖 ∑ 𝑆 𝑁 𝛼 𝑖 𝑖 ∑ 𝑆 𝑁 𝛼 𝑖 𝑆 𝑁 𝛽 𝑖 our proposed 𝑅𝐼 has a range of 1 1 with 𝑅𝐼 1 suggesting a hypothetically perfect responsiveness positive 𝑅𝐼 suggests that the accumulative response within a specific period of time is positive while negative 𝑅𝐼 suggests otherwise the higher the ri the stronger the accumulative responsiveness a geographic region has comparison of mobility datasets and their association with income in this study we aim to crosscompare mobility datasets from various sources and reveal the linkage between mobility dynamics and income at the us county level as a county is the finest geographical unit in mobility datasets from apple google and descartes let 𝑀𝐶𝑃 𝑗 denote the mobility change percentage of a certain county on day 𝑗 we derive the heat map by plotting all the available pairs ie within the time frame for each mobility dataset in addition we apply the pearson correlation analysis for the four opensource mobility datasets to determine 1 the correlation of the derived countylevel 𝑅𝐼 from each pair of mobility sources and 2 the correlation between county median income estimates and the countylevel 𝑅𝐼 to reveal the disparity in mobility changes between lowerincome and upperincome counties we first rank the available counties in each dataset based on the median income and derive the time series of mobility change percentages respectively for lowerincome and higherincome counties by selecting the median values given the fact that state policies may greatly shape countylevel mitigation strategies we also visualize the statewide disparity in the time series of mobility change percentages and the difference in 𝑅𝐼 for upperincome counties and lowerincome counties within each conus state to remove the potential impact resulting from the statewide policies results comparison of the four mobility datasets in general the impact of the covid19 pandemic is well documented from all four mobility datasets evidenced by the clear deviations in mobility from the baseline since midmarch when the who declared covid19 as a pandemic and the united states declared a national emergency in april mobility from all four datasets descended to the bottom and remained considerably lower than baseline throughout the month with the gradually loosened measures from the opening up america again guidelines the mobility gained an upward momentum and started to bounce back in earlymay resulting in the u shape distribution that can be observed from all four datasets despite the similarity in the general trend mobility from each source presents unique and even contrasting characteristics data from apple mobility trend reports show that mobility in the us had returned to the baseline in midmay and remained above the baseline in the entire june which contradicts the mobility dynamics from the other three datasets where mobility is found not fully recovered to the prepandemic level in may and june this characteristic of the apple mobility dataset can be partially explained by its singleday baseline setting although we adjust apples baseline by extending the baseline temporal coverage the intrinsic monthly discrepancies in mobility between january and other months still exist that is the abovethebaseline mobility in may and june is arguably the exaggeration that results from the low baseline value observed on january 13 compared with march and april the mobility change percentages show a more dispersed distributing pattern in may and june indicating the inconsistency of counties in the recovering phase the dataset from descartes labs also suggests a strong recovery in mobility following the lifting of strict measures since earlymay in comparison to the other three datasets the reduction is more obvious in april evidenced by the high concentration close to 100 in mobility change we investigate the counties with barely any recorded mobility in april and find that they coincide well with the counties that were the epicenter and faced strict stayathome orders the closetozero mobility in these counties can be explained by the data sources which own a more passive nature compared to the data collected via smartphone applications despite the slight recovery in may and june google mobility shows a more concentrated distribution that mostly remains below the baseline throughout the time period suggesting that the recovery of mobility in the category of workplaces is presumably slower than other types in addition the reduction in april from google mobility is relatively less dramatic compared with other datasets our twitterbased mobility dataset reveals a similar reducingandrecovering pattern although its heat map presents a rather scattered distribution largely due to the uncertainties introduced from the limited number of geotagged tweets in certain counties despite the scattered distribution pattern the significant mobility drop in midmarch and the constantly low mobility in april are well captured by the heat map the results from the pearson correlation analysis reveal the similarity in computed countylevel 𝑅𝐼 from these four mobility datasets as expected we find statistically significant positive correlations in 𝑅𝐼 between either two data sources albeit with varying pearsons 𝑟 coefficients google and apple share the highest correlation owning to the fact that both of their mobility records are from navigation applications in smartphones despite the high correlation between apple and google however the correlation between apple and the other two datasets is relatively weak 𝑟 033 for apple and descartes and 𝑟 031 for apple and twitter google and descartes share the secondhighest correlation followed by twitter and descartes and twitter and google the histograms of the four datasets suggest that the distribution of their countylevel 𝑅𝐼 follows the normal distribution but the descriptive statistics vary markedly given the low standard deviation mobility computed from google maps reveals less countylevel variance in mobility changes in response to the covid19 pandemic which is supported by its concentrated heat map the 𝑅𝐼 calculated from apple mobility is considerably lower than the other three sources because of documented strong negative responses in most counties since earlyjune as noted above however apples low baseline value on january 13 potentially shifts the entire time series upwards consequently responsible for the low 𝑅𝐼s twitter and descartes share a similar distribution indicating that twitter data is a good proxy of mobile phone data in capturing human mobility correlation between 𝑹𝑰 and income recognizing that the human mobilitybased response to the covid19 pandemic includes both negative responses and positive responses we explore the correlation between the full spectrum countylevel 𝑅𝐼 and the county median income in general all mobility datasets reveal a statistically significant positive correlation between 𝑅𝐼 and income suggesting that counties with higher income tend to react more aggressively in response to the covid19 pandemic by reducing more moving activities compared to the prepandemic baseline nonetheless we acknowledge that correlation no matter strong or weak does not necessarily imply causation a detailed discussion regarding this issue can be found in section 52 despite the statistical significance the strength of the correlation varies among datasets due to the intrinsic nature of their sources the 𝑅𝐼 calculated from the google dataset is strongly correlated with income in comparison apple mobility derived from apple maps also a navigation service shows a rather weak correlation between its calculated 𝑅𝐼 and income three reasons are arguably behind the googleapple difference in the strength of the correlation first google mobility in this study only includes the category of workplaces while apple mobility considers all types of requests second it is reported that the median income for iphone users in the us is 40 higher than that of android users as a result apple maps users possibly do not cover as much demographic spectrum as google maps users third the concepts of mobility disparities in mobility between lowerincome and upperincome counties we further explore the countylevel disparity in mobility dynamics between lowerincome and upperincome counties in response to the covid19 pandemic figure 5 presents the time series of mobility change percentages for all available counties in the four mobility datasets specifically counties in the top 10 and bottom 10 in wealth are highlighted respectively in red lines and blue lines in general the disparity in mobility dynamics is well manifested in all mobility datasets evidenced by the obvious gaps between blue lines and red lines especially after the declaration of the national emergency on march 13 the increase in gaps after march 13 suggests the diverging mobility pattern between lowerincome and upperincome counties in response to the pandemic in addition rich counties are found more responsive as they present more reduction in mobility compared to poor counties which is evidenced by the fact that the red line consistently lies below the blue line in all four mobility datasets among the four datasets descartes mobility presents the most obvious diverging pattern compared to the other three datasets considering the low standard deviation however the separation in google mobility between the rich and poor counties is also noteworthy as the red line and blue line are too separated that the gap between them covers most of the time series in comparison the countylevel disparities between rich and poor counties from apple and twitter are less dramatic but still noticeable note that the number of available counties varies among datasets which potentially introduces a certain level of inconsistency and uncertainty when heterogeneous mobility data are crosscompared to reveal the disparity in mobility dynamics within each state we derive the time series of mobility change percentages for the top 20 and bottom 20 counties in wealth within each conus state removing the potential impact from the difference in statewide mitigation policies the rationale in selecting 20 is to include more counties in each state especially for states with a small number of counties figure 6 for descartes mobility rich counties within a certain state generally tend to react more aggressively in mobility reduction compared to the poor counties within the same state the disparity tends to be exaggerated in the mobility recovery phase ie may and june for example wa has seen a consistent mobility drop after march 13 suggested by the overlapped blue line and red line however the recovery phase in wa highlights the disparity in mobility dynamics as the poor counties obviously gained earlier and greater upward momentum than the rich counties this similar pattern can also be found in pa mn mi and ma in comparison nv stands out by showing the opposite pattern and states that include la tx ca ms and md present unnoticeable disparity between the rich and the poor counties despite the heterogeneity in sources compared with descartes mobility the results from apple and google also reveal the general pattern that rich counties tend to be more responsive by showing a higher mobility reduction rate within most conus states in the selected time period however contrasting patterns although only a few can still be found in some states from different mobility data sources for example ks presents higher responsiveness for rich counties from descartes mobility but lower responsiveness for the rich counties from apple mobility in addition the pattern in nd from google mobility contradicts the pattern from apple mobility figure 6 time series of descartes mobility change percentages for the top 20 and bottom 20 counties in wealth at each conus state for a state with less than five available counties counties with the most median income and the least median income are selected as the top 20 and the bottom 20 respectively to quantitatively reveal the disparity in mobility responsiveness between the rich and the poor counties we calculate the difference in 𝑅𝐼 between the top 20 and bottom 20 counties in wealth at each conus state the values of ∇𝑅𝐼 are presented in table 1 in general states with positive ∇𝑅𝐼 are dominant in number as 40 states from descartes mobility 32 states from apple mobility and 42 states from google mobility out of the 48 states in the conus are with ∇𝑅𝐼 0 mobility datasets from the three sources suggest that despite the noticeable variances in ∇𝑅𝐼 wealthy counties within each state are likely to have more mobilitybased responsiveness during the covid19 pandemic however the inconsistencies from different mobility datasets need to be recognized as it presumably results from the intrinsic nature of the data sources and therefore warrants caution for further studies that rely on only a single mobility data source discussions the fusion value in heterogeneous mobility data our investigation in descartes apple google and twitter mobility reveals that they well capture the impact of the covid19 pandemic on human mobility by showing clear deviations from the prepandemic baseline nevertheless we observe considerable dissimilarities among the datasets as each source presents unique characteristics the four selected mobility datasets in this study demonstrate the multifaceted nature of human mobility that has been documented by many and some believe these heterogeneous data sources reflect human mobility from different yet valuable perspectives zhang et al it is reasonable to assume that the fusion of these mobility datasets mitigates the biases to some degree and provides a holistic view of mobility dynamics in a broad spectrum of the population numerous studies have been conducted attempting to fuse multisource mobility data towards a more comprehensive one to list but a few zhang et al proposed a systematic framework to integrate transit records and cellphone records to mitigate biased sampling similarly montero et al found that the fusion of heterogeneous mobility data sources facilities robust urban transportation models despite these attempts however mobility data fusion is still scarce in the literature especially scarce in studies that tackle public health emergencies by means of mobility monitoring global crises such as the covid19 pandemic we are facing uniquely highlights the need for monitoring mobility dynamics in a comprehensive manner as integrated human dynamics from multiple sources is expected to better reflect the multifaceted nature of human mobility leading to the acquisition of overall knowledge in mobility dynamics that cover a broader spectrum of the population at the same time however we argue that the representativeness of each source largely depends on the demographics of the service users in relation to the demographics of the local population thus a proper weighting scheme based on their representativeness needs to be considered when multisource mobility data are fused the luxury nature of social distancing our exploration of the correlation between countylevel 𝑅𝐼 and county median income indicates that counties with higher income tend to be more responsive in terms of mobility reduction compared to the prepandemic baseline evidenced by the statistically significant positive correlation between 𝑅𝐼 and income from all four mobility datasets most states show a positive difference in 𝑅𝐼 between their upperincome and lowerincome counties where diverging patterns in time series of mobility changes percentages can also be found however we need to acknowledge that correlation does not necessarily imply causation the reasons behind the disparity in mobility patterns for upperincome and lowerincome counties are multifaceted geographically highincome counties in the us often coexist with large cities or urban fabrics in which the dense population is hit first and hardest by the covid19 pandemic a recent study found that 54 of urban residents in the states view the disease as a major threat to daytoday life which compares with 42 of those living in the suburbs and just 27 of rural residents in the same states the urbanrural discrepancy in threat awareness presumably translates to the different mobility patterns in upperincome and lowerincome counties in addition upperincome counties within a certain state tend to be the job centers that receive the commuting inflow of workers from nearby lowerincome counties this difference in the commuting pattern is also responsible for the countylevel disparity in mobility dynamics other possible explanations of less mobility responsiveness for lowerincome counties can be traced to the policies that sometimes unintentionally create inequity among different groups people respond to the mobilityrestrict measures differently largely depending on their financial resources the outcome of these measures may reflect the preferences of the affluent but not the interests of the lowerincome group given the close relationship between human mobility and the transmission of sarscov2 reported from numerous studies the low mobility responsiveness in lowerincome counties deserves more attention as slow reduction and fast recovery in mobility may foster the second ware of infections which could be exacerbated by the vulnerability in the lowincome populations future directions the findings from this study point to some potential areas for future research event with dramatic mobility changes on a large scale provides a great opportunity for us to learn the strengths and weaknesses of each data source laying the foundation for the potential multisource integration third given that county is the smallest geographical unit from apple descartes and google mobility datasets we explore the correlation between countylevel income and countylevel mobilitybased responsiveness however changes in aggregated geographic units might alter the conclusions due to the famous modifiable areal unit problem future studies should investigate the disparity in mobility at various spatial units or scales although income is one of the fundamental factors in socioeconomic status other factors may also contribute to the disparity in responsiveness revealed in this study therefore deserve further investigation finally the spatial incontinuity of the available counties in all four mobility datasets precludes a detailed spatial examination however we acknowledge that spatial nonstationarity may exist in the contribution of socioeconomic factors to the mobility dynamics future studies can consider spatial autocorrelation when using other spatially continuous mobility datasets conclusion this study reveals the similarity and dissimilarity of human mobility from various sources and the luxury nature of social distancing in the us during the covid19 pandemic by highlighting the disparities in mobility dynamics from lowerincome and upperincome counties we collect and compute mobility data from four sources 1 apple mobility trend reports 2 google community mobility reports 3 mobility data from descartes labs and 4 mobility calculated via weighted distance from twitter we further design a responsive index based on the time series of mobility change percentages to quantify the general degree of mobilitybased responsiveness at the us county level the results reveal that the impact of the covid19 pandemic is well documented as all mobility datasets show apparent deviations in mobility from the prepandemic baseline we find statistically significant positive correlations in 𝑅𝐼 between either two data sources revealing their general similarity albeit with varying pearsons 𝑟 coefficients the 𝑅𝐼𝑠 calculated from google and apple share the highest correlation presumably because both of their mobility records are from navigation applications in smartphones despite the similarity however mobility from each source presents unique and even contrasting characteristics demonstrating the multifaceted nature of human mobility when correlation 𝑅𝐼 with income we find that positive correlation between 𝑅𝐼 and income is significant in all mobility datasets suggesting that counties with higher income tend to react more aggressively in terms of reducing more mobility in response to the covid19 pandemic despite the statistical significance the strength of the correlation varies among datasets the 𝑅𝐼 calculated from the google dataset is strongly correlated with income but the correlation is rather weak between the 𝑅𝐼 from apple and income the disparity in mobility dynamics between lowerincome and upperincome counties is well manifested from all mobility datasets most states present a positive difference in 𝑅𝐼 between their upperincome and lowerincome counties where diverging patterns in time series of mobility changes percentages can be found to our best knowledge this is the first study that crosscompares mobility datasets from various sources during the covid19 pandemic the findings contribute to gaining the knowledge of not only the characteristics of multisource mobility data but also the mobility disparity in tandem with the wealth disparity benefiting policy design for better mitigation of future epidemics and pandemics declaration of competing interest this statement confirms the authors have no competing interest in this research for a state with less than five available counties counties with the most median income and the least median income are selected as the top 20 and the bottom 20 respectively

human mobility data provide valuable insight into how we adjust our travel behaviors during the covid19 pandemic • human mobility records from descartes labs apple google and twitter are compared • multisource mobility datasets well capture the general impact of covid19 pandemic on mobility in the us but present unique and even contrasting characteristics • the proposed responsive index quantifies the level of mobilitybased reaction in response to the covid19 pandemic • all selected mobility datasets suggest a statistically significant positive correlation between the responsive index and median income at the us county level

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aged in place but if employment is the primary driver of immigration it is unclear why already in 2000 the asian share of all foreign born residents was similar to that of foreignborn seniors25 and 22 percent respectively jasso and rosenzweig argued that family chain migration including sponsorship of parents is responsible for the rapid growth of migration from asia including lateage immigration to date only a handful of studies have examined how family chain migration drives changes in the demographic composition of legal permanent residents building on claims that the family unification provisions of 1965 amendments drive changes in both the age composition and the regional origins of us legal permanent residents we use administrative data to examine empirically whether and how chain migration links these two trends specifically we ask how does the prevalence of family chain migration differ among major sending regions and how does the surge in lateage immigration since 1980 vary by source regions and major sending countries specifically we derive agespecific migration multipliers for the major sending regions and the four top source countries these nations also feature the largest backlogs for numerically capped family visas which has implications for the age composition of sponsored relatives who age as they wait for visas in multiyear queues in addition to improving on prior estimates of chain migration our analyses clarify why the age composition of the foreign stock population from asia and latin america diverged before describing the data and estimation methods we provide a brief overview of the logic that led to congresss gross miscalculation of the impact of the 1965 amendments on the regional origins of us immigrants the concluding section discusses the implications of family chain migration in the context of an aging society and contemplated comprehensive reform policy background the congressional debates leading to 1965 amendments reveal several issues that preoccupied advocates and detractors of immigration reform in the 1960s according to senator edward kennedy then chair of the subcommittee on immigration reform critics worried that the proposed amendments would greatly increase annual immigration would contribute to increased unemployment and relief rolls would ease the bar to the entry of security risks and would permit excessive entry of persons from africa and asia several members of congress worried that the nations ethnic mix would change if the bans on immigration from asia and africa were rescinded also having nixed the bracero program in 1964 there was little appetite for admitting unskilled workers in allocating a mere 27000 annual visas each for professionals of exceptional ability and for skilled occupations facing labor shortages congress envisioned german not chinese engineers and british rather than indian physicians however these employment visas proved pivotal for the surge in asian immigration regional origins of legal permanent residents in light of longstanding labor agreements with mexico and the explicit exemption of latin american and caribbean nations from the country quotas imposed in 1924 a gradual rise in legal permanent migration from the southern hemisphere is not surprising the termination of the bracero program in 1964 without a legal alternative to satisfy the entrenched demand for agricultural workers had the unintended effect of spurring unauthorized migration from mexico during the 1970s and 1980s moreover prior to the imposition of country limits on western hemisphere countries in 1978 mexico consumed between onequarter and onethird of all visas allocated to the americas by imposing annual quotas on all nations the 1978 legislation was particularly consequential for mexico because it further restricted legal pathways to the us labor market the surge in asian migration was unexpected not only because few us citizens of asian origin had close relatives living abroad but also because the 1965 amendments capped employment visas at less than 55000 annually because large numbers of lprs from asia gained admission as employersponsored skilled workers during the 1970s and 1980s the limited number of employment visas kept asian immigration in checkat least temporarily because congress increased employment visas to 140000 in 1990 refugee flows have proven less predictable in their timing magnitude and source countries between 1955 and1974 about 15000 immigrants were admitted from kampuchea laos and vietnam combined over the next decade over 760000 refugees were admitted from these nations upon receipt of lpr status refugees are entitled to earn citizenship and subsequently sponsor family members published data from the statistical yearbooks of the immigration and naturalization service show that within a dozen years after the enactment of the 1965 amendments the number of new lprs from asia surpassed those from latin america for the next decade immigration from asia was consistently higher than that from latin america because the vast majority of the beneficiaries of the legalization program authorized by the immigration reform and control act of 1986 hailed from latin america lpr admissions from the region spiked between 1988 and 1992 during the early 1990s lpr admissions from asia and latin america converged but owing to a surge in asylum requests from central americans and parole status granted to cubans over the next dozen years immigration from latin america surpassed that from asia since 2010 legal immigration from asia has once again overtaken that from latin america the auspices of entry are important for understanding future immigration flows because of differences in propensities to naturalize and differences in opportunities to sponsor relatives jasso and rosenzweig argued that both employment and governmentsponsored admissions which include both refugees and legalized immigrants have the highest family sponsorship rates because most of their immediate relatives live outside the united states the influx of over 700000 refugees from southeast asia after the fall of usbacked governments in the region and the legalization of nearly three million immigrants during the late 1980s dramatically increased the pool of new lprs eligible to sponsor relatives upon becoming naturalized citizens using administrative data for immigrants admitted in 1985 as spouses of us citizens jasso and rosenzweig report that the foreignborn were four times more likely than nativeborn citizens to sponsor foreign spouses with immigrants from mexico philippines korea china and the dominican republic among the top five beneficiaries of the immediate family member entitlement their analyses also revealed that naturalized citizens from the philippines china korea india and mexico featured the highest parent sponsorship rates although jasso and rosenzweig lacked information about relatives subject to numerical limitation their findings based on numerically unlimited immediate relatives imply that family chain migration contributed appreciably to the dramatic growth of asian immigration this is a testable proposition with important implications for understanding changes in the age composition of future flows age composition of immigrant flows unlike australia and canada the united states does not consider age in determining eligibility for admission although the vast majority of new lprs are in their prime workingages we argue that the expansion of the immediate family member category to include parents of us citizens appears to have altered the age composition of new lprs by increasing lateage migration using administrative data for lprs admitted since 1980 carr and tienda claim that increases in the number of numerically exempt parents of us citizens were largely responsible for the rise in lateage immigration they did not examine the regional origins sponsored migrants thus were unable to empirically validate jasso and rosenzweigs contention based on a single lpr cohort that parent sponsorship is an overwhelmingly an asian phenomenon two primary mechanisms drive the growth of foreignborn seniors in situ aging of adults who arrived during their prime working years and sponsorship of adult siblings and elderly parents by naturalized legal permanent residents he shows that between 1960 and 2000 the number of foreignborn residents ages 65 and over was stable at around three million between 1990 and 2010 however the number of foreignborn seniors nearly doubled rising from 27 million to almost five million because europeans were the major source of us immigrants until the 1960s they comprised the largest group of foreignborn seniors through 2000 by 2010 asians and latin americans surpassed europeans among immigrant seniors with stock measures it is not possible to determine how aging in situ and lateage immigration contribute to changes in the age composition of foreignborn seniors but annual trends in exempt relative admissions reveal a sharp increase after 19653 specifically between 1967 and 1971 the number of exempt sponsored relatives rose from 47000 to 81000 with parents representing 11 percent of uncapped immigrants in 1981 over 151000 exempt family relatives were granted lpr status with parents comprising 22 percent of the total although the size of the exempt lpr cohort varied annually during the 2000sfrom a low of 331286 in 2003 to a high of 580348 in 2006the parent share rose gradually from less than 18 percent in 2001 to 24 percent in 2010 data and methods establishing links between family unification entitlements and the changing regional origins and age composition of new lprs requires information about entry visas and immigrant characteristics over multiple years the best data source to meet these requirements is the immigrants admitted to the united states microdata which we supplement with special tabulations from the us department of homeland security 4 the microdata file consists of records for all lpr admissions between 1981 and 2000 including persons present in the united states who adjusted their status to permanent resident during those years with the exception of the 27 million immigrants granted legal permanent resident status under the provisions of the 1986 immigration reform and control act using custom tabulations requested from the department of homeland security we augment the immigrants admitted data with summary tabulations for lpr admissions for the period 20012009 and for persons granted lpr status under irca for the period 19892000 both the microdata and the customized tabulations contain data requirements for deriving age cohortand originspecific estimates of family unification chain migration year lpr status was granted age at admission to lpr status visa class and region of origin the augmented data file consists of a multidimensional table that crossclassifies admission cohort admission age visa class and region of origin specifically the analysis file consists of 51210 observations with count data over 29 years represent nearly 255 million legal permanent residents admitted to the united states between 1981 and 2009 each observation is a frequency count of lpr admissions for the given set of age cohort visa class and regional origin values in this classification admission years are aggregated into 5year cohorts beginning with 19811985 arrival age is aggregated into three broad categories 016 1749 and 50 and countries are assigned to five broad regions 5 visa class is a key requirement for estimating family unification chain migration following yu we collapse 352 specific visa classes into 10 exhaustive categories that represent the major admission classes importantly these major classes differentiate between initiating versus family unification immigrants accompanying versus latersponsored family immigrants citizen versus lprsponsored family immigrants and numerically capped versus uncapped immigrants the distinction between citizen and foreignborn sponsors is important because of the demonstrated family links between past and future immigration our analyses use the typology developed by yu and modified by carr and tienda to differentiate between initiating and family unification migrants family migration multipliers immigration multipliers represent the total number of future immigrants generated by immigrants who are not themselves sponsored by relatives unlike immigrant sponsorship rates which are based on ratios of sponsored and total lprs admitted in a given year or cohort multipliers are cumulative measures of immigrants directly or indirectly sponsored by an initiating immigrant defined as the first in their families to move to the united states 6 initiating immigrants must be sponsored either by nonfamily entities or marry a usborn citizen we define four categories of initiating immigrants denoted by the subscript 0 and letters e g and s designate employer government and spouse sponsors 7 0 e employersponsored initiating employee immigrants 0 g governmentsponsored initiating immigrants 0 g′ irca amnesty immigrants 0 s initiating spouse immigrants using these admission criteria we estimate a series of family migration multipliers which represent the cumulation of sponsored family members relative to the number of initiating immigrants per admitted cohort only initiating immigrants can start new migration chains which are activated either when spouses and children accompany initiating immigrants after naturalization foreignborn citizens are entitled to sponsor both immediate family members and relatives such as adult offspring or siblings thus activating the multiplicative properties of chained migration family unification immigrants are defined as lprs sponsored by family members who themselves are immigrants or who are the accompanying family members of an initiating immigrant the calculations distinguish among four types of family immigrants accompanying family dependents numericallylimited later following family dependents numerically unlimited immediate relatives of us citizens and numerically limited preference relatives of us citizens 8 the antecedent subscripts 1 through 4 indicate the sequence in the migration chain the formula for the age origin and cohortspecific family migration multipliers is given by 7 irca legalized lprs are distinguished from other government sponsored immigrants because they are generally reported separately in published reports and were excluded from the immigrants admitted microdata files 8 our definition of family immigrants differs slightly from that used by the department of homeland security for consistency with our distinction between initiating immigrants and their family members we classify the accompanying family members of an employersponsored initiating immigrant as family immigrants whereas us dhs assigns them to employmentbased admissions where the terms in the numerator represent counts of specific types of sponsored family migrants and the denominator terms represent the counts of the four classes of initiating immigrants the core notation of each term consists of an upper case letter and a leading subscript representing an aggregated admission class specifically 0 e 0 g 0 g′ and 0 s denominator terms represent employersponsored governmentsponsored and spouse initiating immigrants respectively the numerator includes initiating immigrants accompanying and laterfollowing family dependents us citizens numerically exempt spouses children and parents and us citizens adult offspring siblings and their respective dependents subscript j denotes one of the three age groups at admission among family sponsored immigrants the subscript j which applies to the initiating immigrant terms in the denominator is an aggregate across all ages the subscript k signifies region of origin or in more detailed analyses a top sending country of origin subscripts t and t′ reflect fiveyear admission cohorts corresponding respectively to the early and later stages of the migration chain for initiating immigrants and their accompanying and laterfollowing dependents admission cohort t consists of one of the following cohorts 19811985 19861990 19911995 or 19962000 the multipliers are truncated in the year 2000 because except for accompanying and laterfollowing family dependents activation of family unification entitlements requires acquisition of citizenship which requires appropriate temporal lags in order to estimate family chain migration multipliers sponsorship and naturalization lags sponsorship entitlements are constrained both by decisions of lprs to naturalize and the waiting times to attain citizenship because only citizens can sponsor numerically exempt immediate relatives and several family preference migrants therefore in order to refine the link between initiating cohorts and sponsorship of family members the migration multiplier calculations adjust the cohorts of citizensponsored family immigrants to correspond with one sponsorship generation beyond the initiating immigrant cohort by introducing 9year lags this is analogous to the immigrant generation cohort approach used by others to model mobility with crosssectional data the 9year lag reflects the average eightyear duration in prenaturalization lpr status plus an additional year for visa processing delays but it is generous for migrants from asia but not migrants from latin america whose average time to naturalization is typically longer operationally subscript t′ is applied to numericallyexempt immediate relatives and citizens family preference relatives in order to approximate the timing of naturalization and eligibility for citizenbased sponsorship among initiating immigrants from cohort t such that t′ t 9 figure illustrates the generationlagged citizen sponsored relatives for initiating cohorts included in our calculations annual initiating immigrant cohorts appear on the vertical axis accompanying and laterfollowing lpr dependents are temporally aligned with these cohorts x denotes the corresponding annual cohorts of generationlagged citizensponsored family immigrants which appear along the horizontal axis the 3 s 3 c 3 p and 4 f cohorts are advanced by nine years to reflect this lag and the 19811985 initiating cohort corresponds to 19901994 3 s 3 c 3 p and 4 f family admissions the grey cells indicate the fiveyear admission cohorts in multiplier estimates this pattern is mirrored for all regions with notable variations in both the initial levels and relative growth in lateage immigration over the 29year period during the early 1980s for example lateage immigrants made up 1314 percent of new arrivals from asia and europe but owing to larger cohort sizes the absolute number of lateage asian lprs was four times that from europe by the end of the period lateage immigration from asia approached 20 percentthe largest share among all regions which is consistent with the 2000 and 2010 stock measures by comparison about 17 percent of european lprs from the 20062009 cohort were ages 50 and over and the cohort was approximately onequarter as large as that from asia between 1981 and 2000 both the absolute cohort size and the share of lateage immigrants approximately doubled for new lprs from mesoamerica and south america only africa sent below average shares of lateage immigrants throughout the observation period however even as the size of african immigrant cohorts mushroomed from 77 million to 437 million this region witnessed a doubling in the cohort shares of lateage immigration regional variations in family unification migration the migration multipliers reveal how family unification chain migration drives the regional diversification and shifts the age composition of new lpr flows the first and second columns of table 2 report the absolute number of initiating immigrants and the cumulative number of cohort sponsored family migrants for the major sending regions the last four columns show the cohortagespecific multipliers and the allages cohort multiplier for the major regions with two exceptions discussed below all of the family unification multipliers are above one but there is considerable variation in levels of family chain migration substantively the 178 migration multiplier in the top row of table 2 indicates that every 100 initiating european immigrants admitted between 1981 and 1985 collectively sponsored 178 additional family members of these 22 were ages 50 and older the multipliers which vary in magnitude across regions and according to the size of initiating cohorts yield several insights about how family unification chain migration diversified immigration flows in ways the proponents of the 1965 amendments could not envision contrary to reformers intentions for example the lowest multipliers correspond to europe and for the 19861990 and 19911995 lpr cohorts the multipliers barely exceed one unlike immigrants from asia and latin america moreover the family members sponsored by europeans during the 1980s and early 1990s primarily involved youth or workingage relatives only 12 percent of sponsored european family members during the 1980s were aged 50 and over as european source countries included growing numbers from former soviet bloc nations during the late 1990s the share of lateage family members rose to 20 percent further defying reformers intentions and despite the establishment of hemispheric and country caps designed to limit immigration from asia family unification multipliers for the region are consistently above two the multipliers imply that during the 1980s and early 1990s initiating lprs sponsored between 221 and 256 additional family members per 100 eligible sponsors of these between 20 and 25 percent were ages 50 and over asian family chain migration was particularly intense during the latter part of the 1990s when the ratio of sponsored to initiating asian lprs approached 41 about a quarter of these sponsored lprs were ages 50 and over although african migration streams are considerably smaller than those from asia the initiating cohorts have grown steadily since 1981 as did the number of sponsored family migrants new lprs from africa activated family unification migration chains by sponsoring between 151 and 229 family members per 100 initiating lprs with seniors representing between 14 and 18 percent of sponsored relatives cubans and mexicans dominated us migration streams from latin america during the 1960s but economic dislocations and armed conflicts in south america triggered an exodus from colombia peru and ecuador during the 1980s these flows sparked new family migration chains and fueled large family migration chains during the early 1980s and the late 1990s the multipliers for these cohorts imply that every 100 initiating immigrants sponsored over 500 family relatives of which 16 and 21 percent respectively were ages 50 and over family migration multipliers for mesoamerica exhibit the greatest temporal variation because mexicans and central americans were the largest beneficiaries from the irca legalization program which dramatically increased the size of initiating cohorts during the 1990s new lprs from this region are also taking advantage of their family unification entitlements by sponsoring relatives the share of sponsored relatives ages 50 and over rose from 11 to 18 percent over the observation period which parallels the national trend the family migration multipliers for the 19811985 and 19962000 initiating cohorts indicate that each 100 lprs from mesoamerica sponsored respectively around 350 and 420 additional relatives by 2009 that the multipliers corresponding to the 19861990 and 19911995 mesoamerican cohorts are below unity is an artifact of the outsized initiating cohorts legalized under irca initiating cohorts from the region approached 15 and 14 million respectively during the legalization period which extended through the early 1990s another reason for the comparatively low multipliers for these cohorts is the large representation of mexicans who average longer times to naturalization and whose waiting times in the queue for countrycapped visas are among the longest nevertheless the legalization cohorts jointly sponsored over two million family members by 2009 to summarize not only does the magnitude of family chain migration differ over time and by region but partly owing to large fluctuations in the size of initiating cohorts the absolute numbers also differ appreciably this is dramatically evident for migrants from mexico and the caribbean in the aftermath of the legalization program second although the majority of legal permanent residents are in their prime working ages lateage immigration rose for all regions albeit not uniformly and why the age composition of family unification chain migration differs across regions we focus on the four top sending countriesmexico china india and the philippinesbecause of their potential to intensify lateage immigration due to the growing visa backlogs for nonexempt family relatives and because the absence of a cap for immediate family relatives including parents of us citizens potentially can accelerate the growth of lateage immigration in the future this is particularly important for china whose population will age gradually until 2015 and rapidly thereafter family chain migration the top four sending countries mexico is currently and has been the largest single source of legal us immigrants since the second half of the 20 th century between 19611970 for example 454000 mexicans received lpr status compared with 428000 for all of asia including 35000 and 27000 from china and india respectively despite the longstanding role of mexicans as a source of lowwage labor for the united states employers sponsor relatively few lprs from mexico rather the vast majority of mexican lprs are beneficiaries of family reunification entitlements exercised by us citizens of the mexicans granted lpr status in fiscal year 2010 for example less than 10 percent qualified for an employment visa except for the federal legalization program that enabled over two million mexican nationals to adjust their legal status during the late 1980s and early 1990s family reunification remains the main pathway to legal us residence for mexicans owing partly to us involvement in the pacific during the late 19 th and early 20 th century migration from the philippines has longer antecedents than that from india and china this is reflected in the consistently larger philippine cohort sizes through 2000 thereafter the size of lpr cohorts from india and subsequently china surpassed that from the philippines as shown in table 3 after restrictions on asian immigration were lifted in 1965 india and china joined philippines in sending large numbers of legal immigrants to the united states by first availing themselves to the skilled employment preference visas and after acquiring citizenship sponsoring relatives table 3 shows rather distinct country profiles based on the size growth and age composition of new immigrant streams between 1981 and 2009 about 12 million lprs were admitted each from china and india which compares with 15 million from the philippines and 54 million from mexico both india and china witnessed steady if not monotonic growth in lpr cohort size such that the 20062009 cohorts were over two times larger than the 19811985 cohorts the lpr cohorts from the philippines peaked at 280 thousand during the latter half of the 1990s but generally averaged around 250260 thousand per fiveyear period9 because employment visas served as the primary gateway to asian migration since 1981 primeage workers dominated these streams particularly for migrants from india nevertheless the cohort shares of lateage migrants from the top three asian source countries exceeded the global averages by a considerable margin throughout the observation period for example during the 1980s between 29 and 33 percent of lprs from china were ages 50 and over although this share fell to under a quarter during the 1990s the absolute cohort sizes more than doubled which corresponds to an 80 percent increase in the absolute number of chinese lprs ages 50 and over the size of indian lpr cohorts more than doubled over three decades even as the share of lateage migrants rose from 17 to 22 percent in absolute terms late agemigration from india rose from about 20 thousand during the early 1980s to over 53 thousand for the most recent lpr cohort unlike india and china the cohort shares of lateage filipino immigrants held fairly steady between 2122 percent until after 2005 when almost oneinfour new lprs were ages 50 and over mexico differs from the top asian source countries in two key respects first mexican lpr cohorts are more than twice the size of the three topsending asian countries which is important because cohort size influences the future scale of family unification chain migration second the prevalence of mexican lateage migration is consistently lower than all of the top three asian nations over he entire period however mexico witnessed a trebling in lateage migration since 1981 from about 6 percent to 18 percent which is just above the worldwide average of 173 percent furthermore except for the 19811985 cohort the absolute number of lateage mexican immigrants was significantly larger than each of the three top asian origin nations for perspective fewer than 20000 mexicans granted lpr status between 1981 and 1985 were ages 50 and over compared with 36000 and 48000 respectively from china and the philippines mexico also was the largest single source of lateage immigrants during the 20062009 period when the number of new lprs ages 50 and over exceeded 100000 10 bolstered by the higher worldwide ceilings and the larger number of visas for skilled workers established by the 1990 immigration act countryspecific estimates of family unification chain migration reported in table 4 reveal migration multipliers that are higher than the regional averages enabled by high family sponsorship rates among naturalized immigrants each 100 initiating chinese immigrants sponsored between 767 and 843 family relatives during the 1980s that the united states offered refuge to thousands of chinese following the 1989 tiananmen square massacre increased the size of the 19911995 initiating cohort more than fivefold compared with the 19861990 initiating cohort the low multiplier for the 19911995 cohort reflects the refugeeproduced bulge but as column indicates the absolute number of accompanying and sponsored family migrants cumulated through the 1990s even after the size of the initiating immigrant cohort was halved the family unification migration multipliers for india are even more striking as index values approached 10 during the 1980s indicating that every 100 initiating indians admitted during the 1980s sponsored between 960 and 998 additional relatives by 2009 of these approximately oneinfour were ages 50 and over the multiplier index was nearly halved by the late 1990s however because the size of the initiating cohorts had more than doubled the absolute scale of family unification immigration increased as wellfrom 147 thousand in the late 1980s to about 185 thousand sponsored family members during the late 1990s multipliers imply that every 100 indians granted lpr status between 1996 and 2000 on average sponsored more than 500 additional relatives by 2009 mexicans also have benefited from family reunification chain migration both in absolute and relative terms although mexicos family unification multipliers are smaller than those of the top three asian source countries through the mid1990s after 1996 they surpassed those of india and the philippines and converged with the chinese multipliers the smaller multipliers for the interim lpr cohorts from mexico reflect the hefty irca cohorts in the denominator of the multiplier index however the absolute number of sponsored relatives was over double that from china and india during the 1980s and over three times larger during the 1990s as legalized immigrants acquired citizenship many activated their family unification entitlements by sponsoring relatives exempt from and subject to the numerical caps the former include parents and the latter include adult relatives that may have to wait years for a visa an examination of the uncapped visa category provides further insight into the underlying dynamics and specifically the unintended consequences of broadening the definition of immediate relatives to include parents in 1965 for each of the top asian source countries the number of sponsored parents grew steadily as earlier arrivals naturalized and submitted 10 only between 8 and 6 percent of mexican lprs admitted during the late 1980s and early 1990s were ages 50 and over but in absolute terms this represents over 100000 and 94000 lateage migrants respectively visa petitions on behalf of their parents not surprisingly over 95 percent of sponsored parents from asia are ages 50 and over the modest dip in the number of sponsored parents from asia during the late 1990s likely reflects the impact of the 1996 welfare reforms which restricted senior immigrants access to supplemental security income were enacted this change was particularly consequential for the philippines however after 2005 the number of sponsored parents from the philippines rebounded to the level of the early 1980s by contrast lateage immigration from mexico was lower than that from asia during the early 1980s in both absolute and relative terms however the intensification of mexican family unification chain migration was accompanied by a rise in both the number and share sponsored family members ages 50 and over during the 1980s and early 1990s naturalized mexican immigrants sponsored between 10 and 20 thousand parents and as the outsized irca cohorts began to qualify for the family reunification entitlements that allow naturalized citizens to sponsor parents outside of the country caps there was a surge in lateage migration from mexico between 2001 and 2009 naturalized mexican immigrants sponsored over 200 thousand parents this is well above the roughly 30000 parents sponsored by naturalized counterparts during the 1980s these results suggest that irca indirectly increased lateage migration from mexico yet another unintended consequence of federal policy parents are not the only source of lateage immigration because siblings and adult children of us citizens are subject to annual country caps the number of family preference lprs from asia has remained fairly steady over the last three decades nevertheless due to the long queues for the oversubscribed family visas from china india and the philippines numerically capped relatives also contribute to lateage immigration by aging in place as they wait for their visa in a multiyear queue table 6 reveals that the share of sponsored family members ages 50 and over rose even as the cohort size remained stable for example among numerically limited family relatives admitted from the philippines during the 1980s approximately 75 percent were ages 50 and over however nearly one quarter of capped family relatives admitted after 2005 qualified as lateage migrants for the philippines the wait for a capped family visa can extend over 20 years similar trends obtain for capped relatives from china and india as both nations evince a steady increase in the cohort shares ages 50 and over mexico stands as an exception in two respects first the absolute number of sponsored relatives is higher than that of the top asian source countries for every cohort second the share of lateage family relatives rose more gradually and never exceeds six percent of any given cohort nevertheless partly owing to the outsized initiating cohorts legalized under irca the number of capped sponsored relatives from mexico more than doubled between 19861990 and 19911995 and nearly doubled again during the late 1990s since 2000 the number of sponsored relatives from mexico has fallen but it is conceivable that higher shares will qualify as lateage migrants in the future as family members approved for admission age in the visa backlog queues in 2010 for example unmarried mexican adult children sponsored by us citizens had waited 18 years to receive their entry visa summary and discussion in making family reunification the centerpiece of the 1965 amendments to the 1952 immigration and nationality act congress did not contemplate radical changes in the volume and composition of immigrants proponents of the reforms claimed that tight visa controls for the employment preferences combined with annual hemispheric ceilings and country caps would keep the size of flows in check there appears to have been little discussion about the implications of expanding the definition of immediate relatives to include parents of citizens or how immigration might contribute to population aging at that time the us population was relatively young owing to the baby boom also less than 10 percent of lprs were ages 50 and over neither did congress factor in their calculations how naturalized citizens would avail themselves to the family unification entitlements by sponsoring both exempt and numerically capped relatives in hindsight it is clear that congress did not understand the power of migrants social networks in activating family chain migration not only did this lack of understanding produce the feared changes in the ethnic mix of the nation but it also altered the age composition of subsequent flows as naturalized migrants sponsored parents and approved relatives waited in ever longer queues to receive entrance visas in hindsight detractors worries about increases in the size and composition of future flows were well founded albeit not for the reasons proffered at the time although the number of workrelated visas was kept low at least until 1990 high naturalization rates increased rapidly the number of asian immigrants eligible to sponsor family members and sponsor relatives they did our analyses of new lprs reveal that since 1980 each initiating 5year cohort from asia collectively sponsored over one million family members furthermore the estimates of chain migration indicate an acceleration of family unification chain immigration from asia such that each 100 initiating lprs admitted between 19962000 sponsored almost 400 additional relatives compared with 221 for asian lprs admitted during the early 1980s additional reasons that the family unification provisions intensified the diversification of the immigrant streams are the huge refugee flows from southeast asia during the 1970s and from central america during the 1980s but especially due to the generalized amnesty program that legalized nearly three million lprs during the late 1980s and early 1990s these formidable additions to the planned lpr world quotas initiated migration chains as large majorities naturalized and activated their family unification entitlements for example initiating immigrants admitted from mexico and central america during the 1990s sponsored over 17 million relatives by 2009 that family unification chain migration from mesoamerica appears to be accelerating suggests that the myriad status adjustment programs for central and south americans since irca will continue to increase family migration streams as new lprs qualify to sponsor relatives this study addresses several limitations of prior work by extending the timeline for estimating the magnitude of family unification chain migration beyond 2000 relaxing assumptions of synthetic methods that assume uniform cohort sizes and disaggregating multipliers by age yus estimates based on the immigrants admitted microdata are likely understated because they exclude the outsized irca cohorts the longer observation period also permits an early assessment of how the increase in employment visas after 1990 boosted family unification migration jasso and rosenzweig argue that employment and governmentsponsored immigrants have the highest sponsorship rates both because they are unlikely to have many relatives in the host country and because they naturalize at high rates although their data only permitted estimation of multipliers for labor certified initiating immigrants over a single decade their predictions were spot on for asia following the massive legalization program that disproportionately benefitted mesoamericans parent and sibling sponsorship became a mexican phenomenon as well by increasing the base of initiating immigrants our analyses suggest that other legalization programs such as the nicaraguan adjustment and central american relief act of 1997 will likely foment family unification chain migration from the region parents of us citizens who are not subject to annual country caps or worldwide ceilings are the major source of lateage migration but the numerically limited admission classes consisting of adult sons daughters and siblings of us citizens increasingly contribute to lateage migration owing to long visa queues for oversubscribed countries in fact just a dozen or so years after the 1965 amendments went into effect reimers predicted huge changes in us immigration including backlogs for mexico china and the philippines as well as a large undocumented labor force his predictions were prescient our analyses verify his predictions by showing how the parent exemption changed the age composition of lpr flows and convergence in regionaland countryspecific lpr cohort shares ages 50 and over the provision in the 1965 amendments that explicitly exempts parents from the numerically capped visas is the primary driver of lateage immigration but the sizeable backlogs for numerically capped family visas from mexico and the top sending asian countries portend further growth in lateage immigration proposals to clear the backlogs may reduce the extent of aging in place for oversubscribed countries but could also potentially increase family unification chain migration if the spouses of sponsored relatives activate new chains when congress amended the immigration and nationality act of 1952 by broadening the family sponsorship categories the baby boom was unwinding but times have changed in ways that may warrant a reconsideration of family admission categories particularly during a period of tight fiscal constraints and population aging decisions about the number and categories of family visas should be made with a clear grounding in evidence about the social and economic costs of lateage migration for the migrants themselves as well as for the hosting families and communities many studies examined the impacts of the 1996 welfare and immigration reforms on foreignborn seniors surprisingly few studies consider whether and how the impacts differ according to age at arrival given the rise in lateage migration and evidence that changes in us social welfare policy were particularly deleterious for late age immigrants trends in family unification migration reported here warrant additional research both to investigate how various policy proposals enable or restrict future family migration and to better understand how lateage migrants fare relative to their counterparts who arrive in their prime working ages 19811985 19861990 19911995 19962000 20012005 19811985 19861990 19911995 19962000 20012005

this bill that we will sign today is not a revolutionary bill it does not affect the lives of millions it will not reshape the structure of our daily lives or add importantly to our wealth and power…this bill says simply that from this day forth those wishing to emigrate to america shall be admitted on the basis of their skills and their close relationship to those already here lyndon b johnson 1965 1 emphasis added at the height of the civil rights movement president johnsons vision of the great society resonated with the dismantling of the racist immigration quotas with a system privileging family reunification but history shows that the 1965 amendments to the immigration and nationality act of 1952 1965 amendments had profound unanticipated consequences these resulted partly because architects of the legislation vastly underestimated the power of chain migration in driving future flows and partly because of policy choices made when high fertility rather than aging dominated population policy agendas in addition to making family unification the centerpiece of admissions by broadening the preference categories to include adult relatives of citizens and legal permanent residents lprs the 1965 amendments added parents of us citizens to the uncapped category a large body of research chronicles how the regional origins of new immigrants shifted since 1970 and subsequently altered the ethnoracial makeup of the us population hirschman 2005 smith and edmonston 1997 jasso and rosenzweig 1990 with due attention to the rapid increase in the share of new lprs from asia reimers 1992 nowrasteh 2012 until recently however there has been scant attention to changes in the age composition of immigrant flows batalova 2012terrazas 2009carr and tienda 2013oneil and tienda 2015 this is understandable because workingage immigrants dominate new admissions he 2002 smith and edmonston 1997 and because published reports from the congressional research service and the department of homeland securitys dhs office of immigration statistics provide limited age information about new immigrants changes in the national origin and age composition appear to be related but it has proven difficult to demonstrate how much and in what ways because few nationally representative population surveys include information about visa status for the foreignborn that europeans constitute the largest group among foreignborn seniors is not surprising because of low rates of replenishment with young workers after the flows receded and earlier arrivals 1 cf kennedy 1966 p148

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introduction 2020 has indeed been a challenging year for everyone in the world especially indonesia especially since the pandemic covid19 which happened in march 2020 still needs to be completed we are all still haunted by fear will catch the virus covid19 which can attack us when just and in anything we all know that covid19 or corona virus is a zoonotic transmitted between animals and humans these viruses are dangerous because they can be deadly if exposed to them directly the symptoms most common of an infected virus are fever dry cough fatigue and itch judging from the numbers until now the case of the covid19 pandemic in indonesia continues to grow every day the fact when seen from the last update at jhu csse covid19 a patient who is positive for corona disease extensive 283 million patients who recovered from the disease amounted to 223 million patients who dead totaling 72489 this is why the indonesian government continues implementing various health protocols to prevent more victims from the virus the government has tried multiple ways to educate from the 5m campaign namely keeping a distance washing hands using masks avoiding crowds and limiting mobilization and interaction it continued even in july 2021 the government also implemented ppkm in the areas of the islands of java and bali of course all of this is for the sake of reducing the spread of the number of coronavirus cases in indonesia in the difficulty of dealing with this pandemic of course it is an essential role of all elements including party politics as wrong one element communicator needtoknow communicator is parties that conveys a message to a person or a broad audience 2004 this is to the experts statements stating that the party becomes the target of a message sent by the communicator from here the writer can conclude that the communicator conveys a message to the communicant with specific goals and objectives if talking about the role of the communicator here the author sees that there are critical roles in tackling the covid19 pandemic namely the president as head of state ministers other government officials political party politicians doctors and health workers however in this study the author will focus on the role of the president in persuasively educating the public during this pandemic so far the role of political parties has been optimal in handling the covid19 virus start from campaign 5m use health protocol according to who recommendations and consult with public health experts to certain program bulk various institution party political in indonesia one of which has persuasively campaigned and educated the public during this pandemic namely the national mandate party the party was formed from the locomotive reform movement of 1998 after the overthrow of the new order by amien rais and 49 of his colleagues who were members of the peoples mandate assembly who felt the need to continue the ideals of reform by establishing a new party coat party sun this was declared on 23 august 1998 in istora senayan jakarta almost even a 23year party this stand now is captain by zulkifli hasan who is amien raiss brother and is one of the founders of this party the party structure that was formed from the village level to the central level has given birth to various significant figures including one of its cadres namely desy ratnasari who now serves as general chair of the west java regional leadership council in an era of a pandemic like this of course the politicians who sit in both the executive and legislative governments work together to suppress the pace of the covid19 pandemic at the west java regional level the national mandate party under the leadership of desy ratnasari the legendary singer nicknamed the blue tent who is now a member of the republic of indonesia dpr for the 20142019 and 20192024 periods as well as proposing as general chairman of pan west java to participate in educating the public persuasively in campaigning for the 5m movement as well as mass vaccination in west java organizational communication that is built must of course be educated in the right way and persuasive he wants to pressure the public so that disinformation does not occur and reduce the spread of incorrect information aka hoaxes even the dpw pan of west java involves social organizations or religious organizations and official institutions such as the indonesian ulama council nahdlatul ulama and muhammadiyah to jointly provide education to the public to educate the public to pray protocol health and mover security vaccine when injected into society when viewed from the phenomena and explanations above it cannot be separated from its connection with the communication concept communication is a process in which a communicator conveys a stimulus in the form of words to change or shape the behavior of other peopleaudiences that is in communication of course there are communicators messages and message recipients here the researchers see that the communication between the communicator and the recipient of the message still has obstacles or noise where role communicator as a giver of messages in framework education still needs to be easier to say successful the proof is that there is a miscommunication that is received by the community by seeing that currently there are still people who do not implement health protocols in their daily lives in addition some hold large events without following the health protocol by government recommendations this is where the fundamental role of the communicator is in conveying persuasive communication messages to the people being assessed more is needed as of course this is in line with this research where we want to see persuasive communication formed by the communicator to the recipient message between government and society the persuasive communication that is formed certainly has meaning and purpose so that the recipient can receive the message conveyed by the communicator where the purpose of persuasion communication itself is a change in attitude change in opinion and social change significant in addition to persuasive communication public health communication is also needed with good health communication from the government to the community the message expected from the government will be achieved in addition health communication exists to convey messages and influence decisionmaking processes related to improving and managing health by individuals and communities in addition health communication also includes activities to disseminate information about health to the public to achieve healthy living behaviors create awareness change attitudes and provide motivation to individuals departing from this background the authors are interested in seeing from the point of view of the communicators role in educating the public in a persuasive way of communication during the covid19 pandemic this is because researchers see that there is still much public which still needs to understand the meaning and objective of the government for dealing with the pandemic for more details researchers will discuss it in depth in chapter discussion based on the study of course also from theory the research method used is persuasive communication theory and public health communication descriptive what is the role of west java dpw pan communication in educating the public in persuasive communication during the covid19 pandemic method this research uses a qualitative approach which is essentially research that is intended to understand the phenomenon of what is experienced by the subject study like behavior perception motivation action etc in a manner holistically and using descriptions in the form of words and language in a unique natural context and by utilizing various natural methods for technique collection data carried out in several stages viz interview this method obtains data from direct observation by holding a question and answer to the research object this studys research object was the javanese dpw pan cadres west this is done by direct observation at the office board leader region party mandate national java jln research location jakarta no15 kacapiring batununggal district bandung city west java 40271 results and discussion the coronavirus pandemic has so far spread to 210 countries including indonesia departing from the covid19 outbreak that hit countries around the world the government of indonesia has become crucial in taking policypolicies that will be carried out to reduce the rate of spread of covid19 the latest data shows confirmed coronavirus cases in indonesia have reached 2830000 cases as quoted from jhu csse covid19 party politics is a political organization that undergoes ideology specific or formed with a common goal a group whose members have the same orientation values and ideals as a regional policy maker the general chairperson at the provincial level plays a vital role along with his staff in dealing with the coronavirus one of the public policy implementations is communication quoting mcbeth lybecker andstoutenborough in ramadani in todays policy world communication is a key element in policy making in public communication it is necessary to pay attention to 3 things transmission consistency and clarity of messages gema wiralodra is licensed under a creative commons attribution 40 international license information is consistent aligned and coherent between one message and another it means that the message is conveyed in simple language easily understood by the public one form of consistency is a single narrative about conditions and policies narration single communication something institution interpreted as one understanding of an issue does not differ between data or substance between institutions the communication built by the dpw pan of west java focuses on handling public information because the covid19 pandemic is part of disaster communication and communication health william j paisley in his wrote public communication campaigns the american experience in rice atkin explains that the reduction of health information is considered a public service program if it is supported by public policy makers logan writes on health campaign research in bucchi ditch explain communication information about health is informative and persuasive the goal is to change peoples knowledge awareness and attitudes about how to deal with a disease or health public communication in the health sector seeks to increase awareness and public knowledge attitude behavioral tendencies about diseases threats health problems and solutions a health campaign is an intervention a constructive communication strategy designed to influence and improve public health public health information includes life death hope fear health progress failure facts healing and disease risk the basic policy taken by the west java dpw pan is valid information from the government regarding handling the covid19 pandemic namely regarding the public communication protocol for handling covid19 which becomes instruction technical in area specifically java west this protocol was adapted from the who protocol the regional leadership councils efforts to deal with this pandemic are by forming a task force for the acceleration of handling covid19 in the provinces internal areas the context of handling covid19 so that it is fast precise focused integrated and synergistic media communication and information during the covid19 pandemic including coordination between the central leadership council and the branch leadership council in the regions task force duties plan coordinate control utilize source power supervise as well as report implementation handling covid19 to leader the reason to create a public that calms and understand what must be done for the environment to build the public perception that parties are present and responsive in handling crises all matters done by dpw pan west java this already enters persuasive communication the proof is with the leadership command of desy ratnasari as chairman of the dpw pan of west java and the presence of provincial council members from pan made various communication strategies to the public they focus more on tightening health protocols and doing 1000 free vaccinations for the public figure 1 the dpw pan of west java carried out a mass massacre in the city of bandung which was witnessed directly by desy ratnasari as chairman of the dpw pan of west java besides certain vaccine public dpw pan java west too certain friendship to figure ormas islam in java west that is leader region nahdlatul cleric and west java muhammadiyah regional leadership as the most prominent islamic mass organization which at the meeting invited all community leaders to unite against covid19 by educating members in particular and the broader community on generally figure 2 in the context of educating the public in a persuasive way to communicate with the nahdlatul ulama regional leaders and west java muhammadiyah regional leaders through the picture above it can be seen that the communication role of the dpw pan of west java is going well in providing information through hospitality to community leaders and providing direction to their management in the success of the 1000 free vaccines movement which is spread across all cities and regencies in west java conclusion based on the analysis and research regarding the role of organizational communication of the dpw pan of west java in educating the public in a persuasive communication manner it is very optimal and structural this can be seen from the progress made by the dpw to the dpc and the people of west java generally intensely starting from friendly gatherings at once hearings and carrying out mass eradication programs for free based on the results of the research and analysis conducted by the author the dpw pan of west java can educate the public regarding 5m in persuasive communication as often as possible to reduce the rate of increase of covid19 and the immune community is stronger after being given the vaccine

the objective study is how the party mandates national west java to educate people persuasively during the covid19 pandemic the research method that will be used in this research is descriptive qualitative this research uses source data primary and secondary the researcher also did interviews and observations to obtain preliminary data regarding persuasive community education during the covid19 pandemic based on observation and observation as well analysis done researcher so results from the study of this role of communications organization done by the board leader region java west dpw are already very good from the regional level to the level of the leadership council of the west java national mandate party branch dpw pan west java plays on its intentions by conducting persuasive communication in educating the public about the 5m campaign namely keeping their distance washing hands using a mask staying away from crowds and limiting mobilization and interactions the conclusion from this study is that the role of organizational communication carried out by the dpw pan of west java is very optimal and structural in providing information socialization and educationrelated campaign 5m to the public in a persuasive manner matter this can look at the progress done by the board leader region west java to its members intensely through various routine discussion forums which are also carried out through discussion forums through the internal whatsapp group of the west java pan regional leadership council

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introduction by its very nature spatial attention involves the selection of some locations or objects rather than others this is readily seen when the normal operation of attention breaks down as in the case of patients with unilateral spatial neglect such patients experience pathological disruptions to their spatial attention as a function of right parietal lobe damage this damage results in biased attention to rightward locations and objects at the expense of attention to leftward locations and objects even in the typical population however there is evidence of asymmetries in spatial attention reliably typically developing individuals allocate slightly more attention to the left side of space this small bias to overestimate or overattend the left side of space can be seen in the overestimation of the length of felt and imagined lines in the greater tendency to miss rightward items when left and right locations are stimulated simultaneously in spontaneous looking behavior and perhaps most routinely in the standard visual line bisection task in the prototypical line bisection task participants are asked to judge whether a mark on a long horizontal line is located to the right or to the left of the horizontal lines true center typically onscreen cues that precede the presentation of the line have been shown to attract attention inducing a perceived lengthening of the line segment nearest the cue importantly one study found that distractors could influence line bisection performance without being fixated covert attention therefore is sufficient to produce these effects recently the notion that social stimuli could induce these same types of attention shifts has been investigated in nonbisection tasks gazing eyes have been shown to reflexively bias attention in the direction of their gaze even among patients with leftneglect moreover social stimuli including the eyes are preferentially looked at when images are viewed and when a visible experimenter was used as a distractor in a line bisection task a perceptualattentional bias in line bisection toward the experimenter was documented thus the consensus across a large body of work is that attention shifted by and toward social information within a scene it is unclear however whether the presence of coactors will also shift attention in a similar manner commonly joint action studies feature two individuals facing and acting together on stimuli presented on a computer screen employing the line bisection task in this format could therefore provide a simple index of the coactors impact on the topography of attention within the screen recent papers have found evidence that in contrast to the large body of evidence touched on above attention is directed away from live coactors inducing a perceived shortening of the line segment nearest the other person in the horizontal plane when pairs of individuals sit facing the same direction and in the radial direction when individuals face one another this unique finding that in some cases joint action can lead to changes in the static topography of covert onscreen attention is surprising because it suggests that live coactors impact attention quite differently than one would expect given the established literature in addition this effect seems to extend beyond the physical body of the coactor and to include the jointly attended computer monitor this task could therefore act as a simple and elegant measure of interpersonal effects on attention within particular pairs of participants there are however two outstanding points regarding this measure first the attentional withdrawal effect appears to be quite small social influence score the index of attentional attraction or withdrawal that was used was calculated as a value in millimeters across three experiments this value was obtained by comparing the perceived midpoint of horizontal lines when seated beside a coactor versus when seated alone a shift in the perceived midpoint toward the coactor was taken as evidence of attentional attraction whereas a shift away from the coactor was taken as evidence of attentional withdrawal sis had a negative value in all three experiments consistent with attentional withdrawal away from the coactor but this value was significantly different from zero only for two of three experiments moreover the three sis values were not different from one another across the three experiments rendering any conclusions to be of an equivocal nature thus it seemed valuable to replicate the effect in a different laboratory to assess its reliability second though szpak and colleagues report the attentional withdrawal effect at a group level the significance of the effect across individuals and its relationship to individual and pair factors is not yet known given the potential value of the paradigm regarding social attention the present work sought to replicate the reported bias in horizontal line bisection away from nearby others and to form an exploratory profile of potential individual differences in the population in the extent to which they show an effect based on szpak and colleagues attentional withdrawal hypothesis one would predict that participants will overestimate the length of the line segment nearest themselves to a larger extent when in the presence of a partner rather than when alone on the other hand if the partner draws attention in the same way as other cue types one would expect participants to instead overestimate the length of the more distant line segment to larger extent in the direction of the partners location a third possibility given the possible marginal magnitude of the effect is that nearby others may have no impact on attention in this context from which one would predict no significant shift in line bisection performance across manipulations of partner position materials and methods sample size was selected based on an a priori power analysis using g power 3192 software in their first experiment szpak et al report as their main measure of interest a sis of 022 mm and this was compared to a theoretical value of zero an effect size was calculated to have a value of 051 in order to detect this effect with a power of 080 a total sample size of 16 pairs was required more participants than this were collected in anticipation of the need to make exclusions participants were recruited from a pool of undergraduate students and received course credit for participating twentyseven pairs were tested mean age was 214 years participants selfidentified as female and male their selfreported ethnicities were asian caucasianwhite latin american middle eastern multiethnic and undisclosedcould not be categorized based on their handedness responses they were righthanded or ambidextrous participants were paired with one another at random and provided informed consent before participating three chinrests were placed 450 mm apart stimuli were created and presented using psychopy software each black and white line was 18 mm long and was bisected at one of six possible locations the central chinrest was located in front of the monitor at a distance of 600 mm within peripersonal space on each trial participants were instructed to indicate using keypresses the shorter side of each line 1 the absolute position of each line was jittered between trials from 15 to 15 mm of the true center of the screen three circles indicated when each participant should provide their response participants hands were covered by a cloth preventing them from seeing one anothers responses these circles were also jittered 15 to 15 mm from true center on each trial the order of participants responses was randomized there were 72 trials per block each pair participated in six blocks one person would be seated in the center for three blocks in which their partner 1 after testing was completed we noted that this instruction varied from szpak et al who asked participants to respond to the longer side of the line however our instruction is more consistent with the instruction sometimes used in the literature to judge whether the transector is to the left or right of the true line midpoint in the presence of a cue because task instructions may interact with performance on this type of task we performed a control experiment to address the possibility that task instructions could yield a difference between our findings and those of szpak and colleagues matching the main sample we targeted a sample size of 32 participants after exclusions fortyseven new participants performed two blocks of the control task in one block participants followed the respond shorter instruction in the other block participants followed the respond longer instruction following the same exclusion criteria used for the main sample 11 participants were excluded leaving 36 for the analysis thresholds obtained in the two conditions were not statistically different t 124 p 022 bf 10 036 indicating that the point of subjective equality measurement was not affected by instruction was seated on the left seated on the right and absent from the room then the procedure was repeated with the other participant seated in the center after testing questionnaire responses were collected demographic information ratings of participants liking and awareness of their partner the inclusion of other in the self scale the edinburgh handedness inventoryshort form the selfconsciousness scale and the autism spectrum quotient data from two pairs were excluded because one member failed to comply with instructions in addition three individuals were excluded when testing sessions were forced to end early one individual was excluded for selfreporting an attentionrelated diagnosis and three individuals were excluded after reporting that their vision was below normal and uncorrected but in these cases data from partners was retained in the analysis furthermore 12 additional participants were excluded for responding with more than 90 right or left answers on a single block or who on any block made more right is longer responses in the most extreme leftward bisection condition as compared to the most extreme rightward bisection condition this yielded 31 participants in the final analysis from participants responses the point of subjective equality was calculated for each block in which they were seated in the center this procedure was intended to match previous work line bisection thresholds were estimated separately for each participant and each seating condition by fitting psychometric functions to response data using the palamedes toolbox a cumulative gaussian function was fit to response data using a maximum likelihood criterion where the threshold parameter was free to vary the slope was fixed at 1 and the guess and lapse rate were both fixed at 0 these parameters are consistent with the function fitting performed in szpak et al results all supporting data for this paper are available at pghe5 figures 3 4 were generated using the ggplot2 package in r software preplanned analyses based on the thresholds identified for each participant for each partner location the mean change in threshold toward the other individual was calculated in mm termed the sis a positive sis indicates a shift in attention toward the other individual while a negative score indicates a shift in attention away in their first experiment szpak and colleagues found a mean sis of 022 mm which was significantly different from zero in the current study mean sis was found to be 012 mm with a 95 confidence interval of a bayes factor for this analysis was obtained using the ttestbf function in the bayesfactor package for r mean sis was not significantly different from zero twotailed onesample ttest t 135 p 019 bf 10 044 a bayes factor smaller than one indicates greater evidence for the null hypothesis than the alternative hypothesis in this case the data are 1044 or 23 times more likely under the null than the alternative hypothesis however the present mean sis was significantly different from that calculated by szpak and colleagues twotailed onesample ttest t 387 p 00006 bf 10 557 a bayes factor between 10 and 100 is considered strong evidence for the alternative hypothesis that note that thresholds are not different based on partner position our measured value is different than the comparison value exploratory analyses in the original work by szpak and colleagues calculation of sis involved collapsing effects across left and right seating positions to investigate the possibility that leftward and rightward effects might differ in our sample a withinsubjects anova was performed with partner location as the iv and threshold as the dv this analysis revealed no effect of partner location on line bisection thresholds f 107 p 035 to evaluate whether this constituted good evidence for the null hypothesis a bayesian anova was performed using the bayesfactor package in r the bayes factor for this analysis was 013 therefore these data are 1013 or 77 times more likely under the null hypothesis than under the alternative hypothesis to address the question of whether individual participants could show meaningful shifts toward or away from their partner the error around each participants individual sis was calculated to estimate the error of threshold estimates a nonparametric bootstrap was performed using 1000 bootstrap simulations for each condition the standard error for the sis for each participant was calculated as the standard deviation of the composite bootstrapped sampling distribution created by averaging the subtraction of the no partner from the partner right and the partner left from the no partner bootstrapped sampling distributions the 95 ci was calculated individually for each participant as their sis estimate ±196 times the standard error a negative sis with a 95 ci that did not include zero was considered attentional withdrawal for that individual a positive sis with a 95 ci that did not include zero was considered attentional attraction for that individual within the final sample of 31 participants five instances of attentional withdrawal were found and nine instances of attentional attraction the remaining 17 individuals in the sample did not fit either definition and could be considered attentionally neutral with respect to their coactor to investigate potential sources of this individual difference in sis the correlation between sis and the following measures was calculated rating of liking the partner rating of awareness of the partner selfother integration score total score on the selfconsciousness scale and total score on the autism quotient none of these measures was significantly correlated with sis however male and female subjects differed from one another in their siss t 257 p 002 bf 10 158 with women showing positive scores on average and men showing negative scores on average see figure 3 subjects who were tested first within their pair did not significantly differ in sis from subjects who were tested second t 019 p 085 bf 10 035 discussion the present work attempted to replicate and extend linebisection as an effective method for measuring a spatial change in social attention previous work found that during a joint line bisection task onscreen attention was biased away from the side of the screen nearest the coactor thus this task could provide a useful and straightforward index of social attentional shifts and could be used alongside paradigms that measure action kinematics reaction time and search behavior in joint contexts to further characterize the tool measures about the individual and the pair were collected in order to try to capture sources of individual differences in this measure the task was matched to the original paradigm on a host of factors including stimulus dimensions viewing distance interpersonal spacing and sequence of blocks and of trials task instructions differed from those used in the original paradigm but more closely resembled those used in the literature a control experiment excluded instruction as a meaningful source of empirical variation between experiments this work failed to replicate the effect of attentional withdrawal from the coactor as measured by onscreen line bisection performance these discrepant results suggest three possibilities first it may be that the attentional withdrawal phenomenon is real but fragile such that small crosslaboratory differences or demographic differences between previous and current samples extinguish the effect at the group level in this scenario the present work would represent a false negative with respect to the true effect or would capture a boundary condition under which this effect is not observed assuming that the effect size of the original study is accurate the present failure to replicate is unlikely to be a false negative due to inadequate power due to the combination of an achieved power of 079 the observation of a positive overall sis and strong evidence that this value differed from that obtained by szpak et al a second possibility given the discrepancy between current and previous work is that the attentional withdrawal phenomenon is real but due to the small power of the original study the original effect size estimate was inflated and thus the present study was underpowered this seems unlikely for the same reasons mentioned above the two results were significantly different from one another and differ in their direction rather than simply their magnitude this seems to indicate that the two studies do not capture the same process a third possibility is that coactors do not impact line bisection performance in this paradigm and prior work reflects an unfortunate false positive there are two methodological points that merit consideration here first szpak et al do not report details about the fit of their curves our participants often failed to reach 100 left responses in the leftmost stimulus condition presumably because even the most extreme stimulus conditions remained somewhat difficult assuming that the current data resembles the previous sample this raises a concern about the validity of this procedure as a measure of line bisection thresholds while the current work followed the procedure used by szpak et al for the purpose of a straightforward replication future work might employ more sophisticated curvefitting to ensure that pse calculations are truly reflective of participants response patterns second the present study excluded a number of participants whose data did not meet criteria regarding accurate task performance szpak and colleagues report excluding a maximum of three participants per experiment based on the width of their psychometric functions while it is certainly possible that the original group were able to obtain superior participant compliance through some other means the discrepancy is notable if the present data are reexamined to include all participants who were initially excluded for data quality reasons mean sis actually takes on a significantly positive value m 024 mm twotailed onesample ttest t 206 p 0046 bf 10 111 thus the inclusion of additional participants does not lead to a replication of the attentional withdrawal effect obtained by szpak and colleagues if anything it provides support for an attentional attraction effect that dovetails with much of the social attention literature while evidence of attentional withdrawal in the joint line bisection task was not shown at the group level exploratory analyses revealed an interesting underlying structure within the current sample first a subset of individuals showed evidence of attentional withdrawal while others showed attentional attraction as noted attentional attraction is consistent with the task performance one would expect based on the bulk of the social attention and line bisection literatures suggesting that for these participants the coactor might impact the attention system through similar mechanisms as those involved for other cue types attentional withdrawal on the other hand is consistent with the social discomfort hypothesis that attention is withdrawn from nearby others under conditions of personal space invasion none of the questionnaire measures correlated with the sis so it is difficult to speculate about any underlying dimensions on which participants varied that could explain their different performances selfconsciousness autistic traits integration of the other into the self and awareness or liking of the other individual were all independent of sis however gender emerged as an organizing variable with men generally showing attentional withdrawal from the coactor and women showing attentional attraction it would be interesting to investigate in the future whether men experienced the situation as more invasive of their personal space perhaps due to larger body size andor whether women were more likely to attend to the other individual as they would other cue types the latter prediction could be consistent with work finding differences in sensitivity to social information across the sexes this includes a higher willingness to make eye contact and a stronger tendency to orient to faces by female as compared to male infants and stronger gazecueing effects in female as compared to male adults in conclusion based on the current evidence we see little support for the joint line bisection task as a reliable overall measure of spatial allocation of social attention thus we cannot recommend it for future application within this domain however the data do suggest that should researchers wish to pursue the bisection task as a means for measuring social attention we would encourage its investigation at the individual level rather than the group level ethics statement the protocol was approved by the university of british columbia behavioural research ethics board all subjects gave written informed consent in accordance with the declaration of helsinki conflict of interest statement the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

there is a growing consensus among researchers that a complete description of human attention and action should include information about how these processes are informed by social context when we actively engage in coaction with others there are characteristic changes in action kinematics reaction time search behavior as well as other processes see sebanz et al 2003becchio et al 2010wahn et al 2017 it is now important to identify precisely what is shared between coactors in these joint action situations one group recently found that participants seem to withdraw their attention away from a partner and toward themselves when coengaged in a line bisection judgment task szpak et al 2016 this effect runs counter to the typical finding that attention is drawn toward social items in the environment birmingham et al 2008 birmingham et al 2009foulsham et al 2011 as such the result suggests that joint action can uniquely lead to the withdrawal of covert attention in a manner detectable by a line bisection task performed on a computer screen this task could therefore act as a simple and elegant measure of interpersonal effects on attention within particular pairs of participants for this reason the present work attempted to replicate and extend the finding that attention as measured by a linebisection task is withdrawn away from nearby coactors overall our study found no evidence of social modulation of covert attention this suggests that the line bisection task may not be sensitive enough to reliably measure interpersonal attention effects at least when one looks at overall group performance however our data also hint at the possibility that the effect of nearby others on the distribution of attention may be modulated by individual differences

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introduction it is well known that a higher status in society is associated with better health and the uneven distribution of financial resources between sexes has been shown to explain poorer wellbeing and health among women compared to men 1 2 3 4 5 like women in many other countries swedish women have poorer wellbeing and health than men and there is a substantial income gap between sexes in 2011 swedish women earned 14 less than men 6 7 8 9 10 although labour market participation among swedish women is high women work in professions with lower wages and fewer opportunities for career development and are underrepresented in senior management to a higher extent than women in several other countries 61112 better knowledge regarding the predictors of career success possibly leading to higher status and better health among women is therefore essential in a review of the international literature on predictors of objective career success ng eby sorensen et al found that the association between human capital variables and salary were stronger for women than men whereas they found no gender differences in predictors of promotion 13 however results from two recent prospective studies indicate that human capital variables are better rewarded in terms of salary for men than women 1415 to our knowledge no prospective study of gender differences in predictors of objective career success has been conducted using a contemporary representative sample of the swedish working population the objectives of the present prospective study were to assess 1 whether organisational and individual factors predicted a job promotion and b an aboveaverage salary increase between 2008 and 2010 in swedish women and men and 2 whether the associations differed by sex materials and methods study sample a prospective study was performed using questionnaire data from the swedish longitudinal occupational survey of health slosh is a nationally representative cohort of the swedish working population which started in 2006 as a followup to the 2003 swedish work environment surveys conducted by statistics sweden subsequent followups in slosh are conducted every second year and the participants are followed by means of a postal selfcompletion questionnaire in two versions one for those currently in paid work at least 30 of full time and one for those in paid work fewer hours or who are not working at all a more detailed description of the study can be found elsewhere 16 the present study is based on the respondents from slosh 2008 and 2010 the response rate in 2008 was 611 out of those 767 also participated in 2010 only respondents who identified themselves as in paid work in both waves were included in our analyses respondents to the 2008 and 2010 questionnaire differed from nonrespondents to slosh on a number of characteristics in comparison to nonrespondents a somewhat higher proportion of respondents were women married born in sweden had university education worked in the governmental sector and their mean age was higher the participants received written information about the study and in accordance with swedish regulation and practice responding to and returning the survey indicated informed consent the regional research ethics board in stockholm approved the study variables respondents who reported having a higher position in 2010 than 2008 were categorised as having been promoted and those who reported an unchanged position as not promoted respondents with a lowered position in 2010 relative to their position in 2008 were excluded from the analyses of promotion yearly salary in sek was derived from national registers and includes all taxable income respondents with a decreased salary were excluded from analyses of salary increase since these individuals may have started working fewer hours due to a variety of reasons such as parenthood retirement or sickness the mean increase in salary among men and women included in our study between 2008 and 2010 was 50000 sek any value higher than this threshold was categorised as an aboveaverage salary increase a higher cutoff was not used in our analyses because it would have included too few women labour market sector was categorised into private public and other and adjusted for in the regression analyses in addition to staff category categorised into bluecollar whitecollar manager and other age was divided into the categories 1930 3140 4150 and 5170 years whether children were living at home or not was included in the analyses as a dichotomous variable educational level was analysed in three categories up to 12 years of school university education and postgraduate education number of hours worked was categorised into 40 4150 5160 and 60 hours per week procedural justice consists of 7 items reflecting whether the decisionmaking procedures are accurate correctable consistently applied and whether the procedures include opinions from the people involved the 5 response alternatives range from completely agree to completely disagree the internal consistency of the sum index was high the sum score was divided into quartiles with the best quartile categorised as high procedural justice and the others comprising the reference category 17 taking part in decisionmaking processes was measured with the question to what extent are you involved in decisionmaking at your workplace the response alternatives to a very great extent and to a great extent were categorised as to be part of decisionmaking and the response alternatives to a small extent and to a very small extentnot at all formed the reference categories having a manager who listens to you was measured with the question does your manager genuinely listen to what you have to say the response alternatives to a very great extent and to a great extent were categorised as a manager who listens and the response alternatives to a small extent and to a very small extentnot at all formed the reference categories conflicts with superiors were measured with the question in the past two years have you been involved in any kind of conflict with bosses at your workplace with the response alternatives yes or no the question regarding coping strategy is worded as during the past two years when you have felt steamrollered or unfairly treated by your managermanagers how have you reacted immediately made clear and clearly showed my feelings and suggested a compromise or other solution formed the open coping strategy and kept quiet and brooded over it and taken it out on my familythose closest to me the covert coping strategy using any coping strategy always or most of the time indicated a use of this coping strategy 1819 motivation to advance professionally was categorised into not at all to some extent and very eager to advance statistical methods in order to assess whether organisational and individual factors predicted job promotion and an aboveaverage salary increase our first objective we analysed data with two separate logistic regression models each stratified by sex we obtained odds ratios and 95 confidence intervals of each outcome in 2010 for possible predictors measured in 2008 the predictors were sociodemographic variables human capital variables organisational variables relationship with manager and coping strategies and motivation the predictors were all included simultaneously in each of the two models and were thus mutually adjusted for each other we furthermore adjusted for labour market sector and staff category at baseline to investigate whether the associations differed by sex our second objective we tested for interactions on the additive and multiplicative scales between sex and the potential predictors additive interaction was measured with relative excess risk due to interaction in stata v13 20 each multiplicative interaction term was added to the full model in separate nonstratified logistic regression analyses statistical differences in the distribution of variables between men and women were estimated with chisquare tests all analyses except the tests of additive interactions were conducted with spss version 21 results men and women were promoted to the same extent over the study period but men more often received aboveaverage salary increases equally men more often worked within the private sector and as managers the proportion of women who were very eager to advance was almost equal to that of men but there was also a higher percentage of women than men who were not at all eager to advance in total 12 percent of the women and 24 percent of the men reported working at least 51 hours a week reporting high procedural justice being part of decisionmaking processes at work having conflicts with superiors and using open coping strategies were more common among men and covert coping strategies were more common among women sociodemographic variables as shown in tables 2 and3 lower age was associated with higher odds of both promotion and receiving an aboveaverage salary increase having children living at home was not a significant predictor of promotion in either sex but was positively associated with an aboveaverage salary increase among women further analyses showed that adjustment for taking days off work to care for sick children in the past 12 months made the relationship between having children living at home and an aboveaverage salary increase among women nonsignificant human capital variables educational level was not associated with promotion among women but both university education and postgraduate education significantly predicted an aboveaverage salary increase among men a postgraduate education predicted promotion and a university education predicted an aboveaverage salary increase working 60 hoursweek was significantly related to promotion among women but weekly working hours were not associated with an aboveaverage salary increase among men working hours were not significantly associated with promotion but men who worked 5160 hoursweek had higher odds of an aboveaverage salary increase organisational variables as shown in tables 2 and3 procedural justice was not related to promotion or an aboveaverage salary increase in either sex both women and men who reported to be part of decisionmaking processes at work had higher odds of being promoted taking part in decisionmaking also predicted an aboveaverage salary increase among men relationship with manager reporting to have a manager who listened neither predicted promotion nor an aboveaverage salary increase in either sex both men and women who reported having conflicts with superiors had higher odds of promotion but conflicts did not predict an aboveaverage salary increase coping strategy and motivation coping strategies were not associated with career success among women men who reported using an open coping strategy when in conflicts with superiors had higher odds of job promotion motivation to advance professionally was a significant predictor of promotion in both sexes and furthermore predicted an aboveaverage salary increase among women gender differences the tests of additive interaction between sex and the other variables indicated two significant differences by sex although procedural justice did not predict promotion in either sex the associations pointed in different directions for men and women and procedural justice was shown to be more important for womens odds of promotion than mens furthermore men who used an open coping strategy had significantly higher odds of a promotion than women the test of additive interaction furthermore showed that although open coping did not predict an aboveaverage salary increase in either sex open coping was shown to be more important for mens odds of a salary increase than for womens the tests of multiplicative interaction between sex and the other variables in the full regression model yielded no significant associations regarding promotion however for aboveaverage salary increase there were significant interaction effects between sex and postgraduate education very high motivation to advance and having children living at home such that women had higher odds of an aboveaverage salary increase and with using an open coping strategy such that men had higher odds discussion in the present study we found age education working hours taking part in decisionmaking processes having conflicts with superiors and motivation to advance professionally to predict career success in women and men several gender differences were observed men and women were promoted to the same extent over the study period however for women high procedural justice was more important for promotion between 2008 and 2010 and for men using an open coping strategy was more important furthermore men more often than women increased their salaries by more than the average amount between 2008 and 2010 and men had higher odds of an aboveaverage salary increase relative to women when using an open coping strategy women had higher odds than men of an aboveaverage salary increase if they had been educated to postgraduate level had high motivation to advance and had children living at home the results are discussed below sociodemographic variables based on previous findings it was expected that women with children living at home would have a smaller salary increase than men 1415 21 22 23 24 contrary to expectations the present results indicated that having children living at home predicted an aboveaverage salary increase among women to a significantly higher extent than among men however further analyses showed that the true income raise among mothers was due the fact that their children had grown older and were less sick in 2010 than in 2008 human capital variables only men with a postgraduate education had significantly higher odds of promotion although a trend towards higher odds was seen also among women the number of hours worked was a significant predictor of promotion among women only which might be explained by the fact that the relatively few women who worked such long hours became visible to decisionmakers 25 however in accordance with results reported by ng et al no statistical differences between sexes were found in the associations between human capital variables and promotion 13 women with a postgraduate education were rewarded in terms of an aboveaverage salary increase to a significantly higher extent than men it should be noted that a salary increase of 50000 sek indicates a higher relative increase among women than men the result may be explained by greater demands on specialised knowledge in fields where women work such as in health care regulations implemented to equalize income differences between sexes may furthermore have favoured women over the time period however the result could also indicate that women need better formal merits than men in order to reach higher salary levels also discussed by ng et al 13 hours worked predicted an aboveaverage salary increase among men but not women however contradictory to results reported by ng et al there was no statistically significant gender difference organisational variables there was no main effect of high procedural justice on career success for women which may seem surprising given reports of gender discrimination 2627 however tests of additive interaction revealed that procedural justice may be more important for women to advance than for men this indicates that procedural justice may be an important tool if wanting to increase womens representation on higher organisational levels being part of decisionmaking processes at work predicted job promotion two years later which may not seem surprising a promotion may be a natural step following taking part of decisionmaking processes taking part in decisionmaking was significantly associated with promotion regardless of other factors which suggests that decisionmakers could choose to engage women in decisionmaking processes if they are interested in promoting more women to higher organisational positions men who were part of decisionmaking processes at work were rewarded in terms of aboveaverage salary increase which may be explained by beneficial salary trends in maledominated occupations 12 relationship with manager reports of having a manager who listened were not predictive of promotion or an aboveaverage salary increase in contrast ng et al found supervisor support to be significantly associated with salary 13 this difference may be due to the fact that slightly different concepts were measured a manager who listens may not necessarily be supportive furthermore many supervisors may have limited control over their subordinates pay since salaries are often regulated in agreements between employers and unions the significant association between conflicts with superiors and promotion suggests that individuals who do not shy away from conflicts may be viewed as having leadership skills the participants promotions may also have been preceded by power struggles with a superior that led to successful outcomes for the respondent the lack of association with an aboveaverage salary increase could be due to more frequent conflicts with superiors in parts of the labour market where salaries are lower 28 coping strategy and motivation results of tests for interaction between sex and coping strategy showed that men who used open coping strategies had significantly higher odds of promotion and an aboveaverage salary increase than women this result supports that open coping strategies are associated with better career outcomes for men than women in previous studies men have also been shown to use open coping strategies more often than women 1819 agency which theoretically could be linked with open coping strategy has previously been shown to be associated with career success in both sexes 1429 however the present result suggests that an open communicative style is regarded positively among men but not women this result supports the theory of a double bind for women meaning that women who show competencies associated with successful leadership may be punished for violating gender role expectations 30 a larger proportion of women than men were not at all eager to advance which may be explained by lower expectations to prioritize a professional career associated with the female gender role it could also be due to the fact that in occupations dominated by women possibilities for promotions are very limited and job promotions may furthermore imply more work but not considerably higher rewards 12 however our results also show that women with high career motivation are rewarded with job promotion and higher salaries strengths and limitations of the study the present results support previous findings that very highly educated women are better rewarded in terms of salary than men to our knowledge it has not previously been shown that a high motivation to advance professionally may predict an aboveaverage salary increase among women more often than among men furthermore the result that women who report a high procedural justice have higher odds of a promotion than men is important it indicates that improving procedural justice in organisations has the potential to increase the female representation in more senior roles the finding of a gender difference in positive career outcomes associated with using an open coping strategy is also interesting it supports the existence of strong gender role expectations in behaviours also in a country sweden which has relatively high gender equality however there are several limitations to take into account when interpreting our results the participants were followed for only two years and the longterm effects of career interruptions known to strongly impact career success were not evaluated 14212431 there are also several other possible predictors of promotion not included in this study eg mentoring and further training because no such data were available in slosh another limitation is that we did not have data regarding which organisational levels the participants were working at furthermore many of the variables used represent the perception of the individuals which may be influenced by the dependent variable of promotion however because the predictors were measured before promotion there is limited risk that the results are influenced by an erroneously positive or negative perception of for example procedural justice depending on promotion furthermore data on salaries were taken from national registers and could thereby not be influenced by other factors measured in the study as mentioned above the study is derived from a nationally representative sample but due to attrition bias there are some limitations in the generalizability of our results there was for example a lower representation of younger age groups in this study and therefore we cannot fully generalise our results to the youngest swedish workers in spite of these limitations the results add considerably to the literature by assessing gender differences in predictors of career success in prospective data derived from a nationally representative sample in a country that has relatively high gender equality conclusion the present prospective study supports previous results showing gender differences in human capital predictors of salary our results indicate that women need to attain higher educational credentials and have a stronger career ambition than men in order to obtain an aboveaverage salary increase women furthermore appear to be more dependent on organisational characteristics in order to advance than men men were more successful in their careers than women when they exhibited typical male attributes our results support the existence of gendered structures in swedish working life where women rely more on formal knowledge ambition and justice within the organisation to be successful and men rely more on behavioural components related to their gender role the slosh data cannot be made fully publicly available due to legal restrictions we are not allowed to publish the data set underlying our findings since that would compromise the integrity and privacy of the study participants for data requests please contact the slosh data manager constanze leineweber

the aim of this prospective study was to explore predictors of objective career success among swedish women and men focussing on gender differences data were drawn from the 2008 and 2010 waves of the swedish longitudinal occupational survey of health slosh with a total of 3670 female and 2773 male participants odds ratios and 95 confidence intervals for job promotion and an aboveaverage salary increase between 2008 and 2010 were obtained through binary logistic regression analyses individual and organisational factors measured in 2008 were used as predictors in analyses stratified by sex mutual adjustment was performed for these variables as well as for labour market sector and staff category at baseline in both sexes younger age predicted both job promotion and an aboveaverage salary increase job promotion was also in both sexes predicted by being part of decisionmaking processes having conflicts with superiors and being eager to advance furthermore promotion was predicted by among men being educated to postgraduate level and having an open coping strategy and among women working 60 hours week an aboveaverage salary increase was predicted in both sexes by having a university education postgraduate education having children living at home and being very motivated to advance predicted an aboveaverage salary increase among women as did working 5160 hoursweek and being part of decisionmaking processes in men gender differences were seen in several predictors in conclusion the results support previous findings of gender differences in predictors of career success a high level of education motivation to advance and procedural justice appear to be more important predictors of career success among women while open coping was a more important predictor among men

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introduction disparate abilities to obtain needed medical care in the us are at the heart of health disparities across americas diverse population with immigrants perhaps the most disadvantaged notable social and economic diversity exists within the immigrant population however leading us to ask how do perceived medical need and access to regular physician care compare for the largest immigrant groups in the us together hispanics and asians make up more than 80 of the us immigrant population 1 and in the face of continuing large immigrant streams as well as relatively high hispanic immigrant fertility 2 the health of the foreignborn and their offspring has important implications for overall public health specifically extant raceethnic health inequalities in the us will be greatly affected by these two large and transformative immigrant groups most past research on health and health care access focuses on majorityminority health differences eg natives versus immigrants whites versus blacks or nonhispanics versus hispanics 3 4 5 6 7 8 9 10 the current study compares hispanic and asian immigrantsimmigrant streams that possess unequal levels of individual and family human and economic capital notably in educational attainment and income given that these characteristics are key determinants of health care access 11 it is not surprising that hispanic and asian immigrants exhibit different patterns of morbidity and mortality 9 furthermore while most prior studies analyze general physical health outcomes we consider immigrant group inequalities in both perceived medical need and receipt of regular physician care our study uses recent panels of the survey of income and program participation to address four main questions do hispanic and asian immigrants differ with respect to perceived medical need and regular physician care does socioeconomic status mediate immigrant group differences in perceived medical need and regular physician care how does immigrant assimilation relate to the immigrant group differences in perceived medical need and regular physician care are the relationships between socioeconomic status and immigrant assimilation and the health care outcomes mediated by health insurance coverage disparities background studies of health care access and utilization primarily draw on andersens behavioral model 12 which delineates three determinants of using health care services predisposing factors enabling resources and need predisposing factors include demographic traits social structure or determinants of an individuals social standing and health beliefs these factors influence the presence of enabling resources which may be at the community or personal level to improve the relevance of andersens model for hispanics mejia and colleagues introduced immigrantspecific characteristics such as years in the us and acculturation generally as enabling resources 13 these characteristics fit with andersens model well whether one considers economic assimilation as an enabling resource aiding access to care or as a predisposing sociocultural characteristic that influences the social structure within which immigrants function or that influences their culturally directed health beliefs and behaviors andersens third component need captures the biological and social imperative that catalyzes individuals help seeking and consumption of health services 12 studying immigrants as a group may mask hispanic and asian immigrants distinct socioeconomic profiles with asians on average having more enabling resources such as more education and wealth than hispanics 14 15 16 17 18 acs 2010 figures indicated that only 53 of latin american immigrants had completed a high school degree or higher compared to nearly 84 of asian immigrants 18 similarly immigrants from latin america had a median family income of 38238 approximately 25000 less than asian immigrants whose median family income was 63777 18 importantly higher educational attainment is associated with better income and linked to a greater likelihood of having health insurance coverage indeed almost a quarter of the poorest americans with annual family incomes less than 25000 had no health insurance coverage in 2012 compared with just over 21 of the next poorest income group with family incomes between 25000 and 50000 only 15 of those with annual incomes between 50000 and 75000 and fewer than 8 of the highestincome americans 19 in establishing the theoretical foundation for the connection between education and health ross and wu 11 began by noting the wellresearched and longstanding acceptance of the link beginning with studies in the 1980s the reason for the link they explained is that educational …inequality sorts people into different positions that are associated with different risks and rewards with different …work and economic circumstances social psychological resources and lifestyle s … these three aspects in particular they noted explain why the socioeconomically advantaged tend to be healthier the better educated are more likely to work to work in psychologically and financially fulfilling jobs to have selfperceptions of mastery and selfcontrol as well as good communications skills and problemsolving abilities and to engage in healthier lifestyle behaviors which include accessing preventive medical care in addition to socioeconomic disparities sociocultural differences also distinguish hispanic and asian immigrants which may influence knowledge of and the perceived need for health care for instance as of 2010 43 of all hispanics lived in census tracts with a hispanic majority compared to 11 of all asians who lived in asianmajority census tracts 20 living near more coethnics may abate the assimilation process by limiting immigrants contact with natives or noncoethnics or may simply indicate less assimilation to mainstream behaviors less assimilation may be associated with reliance on traditional health remedies or low cultural recognition of a need for regular physician care 21 furthermore more recently arrivedless assimilatedimmigrants are at a double disadvantage in gaining health insurance coverage an important proximate health careenabling resource recent immigrants may not be as likely as established immigrants to gain coverage through employment and are ineligible for publicly provided assistance within the first 5 years of living in the us in most states of course segregated living among coethnics also has the potential to increase knowledge about and transportation resources for traveling to community health care facilities through the provision of social support from others who share language cultural scripts for health behaviors and a need for information to navigate an unfamiliar health care context these competing interpretations of the role of assimilation add to the complexity of the link between assimilation and use of formal health care further complicating this concept as an explanation for immigrant group differences is that the assimilation process as articulated in its classic form 2223 is expected to function similarly for all recent immigrants nevertheless observed differences in coethnic residential segregation and other work on the unique assimilation patterns of immigrants from diverse origin countries hint at possible differences in assimilation between these two immigrant groups which may help to explain any hispanicasian immigrant disparities in perceived or realized access to health care given these socioeconomic and contextual differences providing health care to hispanic immigrants may present different challenges than it does for asian immigrants consequently hispanic immigrants may experience lower levels of perceived met medical need and have fewer doctor visits than their asian counterparts which in the long run may lead to greater health problems among hispanics we expect that asian immigrants who tend to have higher educational attainment and income on average are better able to access health care services than hispanic immigrants and thus are more likely to have had their medical needs met and receive routine physician care we therefore expect that education and income levels will mediate the hispanicasian immigrant inequality in access to health care because immigrant assimilation is likely to elevate socioeconomic status assimilationrelated characteristics are expected to be related to access to health care by this reasoning any relationship between assimilation characteristics and our health outcomes is expected to be mediated by socioeconomic status health insurance coverage is a key enabling resource expected to increase access to health care because health insurance is provided primarily through employment624 of nonelderly americans were covered by employersponsored insurance in 2006 26 we anticipate that insurance coverage will mediate the relationship between socioeconomic status and access to health care we also expect it to mediate the association of assimilationrelated characteristics and health care access because of the relationships among assimilation socioeconomic status and health insurance coverage methods data data came from the 2004 and 2008 panels of the sipp the us census bureau has conducted sipp since 1984 to measure the effectiveness of existing government programs and to estimate the countrys income distribution throughout the fouryear study interviewers collected monthly data every 4 months for all members of the sampled household in addition to the core questionnaire a topical module was administered at each wave to gather additional information for the 2004 panel the study variables came from the core questionnaire at waves 3 5 and 6 and the second third fifth and sixth topical modules for 2008 the corresponding sources are the core questionnaire at waves 4 and 6 and the second fourth and sixth topical modules the analytic sample was restricted to hispanic and asian immigrants aged 19 and older who had a nonmissing value on either dependent variable the data were organized in long format where each row represented a unique personwave in order to use as much of the original data as possible the final individuallevel sample included 15331 personwaves contributed by 11398 persons approximately 62 of the individuals in the sample were hispanic study variables we analyzed two dichotomous measures of health care accessutilization in this study a respondent was considered to have met need if all household members had obtained needed health care services or did not perceive a need for health care in the past year 27 since this question applied to the entire household we randomly selected one adult from each household to be included in the secondary dataset individuals perception of their health status and their relatives health status dictated whether and which health care services were needed in contrast regular access to a doctor is a behavioral measure of whether respondents had had contact with a physician within the past year although guidelines for adult routine care differ by age gender and service the benchmark of one doctor visit per year was used to indicate respondents regular access to health care we expect that individuals who visit a doctor at least once a year are able to navigate the health care system and are more likely to sustain a relationship with if not the same provider medical providers in general our explanatory variables are shown in table 1 immigrant group distinguished nonhispanic asian immigrants from hispanic immigrants of any race following previous literature educational attainment and income were both operationalized as categorical variables income or the ratio of family income to the federal poverty line had four categories below the poverty line low income medium income and high income health insurance coverage was dichotomized as ever being uninsured versus having continuous insurance coverage during the past year age most recent selfreported health status marital status and presence of children in the family were included as control variables pertaining exclusively to the immigrant experience three assimilationrelated characteristics were included length of time in the us english language proficiency and us citizenship status analytical approach using sas version 9 descriptive statistics were generated to summarize the study variables and multivariate logistic regression was used to assess the association between the independent variables of interest and the two binary measures of health care access utilization for each outcome we started with a bivariate model to determine if hispanicasian immigrant inequality was present and proceeded according to the research questions because social support is often noted as important for immigrant wellbeing we included this variable in preliminary mediation analyses however finding that perceived social support did not play a role in explaining the immigrant group difference we chose to exclude the indicator from our final models strata and cluster variables accounted for the complex sampling design and repeated measures for the same individual 1 person weights were used to accurately represent the us noninstitutionalized population this study has been approved by the penn state irb results descriptive statistics table 1 presents descriptives for the total sample and for hispanic and asian immigrants separately the person is the unit of analysis unless otherwise noted personwave descriptives did not vary substantively from what is presented here in terms of perceived medical need 953 of asian immigrant households had met need compared to 888 of hispanic immigrant households similarly asians were more likely to have a doctor visit in the past year than hispanics together these findings suggest that hispanic immigrants are at a greater disadvantage than asian immigrants with respect to the formal health care system 28 29 30 hispanic immigrants were more likely to be younger male without a high school diploma or bachelors degree low or middle income ever uninsured in the past year and of unknown length of time in the us in contrast asian immigrants were more likely than hispanic immigrants to be in excellent health have a bachelors degree high income speak english at home and be a us citizen there are important intragroup differences within the hispanic and asian immigrant samples while the majority of hispanics had income below 200 fpl almost 20 had income greater than or equal to 300 fpl the reverse is true for asian immigrants 380 of asians had income below 200 fpl while the majority had income in the high income category for length of time in the us most hispanic and asian immigrants had lived in the country for more than 15 years yet for both immigrant groups a considerable portion had lived in the us for a shorter period less than 5 of both groups had lived in the us for less than 5 years since these two groups do not vary greatly in their length of us residency this variable in particular may not explain much variation in our outcomes furthermore the outcome variables will reflect primarily the experiences of immigrants who have been in the us for longer periods of time multivariate logistic regression results table 2 shows regression results for models predicting perceived met medical need in the base model asian immigrants had higher odds of reporting met need than hispanic immigrants however hispanicasian inequality in subjective met need was attenuated to nonsignificance by the model covariates namely education income and ever being uninsured in the past year as expected educational attainment and income were key mediators of the relationship between immigrant group and met need comparing models 1 and 2 the odds ratio for immigrant group was reduced by more than half in other words if hispanic immigrants attained the same education and income as asian immigrants hispanicasian immigrant inequality in met need would be significantly ameliorated additionally if hispanic immigrants were as likely as asian immigrants to be continuously insured there would be no gap in met need between the two groups the assimilationrelated variables did not mediate the relationship between immigrant group and met need only us citizenship was significantly related to having met medical need among us citizens the odds of reporting no unmet needs increased by almost 60 health insurance coverage partially mediated the relationship between income and having met medical need the coefficients for the second and third income categories were no longer significant at the 5 level when controlling for unstable health insurance likewise health insurance coverage in conjunction with education and income attenuated the positive relationship between us citizenship and met need us citizenship confers greater access to health insurance which in turn reduces immigrants likelihood of having unmet medical need it is noteworthy that the positive association between education and perceived medical need remained significant in the full model controlling for the myriad covariates having less than a high school degree decreased the odds of reporting met need by more than 40 table 3 reports regression results for models predicting regular access to a doctor like for perceived medical need in the base model asian immigrants had higher odds of at least one doctor visit in the past year than hispanic immigrants again the model covariates attenuated hispanicasian immigrant inequality in the full model asians had lower odds of regular access to a medical provider than hispanics though not statistically significant at the 5 level education and income mediated the relationship between immigrant group and regular access to a doctor controlling for education and income in addition to the control variables the odds of regularly visiting a doctor were only 15 greater among asian immigrants compared to hispanic immigrants the assimilationrelated variables are highly positively significantly associated with having a regular doctor visit but they did not mediate the relationship between immigrant group and having a regular doctor visit even more so than for perceived medical need health insurance coverage mediated the group difference in having a regular doctor visit while partially mediating the associations between education income and the assimilationrelated variables and having a regular doctor visit however in the full model education income length of time in the us english language interview and us citizenship retained significant relationships with having a regular doctor visit holding all other variables constant speaking english at home and being a us citizen were associated with higher odds of visiting a doctor in the last year conclusion in this study we explored whether hispanic and asian immigrants exhibit different accessibility to health care measured as their perceptions that their medical needs had been met and whether they had seen a physician in the past year whether the socioeconomic predisposing and enabling characteristics educational attainment and income mediate or explain the hypothesized immigrant group inequality whether other sociocultural enabling factorsie assimilationrelated characteristicsplay a role in explaining the relationship between immigrant group and our measures of health care access and utilization and whether these socioeconomic and sociocultural factors work through health insurance coverage to increase access to health care overall for both perceived medical need and regular access to a physician we found strong initial support for the group difference hypothesis it is clear that hispanic immigrants have greater difficulty accessing medical care than their asian counterpartsthey are more likely to believe that there were times they should have seen a doctor but were unable to do so and they are less likely to report that they have seen a doctor in the past year consistent with the logic of andersens behavioral model key predisposing and enabling factors fully mediate the hispanicasian immigrant inequality in perceived met medical need and regular access to a physician although the process differs somewhat for each outcome educational attainment and income as expected proved to be key human and financial capital factors that explained much of the immigrant group differences in both measures of health care access suggesting that educational and income equity would eliminate much of the health care access inequality between hispanic and asian immigrants furthermore andersens proximate enabling factor health insurance coverage does not fully mediate the relationship of educational attainment with either health care access indicator this result signifies that although educational attainment is positively related to structural resources its impact on how people feel about their ability to acquire needed health care and in promoting routine medical care goes beyond providing dollars for accessing care but perhaps gives a certain sensibility about caring for oneself thus our findings suggest an important potential for public health education efforts to promote preventive medical care among immigrants of course the importance of financial access to medical care provided by health insurance cannot be overlooked in general we found support for our research question regarding whether health insurance coverage mediates the relationships of income and assimilationrelated characteristics furthermore the disparity in health insurance coverage can completely explain the health care access differences between asian and hispanic immigrants since the majority of the study sample had been in the united states for more than 5 years most of these immigrants would have had time to find a job with health benefits if one were available if not in most states they would have met us residency requirements for access to federal andor state health benefits in nonemergency situations however hispanic immigrants were still much less likely to be insured contrary to our hypothesis based on mejia et als expanded model for hispanic health care assimilation indicators did not help to explain hispanicasian immigrant health care access inequalities however our results did show that time in the us english language ability and us citizenship are important determinants of access to regular physician care for both immigrant groups as expected from past research 31 32 33 not speaking english at homeand by extension poor englishspeaking skillsis a particularly important barrier to seeing a doctor and this is a problem that can be solved 34 and has been addressed in many places by outreach and public policy efforts 35 36 37 there are several limitations to this study first a number of probable determinants of immigrants health care access were omitted country of origin legal status and geographic context legal status especially differs considerably for asian and hispanic immigrant groups 38 although similar proportions of each group in our study sample have been in the united states for a relatively short period of time recent hispanic immigrants would be more likely than asian immigrants to be undocumented both recent immigration and undocumented status are expected to compromise access to health insurance coverage nevertheless by considering both time in the us and health insurance coverage in our analysis we capture the important mechanisms through which legal status is expected to operate another limitation is that the measure of perceived medical need was measured at the household rather than the individual level however even if the selected adult did not forgo care personally he or she was responsible for the health care utilization of those in the household despite these limitations our study makes an important contribution by using a nationally representative sample to consider how hispanic and asian immigrants differ in access to the formal health care system our results indicate that educational attainment and access to health insurance have critically important relationships with hispanicasian immigrant health access inequalities but that enhanced integration is also an important determinant of health care access for both groups the policy implications of this research highlight not just immigrant access to health insurance but also the importance of educationrelated public health program initiatives for lower ses hispanic immigrants odds ratios for determinants of perceived met medical need odds ratios for determinants of regular doctor visit

in the face of continuing large immigrant streams hispanic and asian immigrants human and social capital inequalities will heighten us raceethnic health and health care disparities using data from the 2004 and 2008 panels of the survey of income and program participation this study assessed hispanicasian immigrant disparity in access to health care measured by perceived medical need and regular access to a physician logistic regression results indicated that hispanics had lower perceived met medical need and were less likely to see a doctor regularly these disparities were significantly attenuated by education and health insurance assimilationrelated characteristics were significantly associated with a regular doctor visit and were not fully mediated by socioeconomic variables findings indicate the importance of education above and beyond insurance coverage for access to health care and suggest the potential for public health efforts to improve preventive care among immigrants

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introduction over the last decade the field of adolescent health literacy has gained momentum globally 1 2 3 4 as a personal asset it highlights the empowerment of adolescents and their own rights of citizenship in society 5 low health literacy in adolescents is associated with a range of adverse health outcomes including healthcompromising behaviours poor health status and overweightobesity 6 7 8 adolescent health literacy is an important and modifiable determinant of health promoting health literacy at an early age is a key intervention strategy to reduce disease burden and health disparities 9 compared to adult health literacy adolescent health literacy is underresearched particularly from a cultural and societal perspective 10 the seminal health literacy framework proposed by the institute of medicine highlights three settings where health literacy can be developed and enhanced at both individual and population levels 11 however most current research focuses on health literacy in either the healthcare context or educational settings 12 13 14 cultural and social contexts shape an individuals beliefs and languages and therefore influence health literacy 11 the relationship between health literacy and an individuals cultural beliefs and language backgrounds has been well documented with immigrants and ethnic minority groups having a higher risk of low health literacy 1015 in the present study we focused on the broad cultural and social environment rather than an individuals cultural beliefs and language backgrounds culture provides a context through which meaning is gained from health information and provides the purpose by which people come to understand their health needs and take actions in healthcare disease prevention and health promotion to maintain good health 1116 similarly the social environment is well documented regarding the conditions over which an individual has little control but that affects his or her health literacy 1 understanding the role of the cultural and social environment in health literacy is important because this will inform strategic directions for health literacy interventions in this multicultural and globalized world particularly in a diverse multicultural population international health literacy studies revealed that the distribution of health literacy levels differed substantially across cultural groups 17 18 19 for instance the european health literacy survey conducted in eight countries revealed that around half of respondents aged over 15 had low health literacy with the prevalence ranging from 287 in the netherlands to 621 in bulgaria 17 while these comparison studies provide an overall picture of health literacy between different cultural groups they mostly focus on adult health literacy the comparison of adolescent health literacy remains unclear using multiple measures of health literacy in a single study allows researchers to learn about how each measure performs to compare results between different measures and to enhance the rigor of findings 20 pleasant et al 21 recommended seven principles to advance the field of health literacy measurement these principles include explicitly built on a conceptual framework multidimensionality in content and methodology measure health literacy on a continuous basis treat health literacy as a latent construct honour the principle of compatibility allow comparison across different contexts including across cultures and prioritize public health applications versus clinical screening however little is known about the utility of these principles in practice given that health literacy is a broad concept with a wide range of assessment tools 3 it is essential to consider it within a specific context for a specific content 22 in this present study we defined adolescent health literacy as an individuals ability to find understand and use health information and services to promote and maintain good health 23 and applied it into school settings schools were chosen because they are critical venues for improving adolescent health literacy through schoolbased programs 13 additionally schools are the most common places where adolescents spend most of their daytime it was therefore feasible and achievable to recruit large samples in a short time we targeted two cultural groups of schoolaged adolescents in china and australia due to two reasons one reason is that low health literacy in adolescents is prevalent in both countries however health literacy measurement is inequivalent and making its results incomparable using consistent measurement tools will enable researchers and policymakers to understand the status of health literacy across cultures and identify unique andor common health literacy needs and influencing factors within each culture thus contributing to directional strategies about nextstep health literacy interventions the second is an opportunistic reason because of the research teams background and partnership networks in china and australia based on pleasants health literacy measurement principles 21 we aimed to examine and compare health literacy between chinese and australian schoolaged adolescents in order to understand the effect of cultural and social environment on adolescent health literacy and identify areas for improvement across different cultural contexts a secondary aim was to advance the practice of health literacy measurement materials and methods study population and sampling design a crosssectional study was designed to recruit adolescents from five secondary schools in two cities four schools in beijing china and one school in melbourne australia using cluster and convenience sampling utilizing existing partnerships with beijing secondary schools we selected two public government schools in a high socioeconomic district and two in a low socioeconomic district at each school two whole classes in each year level were chosen with the number of students in each class ranging from 20 to 35 in melbourne one public government school in high socioeconomic district was recruited and all students in years 79 were invited to participate in the field survey ethics approval to conduct this study was obtained from the university of melbourne and peking university institutional review board to ensure the reporting and methodological quality of this study the strobe statement 26 and pleasants health literacy measurement principles 21 were employed further details are presented in appendices a and b data collection the field survey in beijing was conducted between november and december 2015 passive and optout consent was obtained from both parents and students prior to data collection the principal researcher gave a brief training to ten investigators to ensure consistency of the administration all secondary students were then asked to complete a selfadministered print version questionnaire during class or a class break the field survey in melbourne was conducted between july and september 2016 active and optin consent was obtained from both parents and students with school representatives support a web link of our questionnaire was sent to all students who had parental consent in years 79 by class email students were invited to complete an online questionnaire when participating in the first health and physical education class in the third school term questionnaire the english version questionnaire was developed first based on manganellos health literacy framework 1 which included students health literacy key upstream factors and health outcomes then it was translated into chinese using a translation and back translation technique 27 given that some measurement scales have been translated and validated in chinese adolescents we only translated those without a chinese version intrapersonal factors intrapersonal factors included sociodemographics and selfefficacy sociodemographics included age gender year level family composition and family affluence level 28 personal selfefficacy was measured by the general selfefficacy scale 29 a 10item scale that assessed personal belief in the ability to cope with a variety of challenges in life respondents indicated their level of agreement on a 4point scale the gses total score range was 1040 with higher scores indicating higher levels of selfefficacy in the present study cronbachs α for the gses was 089 interpersonal factors interpersonal factors were assessed using the multidimensional scale of perceived social support 30 a 12item scale that measured an individuals perceived support from family friends and significant others respondents answered each item on a sevenpoint likert scale the mspss total score range was 1284 with higher scores reflecting higher levels of social support cronbachs α for the mspss was 093 for our sample environmental factors school environment was assessed by the school environment scale which was derived from the communities that care youth survey 31 the ses comprised 10 items measuring students subjective feelings about opportunities and rewards for prosocial involvement at school respondents indicated their level of agreement with each statement on a fourpoint likert scale the ses total score range was 1040 with higher scores suggesting stronger bonds of attachment to school cronbachs α for the ses was 088 in this study community environment was assessed by the community environment scale which measured respondents subjective feelings of their neighbourhood environment such as cleanliness and safety 32 participants answered each item on a fivepoint scale the ces total score range was 036 with higher scores indicating a more liveable and supportive community in this study cronbachs α for the ces was 084 health literacy three health literacy instruments were used to compare results between different measures and enhance the rigor of findings 20 the eightitem health literacy assessment tool 23 the sixitem newest vital sign 33 and the 47item health literacy studyasiaquestionnaire 34 the hlat8 and the hls47 were selfreport instruments that measured an individuals ability to access understand evaluate and communicate health information in everyday life 2334 whereas the nvs was a performancebased measure for reading comprehension and numeracy 33 the total score range was 037 06 and 050 respectively with higher scores indicating higher levels of health literacy scores of 4 to 6 for the nvs and scores of 3350 for the hls47 indicated adequate health literacy the nvs and the hls47 have shown satisfactory internal consistency and structural validity 3435 the hlat8 has been validated in chinese secondary students 36 with a cronbachs alpha of 079 health outcomes three health outcomes were assessed including health behaviours health service use and health status health behaviours were measured by five items derived from previously wellestablished student health and wellbeing surveys 37 the total score for health behaviours is 535 with higher scores indicating more healthpromoting behaviours health service use was assessed by a single item of patientprovider communication 34 health status was assessed using a widelyused general selfreport health question 38 statistical analysis all statistical analyses were conducted using stata 151 descriptive statistics were first used to examine participants sociodemographics both overall and by two locations univariate analysis was then conducted to examine the differences in health literacy its antecedents and health outcomes between beijing and melbourne students finally multivariate analysis was used to investigate the association between health literacy and its antecedents health literacy and health outcomes the individual mean substitution was conducted for nonresponse items in selfreport scales data normality was assessed using skewness and kurtosis values results showed that scores on selfefficacy health literacy and school environment were distributed normally whereas scores on social support community environment and health behaviours showed nonnormal distribution results participants sociodemographics in total 770 students in years 79 were recruited from five secondary schools in beijing and melbourne the mean age of participants was 1345 ± 102 the distribution of location gender year level family composition and family affluence level are shown in table 1 health literacy its antecedents and health outcomes table 2 shows differences in health literacy its antecedents and each health outcome both overall and by locations univariate analysis showed that students health literacy in melbourne was higher than that in beijing 2825 ± 600 versus 2637 ± 589 431 ± 173 versus 365 ± 164 the proportion of students with low health literacy varied by selfreport and performancebased instruments representing 237 322 in melbourne and 290 455 in beijing when examining the difference in health literacy antecedents we found that melbourne students had higher scores in selfefficacy and community environment than their counterparts in beijing in addition there were also differences in scores of health behaviours and health status with melbourne students showing more healthpromoting behaviours and better health status association between health literacy and its antecedents based on manganellos health literacy framework 1 we tested the relationship between health literacy and its antecedents according to each health literacy instrument here we laid emphasis on four modifiable factors that were potentially related to health literacy and reported their results in order to provide strategic implications for nextstep intervention after controlling for potential covariates we found consistent evidence on the positive association between overall health literacy and selfefficacy social support and school environment when using the hlat8 and hls47 respectively in addition community environment was associated with students health literacy when using the hls47 on the contrary the relationship between health literacy and its antecedents was not clear when using the nvs but we observed a positive effect of selfefficacy social support school environment and community environment on health literacy when comparing the standardized coefficients between independent variables we found that school environment was the most significant influencing factor for health literacy suggesting the important role of schools in developing students health literacy association between health literacy and health outcomes after controlling for all potential covariates we examined the relationship between health literacy and each health outcome according to each health literacy instrument respectively results showed that health literacy was positively associated with healthpromoting behaviours frequent patientprovider communication and good health status when using the hlat8 and the hls47 on the contrary there was little evidence about the relationship between health literacy and all health outcomes when using the nvs discussion summary of key findings the present study investigated and compared secondary students health literacy in beijing and melbourne using different health literacy assessment tools specifically there were three key findings differences in adolescent health literacy were observed between two cultural groups with melbourne students showing higher health literacy the use of different health literacy instruments resulted in different prevalence of low health literacy in both cultural groups and there was consistent evidence on the common determinants of health literacy and impacts of health literacy on health outcomes across both cultural groups the role of the cultural context in predicting adolescent health literacy consistent with previous theoretical and empirical studies 1117 we found differences in health literacy between melbourne students and beijing students suggesting adolescent health literacy is sensitive to the broad cultural context given that school health education is one of the main approaches to equipping adolescents with adequate health literacy skills 21 one possible explanation of our results is due to the cultural difference in the implementation of school health education between china and australia although health literacy is explicitly included in the rationale and aims of school health education in both china and australia 1339 there are two key differences in terms of its conceptualization and the learning environment health literacy in china focuses on health knowledge and behaviours 39 whereas health literacy in australia lays more emphasis on health skills such as critical thinking 13 which aligns with the component of health literacy measures used in the present study in addition chinas educational system traditionally expects students to be passive and not to question their teachers and health professionals 40 this topdown pedagogical approach focuses on communication of health knowledge rather than developing health skills and empowering students to consider how to take action to improve their health another likely reason is due to the fierce academic pressure in chinese secondary schools compared to australian schools 41 due to limited class time of school health education and inadequate teaching resources chinese students are less likely to acquire enough health knowledge and skills for better healthy decision making in such an academicfocused culture 42 except for the above two reasons there might be other social and structural determinants within each cultural group such as an individuals beliefs languages and attitudes 15 to fully examine the impact of culture on health literacy at both the individual and societal level there is a need for future research such as using qualitative methods to explore the underlying factors and mechanisms linking culture to adolescent health literacy differing performance of health literacy measurement tools compared with previous similar research in adults 43 the present study extends what is known about health literacy comparison in adolescents using different assessment tools the nvs a performancebased instrument 33 captured a higher proportion of students with low health literacy than the hls47 a selfreport instrument 34 one possible reason was the different underlying constructs of health literacy in each instrument the nvs mainly focused on functional domain 33 whereas the hls47 captured a more comprehensive health literacy which included functional interactive and critical domains 34 another possible reason was due to the measurement error inherent in selfreport instruments as shown in a study by chew et al 14 respondents with high selfefficacy were likely to rate highly in perceived competence with health as the present study did not focus on the comparison of selfreport and performancebased measures whether this overestimation exists needs to be explored in future research a holistic approach to improving adolescent health literacy consistent with existing theoretical frameworks 144 we found that adolescent health literacy was related to intrapersonal interpersonal and environmental factors additionally our findings are in line with previous empirical findings which suggested a close relationship between health literacy and personal selfefficacy 45 social support 46 and school environment 47 compared to previous quantitative studies 4547 we did not analyse the relationship between health literacy and its antecedents separately instead we considered all these antecedents together based on manganellos health literacy framework 1 in addition our finding extends the ecological evidence from a quantitative perspective using three different health literacy assessment tools understanding which influential factors are the most important can assist researchers to identify effective entry points for health literacy interventions as shown in our results providing a supportive school environment seems to be the most effective intervention strategy in enhancing students health literacy for example the health promoting schools programs have been successful and widely accepted as a wholeschool approach to provide students with a supportive environment to develop health literacy 4849 the key principles underlying these programs include clarifying a vision for health literacy in school policies improving the schools physical and social environment and building partnerships with local communities 5051 similarly aligning with previous findings 65253 we also found that adolescent health literacy was associated with a range of health outcomes suggesting that promoting health literacy could be a useful strategy to improve students overall health however we did not verify the mediating role of health literacy in the relationship between its antecedents and each health outcome further research is needed to use longitudinal data and causal mediation analysis to examine the role of adolescent health literacy in predicting health outcomes strengths and limitations we used two methodological frameworks to ensure the clarity transparency and rigor of the present study first manganellos health literacy framework was used to guide our study design and data collection 1 second pleasants health literacy measurement principles were employed as methodological guidelines to advance the practice of health literacy measurement 21 particularly three different health literacy assessment tools were used to provide a comprehensive understanding of health literacy in secondary school students limitations should be noted first due to convenience sampling students in beijing and melbourne secondary schools were not representative beijing and melbourne secondary students health literacy might be higher than the general population of secondary school students because they live in metropolitan cities which means that they have better access to education than their counterparts from disadvantaged backgrounds second the sample size was not equivalent to beijing and melbourne secondary students due to recruitment challenges and nonexisting partnerships with melbourne secondary schools only 120 australian students were recruited from one school this may limit the statistical power of our findings for melbourne students future research is needed to replicate our findings with larger and more representative samples across cultural groups third this study only investigated the role of the broad cultural context in health literacy at the school level rather than an individuals cultural beliefs ethnicities and language backgrounds for example we did not investigate the difference in melbourne students health literacy by their country of birth and primary language spoken at home due to the small sample size further research is needed to explore the influence of culture at both the individual and societal level fourth findings of the associations between health literacy its influencing factors and health outcomes were based on crosssectional data longitudinal studies or intervention studies with participant followup are needed to further confirm the causal relationship we observed here implications given that health literacy measurement varies by its dimensions health topics forms of administration and participants characteristics 3 it is important to consider using pleasants health literacy measurement principles as methodological guidelines to reduce disparities in health literacy measurement for example using multiple assessment tools can assist researchers to capture health literacy from different perspectives and verify if there are replicated findings thus enhancing the rigor of evidence 21 in the meantime it remains unclear about the rationale of obtaining an accurate and continuous score of health literacy consistent with the approach used in previous studies 17 18 19 we treated each domain of health literacy measurement as having equal weight and then got an overall score there is a need for future research to explore the degree to which each domain contributes to the overall health literacy score establishing such a specific scoring system will assist researchers to better understand the role of each domain and further advance the field of adolescent health literacy despite the differing performance of each health literacy instrument we found that at least onethird of adolescents did not have adequate health literacy skills which in turn predicted their health outcomes compared to previous generations adolescents nowadays face significant health challenges in the 21st century such as the shift in disease burden from traditional communicable diseases to noncommunicable diseases and conditions 54 and challenges that adolescents face when using the internet to access online health information 55 therefore it is imperative to equip themselves with health literacy particularly critical thinking and decisionmaking skills to address these health challenges at an early age in practice low health literacy is not an individual issue but an interactive outcome affected by an individuals health skills and the broad cultural and social environment health literacy as an outcome of school health education 48 should be continued and strengthened using the hps framework to promote the health and wellbeing of all children and adolescents culture is commonly associated with many antecedents of health disparities 56 our findings showed that cultural and social environments were related to adolescent health literacy cultural perspectives of health literacy help deepen the understanding of the global context within which health literacy plays an important role 57 for example health literacy initiatives such as the optimising heealth literacy toolkit can help address sociocultural differences between health providers and patients thus narrowing the communication gap and improving access to health information and services 58 meanwhile given that little empirical evidence is available from the young generation 1059 there is also a need to examine the specific role of culture and how it interacts with health literacy and eventually contribute to health outcomes conclusions adolescent health literacy is sensitive to the broad cultural context while the prevalence of low health literacy varies when using different health literacy assessment tools low health literacy is common with at least onethird of adolescents facing challenges of accessing understanding and using health information in everyday life except for the impact of culture on health literacy there is consistent evidence showing that adolescent health literacy is associated with personal selfefficacy social support and perceptions of school environment in both cultural groups in addition adolescent health literacy is related to health behaviours patientprovider communication and health status given the nature of our study design and small samples we have made a cautious conclusion that adolescent health literacy might be an interactive outcome influenced by an individuals health skills and the social environment particularly creating a supportive school environment is critical to develop adolescent health literacy that would eventually contribute to better health outcomes 1 outcome data 15 report numbers of outcome events or summary measures 56 and table 2 main results 16 give unadjusted estimates and if applicable confounderadjusted estimates and their precision make clear which confounders were adjusted for and why they were included 68 tables 3 and4 report category boundaries when continuous variables were categorized author contributions conceptualization and methodology sg xy ed and ln formal analysis sg investigation and resources sg ed and xy writingoriginal draft preparation sg xy ed ra er and ln writingreview and editing sg xy ed er ra and ln supervision xy ed ra and ln all authors have read and agreed to the published version of the manuscript funding this research received no external funding appendix a pleasants health literacy measurement principles as a methodological guideline to advance and standardize the field of health literacy measurement pleasant et al 1 proposed a research agenda that recommended seven evaluation principles for health literacy measurement in 2011 these evaluation principles were used as a methodological guide in our study • recommendation 1 explicitly built on a conceptual framework of health literacy manganellos health literacy framework 2 was used to measure the construct of health literacy and the relationships between health literacy and other variables such as socioeconomic status • recommendation 2 multidimensional in content and methodology as for multidimensionality health literacy was measured using three dimensions including functional interactive and critical as for methodology two ways were considered one way was that multiple measures of health literacy were used in a single study this way could assist researchers to capture the status of students health literacy from different perspectives 3 the other way for considering the multidimensional nature of methodology was that two forms of data collection were used in our study however the online survey was only conducted among australian secondary students and the paperandpencil survey was only conducted among chinese secondary students • recommendation 3 measure health literacy on a continual basis all three health literacy assessment tools measured health literacy based on a continuous score • recommendation 4 treat health literacy as a latent construct health literacy was treated as a latent construct in the univariate analysis and multivariate analysis • recommendation 5 honour the principle of compatibility the content of the hlat8 was piloted on both chinese and australian secondary students the wording and content of questions were appropriate to the context of the field use • recommendation 6 allow comparison across different contexts including cultures health literacy measurement was considered for use in both chinese and australian secondary students • recommendation 7 prioritize public health applications versus clinical screening the present study targeted secondary schools as research settings therefore health literacy measurement occurred in the public health context rather than in clinical settings findings from this study can be used to inform school health education practice and policies

while adolescent health literacy has gained momentum it is underresearched from a crosscultural perspective this study aims to compare health literacy among two cultural groups of secondary students in beijing and melbourne a crosssectional study was conducted with 770 students from five secondary schools in beijing and melbourne a selfadministered questionnaire was designed to collect information on health literacy the eightitem health literacy assessment tool hlat8 the newest vital sign nvs and the 47item health literacy survey hls47 its antecedents and health outcomes overall students health literacy in melbourne n 120 was higher than that in beijing n 650 2825 ± 600 versus 2637 ± 589 hlat8 and 413 ± 173 versus 365 ± 164 nvs the proportion of students with low health literacy varied by instruments representing 237322 in melbourne and 290 455 in beijing in both cultural groups students selfefficacy social support and perceptions of school environment were associated with their health literacy which in turn predicted their health behaviours patientprovider communication and health status given the nature of our study design and small samples a cautious conclusion would be that adolescent health literacy is sensitive to the broad cultural context and might be an interactive outcome influenced by an individuals health skills and the social environment particularly creating a supportive school environment is critical to develop adolescent health literacy that would eventually contribute to better health outcomes

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introduction sexuality is an integral part of ones personality it includes everything about maleness or femaleness that is thinking and behavioral reaction to person 1 sex is still a taboo subject in our society because it is equated with just a physical act or child birth but sexuality includes the process of growing up puberty adolescence marital post marital sexual relationship conception contraception childbirth menopause etc 1 early education on sex is a very sensitive subject that is still considered a taboo in indian society and this topic is not discussed so much so far even there is a growing recognition of the need to inculcate responsible reproductive behavior among the adolescents thus before formally introducing the topic of sex education it is extremely important to know the perception of people parents teacher and school children regarding sex education to avoid any adverse effects 2 adolescents tend to discuss sexuality with friends and classmates they gather information from friends servants neighbors throughout prints electronic medias etc often this information is wrong and unscientific this often leads to anxiety negative attitude phobia and misconception etc 3 parents are uncomfortable in talking about sexuality with children you dont have to tell them they know it all is what the new age parents think about their teens most parents in india are not aware of their role in imparting sex and sex education 4 sex education is about biology and the sexual act with need to be clarified 118 sex education looks at the total persona or understanding of our bodies of our motions of intimacy in relationship our evolution as sexual beings and our safety from sexual abuse and maintaining reproductive health 5 sex education is important because sexual phobia affect the physical emotional and academic growth of the child argues dr padmini prasad noted gynecologist and sexologist she spoke to deccan herald about the need for sex education in schools and colleges 6 a study was conducted on valuesbased sexuality education the teenage pregnancy rate remains high and more and more people are infected with sexually transmitted diseases and aids the most sex education is limited to anatomy and sexual abstinence most people approved of sexuality education in the schools including contraceptive information youth armed with knowledge about sex tend to delay first intercourse and use of contraceptives 7 the investigator was motivated to take puc students as a population for the study because the sex education is not included in their curriculum when the pu students learn they can impart sex education to their peer group even it can be utilized in their own personal life also thus sex education can be utilized by all objectives 1 to assess the knowledge and attitude regarding sex education among the students of selected pre university colleges 2 to find out an association between levels of knowledge regarding sex education among the students of selected pre university colleges and with their selected socio demographic variables 3 to find out an association between levels of attitude regarding sex education among the students of selected pre university colleges and with their selected socio demographic variables hypothesis h1 the levels of knowledge of pu students regarding sex education will be significantly associated with their selected personal variables h2 the levels of attitude of pu students regarding sex education will be significantly associated with their selected personal variables methodology research approach an quantitative research approach research design descriptive survey design study setting pre university colleges of vijayapura district karnataka population students of pu colleges sampling technique nonprobability convenient sampling sample size 60 source of data collection primary and secondary data will be collected from the students of pre university colleges method of data collection selfreport tools of data collection the tool for data collection was divided into 3 parts which consists of demographic data structured knowledge questionnaire and structured attitude scale  procedure of data collection after obtaining permission from concerned authority of selected pre university colleges vijayapura and consent from subjects the data was collected by 60 participants using structured knowledge scale and attitude scale approximately 45 minutes were spent for collecting data results section 1 description of selected personal variables of participants the data presented in the table 3 depicts the participants level of knowledge regarding sex education it reveals that majority 52 of participants were had moderate level of knowledge 7 of participants were had poor level of knowledge and remaining 1 of participants were had good level of knowledge level of knowledge c findings related association between levels of knowledge and attitude with selected socio demographic variables of participants knowledge the computed chisquare value for association between pretest level of knowledge of pu students regarding sex education is found to be significant for educational qualification of parents and not found to be statistically significant at 005 levels for age gender religion place of residence previous knowledge on sex education and source of knowledge regarding sex education attitude the computed chisquare value for association between pretest level of attitude of pu students regarding sex education is found to be statistically significant at 005 levels for religion and not found to be statistically significant at 005 levels for age gender place of residence educational qualification of parents previous knowledge on sex education and source of knowledge on sex education conclusion the findings revealed that pre university students were had moderate level of knowledge and favorable attitude towards sex education this suggests that there is a need for the education for the adolescent students for the prevention of sexually transmitted disorders and improves their knowledge attitude and practice related safe sexual life conflict of interest not available financial support not available

background sexuality is an integral part of ones personality it includes everything about maleness or femaleness that is thinking and behavioral reaction to person sex education is about biology and the sexual act with need to be clarified sex education looks at the total persona or understanding of our bodies of our motions of intimacy in relationship our evolution as sexual beings and our safety from sexual abuse and maintaining reproductive health methodology a quantitative approach with descriptive survey design was adopted for the study the samples from the selected pre university colleges of vijaypura district were recruited by using non probability convenient sampling technique the samples of present study comprises of 60 pre university college students the tools used for data collection was structured knowledge questionnaire and attitude scale results the participants knowledge mean was 1778 median was 17 mode was 17 with standard deviation 413 and score range was 20 and the participants attitude mean was 794 median was 815 mode was 79 with standard deviation 1117 and score range was 53 with regard to knowledge majority 52 867 of participants were had moderate level of knowledge 7 117 of participants were had poor level of knowledge and remaining 1 17 of participants were had good level of knowledge and with regard to attitude majority 47 783 of participants were had positive attitude 12 20 of participants were had favorable attitude and remaining 1 17 of participant were had non favorable attitudethe findings revealed that pre university students were had moderate level of knowledge and favorable attitude towards sex education this suggests that there is a need for the education for the adolescent students for the prevention of sexually transmitted disorders and improves their knowledge attitude and practice related safe sexual life

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book review goodnough k galway g badenhorst c kelly r inspiration and innovation in teaching and teacher education toronto on lexington books n inspiration and innovation in teaching and teacher education editors karen goodnough gerald galway cecile badenhorst and rob kelly offer overviews of a collection of 13 chapters in three sections titled the essence of teacher education innovative practices in teacher education and emerging issues in teacher education this is a timely text as teacher education in canada while historically a site for change has become in many contexts a flash point for debate and reform dialogue has been particularly forthcoming in recent years related to the positioning of particular subdisciplines within the field of education and the dialogue between these subgroups is resonant as interdisciplinary possibilities emerge to create new and interesting yet controversial relationships between content knowledge and pedagogy in his chapter bridging the grand chasm john r wiens addresses what he describes as a crisis in education and democracy that is catalyzed by the division that exists between school systems and faculties of education wiens uses metaphors of chasms and bridges to invite the reader into possibilities for change where each sideteachers and schools faculty members and collegesventures towards the other in favor of the welfare and future good of the education system the next chapter reorienting postsecondary education toward sustainability offers garth pickards notions of a necessity to return to the high seriousness exemplified by academic programs of the past an effective articulation of the journey towards teacher certification is described as an opportunity to focus attention on three key conceptual elements which are not always recognized as necessary traits of postsecondary education sustainability community and humility in addition pickard reminds readers that active learning through integrality at the postsecondary level requires that adult teachereducators recognize the collective value of these topics clive beck and clare kosnick present a focus on departmental initiatives in their chapter giving higher priority to subject content and pedagogy in preservice education longitudinal research in the form of interviews with teacher candidates alongside the results of other related studies offered the following results subject content and pedagogy are crucially important particular challenges seem to commonly stand in the way of acquiring both subject content and pedagogy and selection with related goal clarification is necessary when it comes to delivering subject material although integration may narrowly support particular outcomes across two or more subject areas finally while inservice education can move teachers further in their respective journeys both pedagogical knowledge and subject knowledge should be targeted here just as they should be covered in teacher education programs beck and kosnicks discussion elaborates further on how preservice education programs might consider the above findings through program design the last two chapters in this first section deal respectively with supporting exceptional children and youth and teacher candidates perceptions of effective teaching at i the university level in terms of the latter topic jerome delaney albert n johnson trudi d johnson and dennis l treslan outline nine characteristics of effective teaching drawn from student feedback in their chapter titled students perceptions of effective teaching in higher education carla digiorgios discussion of the former in preparing future teachers for inclusive education involves findings from her original research study exploring how actions and beliefs are closely connected and the idea that positive experiences supporting inclusion lead to internally motivated inclusive philosophies of educationan important point as preservice education programs are developed and revised the second section of the text deals more directly with innovation in education contexts ron tinsley and kimberly lebaks videocentred communities of practice presents some intriguing statistics including the idea that in countries such as finland south korea japan and singapore teachers spend 50 percent or less of their workday teaching pupils leaving time open for collaboration in canada where teachers have less time during the day for collaboration the authors suggest videocentred communities of practice in order to vicariously participate in one anothers classrooms towards professional development a detailed model of vccop is presented alongside two case studies of veteran teachers who experienced the model in action the idea of teaching partnerships is extended in making a difference with a first nations school and university school of education collaboration by authors dianne glasbydebassige gayle payette karen mccolman david buley jan buley and patricia danyluk this chapter is a narrative description of a longterm partnership developed in 2006 between laurentian universitys school of education and lakeview school in mchigeeng manitoulin island perusal of this chapter is particularly recommended for any faculty or school personnel interested in partnerships across cultural spaces karen goodnough and pam osmonds critical friendship selfstudy describes the experience of delivering and evaluating classroom experiences based on a hybrid of webbased assignments and facetoface class time this chapter contributes to selfstudy research through an exploration of the role of a critical friend the last chapter in this second section of the text is katina pollock and sue wintons innovation in graduate educationanother kind of hybrid class taught as a course collaboration between two different universities one in canada the other in the united states the third section of the text invites thinking related to the future of teacher education tom russells chapter inspirations and challenges for innovation in teacher education warns that a tendency of looking without rather than within in the search for progress will continue to stand in the way of true innovation in teacher education selfstudy and the support of a critical friend are practices russell also foregrounds in his call that particular principles of learning and teaching be considered carefully he concludes with the provocative statement that we the teacher educators are the ones who must innovate and change our teaching practices if genuine innovation is to occur in teacher education ken stevens chapter using technology to expand teaching and learning opportunities in rural canada offers a discussion of school networking that comprehensively reviews particular technological innovations currently in operation although not consistently in use across canada louise watson jim woolnough iain hay lynne hellyer and darryl stuckeys chapter challenging the theorypractice divide in higher education also reviews innovations in the form of workintegrated learning where university lecturers are embedded in workplaces with their students key in the latter chapter is the idea that simply exposing preservice teachers to more time in school settings is unlikely to lead to any significant change in the learning outcomes of teacher education programs finally shunwing ngs chapter an induction and mentoring framework for student teachers and beginning teachers professional development explores the role of teacher training in student teachers and beginning teachers ongoing learning postgraduation with references to frameworks proposed by the advisory committee on teacher education and qualifications in hong kong this is a text worthy of researchers interested in the field of teacher education faculty members engaged in teacher education at both the graduate and undergraduate levels and other education stakeholders including teachers and administrators while not a title conducive to perusing at one sitting it is a wellorganized and thoughtprovoking opportunity to return again and again to subjects of interest in particular ways that lenses both new and traditional may help us conceive a forward trajectory that honours and promotes teaching and learning in the canadian context and beyond

education is an edited book by karen goodnough gerald galway cecile badenhorst and rob kelly 2013 presenting a collection of 13 chapters with three overview chapters in sections titled the essence of teacher education innovative practices in teacher education and emerging issues in teacher education the book serves to remind readers of the history of teacher education as a landscape for new and future endeavors in the field and it offers current research to address provocative questions related to a profession in which first responsibilities are presented as both political in terms of the future of democracy and personal in terms of students who demonstrate particular values such as a sense of responsibility for themselves others and the land through sustainability as well as the skills to live those values this text is a comprehensive and contemporary read and as such is highly recommended for canadian curriculum scholars and students as well as others interested in the field of education

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background united nations population division states that by 2050 approximately 66 of the globes population will live in urban areas 1 the urban poor have higher fertility high unmet need for family planning services and poor maternal health outcomes 1 a range of factors that characterize urban poverty contribute to these poor reproductive health outcomes unemployment unsanitary and overcrowded living conditions inadequate access to formal health services genderbased violence and limited autonomous decisionmaking for women 1 the urban poor therefore face vulnerabilities that can put them at the disadvantage compared to their rural counterparts 1 also the unmet need for family planning has been reported to be the highest among women who are younger than 20 years of age and lowest among women aged 35 and older these differences being found to be widest in south central asia including india 2 similar findings have also been reported in the studies done in south east asia 3 south africa 4 and other developing nations of the world 5 the unmet need for family planning among all ages married women in india is 129 6 with unmet need for spacing and limiting being 56 and 72 respectively 6 no significant decline in the unmet need for family planning has been observed over the past decades in the country 67 a high level of unmet need for family planning is seen among the age groups of 1519 years and 2024 years 7 among all the states uttar pradesh with one sixth of indias population 8 shows an even worse picture with very high levels of unmet need of about 181 6 the state has an annual growth rate of about 165 8 with total fertility rate of 27 6 also in the two target age groups ie 1519 and 2024 years the age specific marital fertility rate is reported to be the highest 8 in addition to that low contraceptive prevalence rate was also reported in these age groups 7 high fertility and low contraceptive prevalence rate have also been reported in slums in comparison to nonslum areas 7 state level data for slums in uttar pradesh shows a wide difference in unmet need between slum and nonslum areas 7 other studies conducted in urban slums of uttar pradesh have also indicated a high unmet need among married women of 1545 years age group 9 10 11 about 445 million people reside in urban slums in up 8 mostly young people migrating from rural areas in search of earning opportunities are settling in slums here they not only lack basic amenities for living they also do not have enough access to health services which negates them from utilizing the facilities of health programs large population with relatively high fertility due to low use of contraceptives by this age group and living in suboptimal conditions makes them the most preponderate group for family planning services from public health perspective 14 to catch this young population it is imperative for policy makers and program managers to understand their need for fp services and factors influencing their needs for family planning no such data is currently available in the country for this age group especially for the young married women living in the urban slums as the reproductive health needs of the millions of urban poor cannot be ignored therefore this study was conducted with an aim to assess the unmet need for family planning services among the currently married young women living in urban slums of lucknow the reasons for this unmet need for family planning services and the factors influencing it this will help in delineating the individual community and health services level factors that can be harnessed or changed to improve the contraceptive use and enable young women living in fig 1 trends of unmet need for family planning uttar pradesh 671213 urban slums to satisfy their need for contraceptives at this stage of family building process objectives 1 to assess the unmet need for family planning services among the young married women living in urban slums of lucknow india 2 to explore the facttors influencing the unmet need of family planning services among the young married women methods study design cross sectional study study settings the study was conducted in the catchment slums of urbanprimary health centres of lucknow 15 health services to the urban poor are provided through urbanprimary health centres bal mahila chikitsalays district hospitals and plethora of private practitioners study period the study was conducted from august 2015 to july 2016 study universe all the young married women living in urban slums young married women 7 16 currently married young women in the age group of 1524 years study population young married women living in the urban slums of lucknow study unit young married woman currently living in the urban slums of lucknow for at least 6 months however women who were currently pregnant or had undergone hysterectomy bilateral oophorectomy or were divorced separated disserted from their husband were excluded from the study sample size determination sample size was calculated by the following formula n z 2 p d 2 taking the unmet need of family planning services in uttar pradesh as 146 15 an allowable error of 3 and the value of the standard normal variable at 005 level of significance as 196 the sample size was calculated to be 533 considering a 10 nonresponse rate the final sample size was calculated as 586 excluding 37 non responding women a sample of 535 was analyzed sampling to identify the eligible young women to be selected in the sample a three staged random sampling technique was used all the eight municipal corporation zones in lucknow city were taken into consideration for selection of the study participants one uphc was randomly selected from each municipal corporation zone the zone wise list of slums notified by the municipal corporation was obtained from the municipal corporation office and two slums were randomly selected from each uphc to obtain the desired sample from each slum the total sample size was divided equally among the eight municipal corporation zones a sample of 67 young married women was obtained for each zone thus at least 33 young married women were selected from each slum in each slum the centre of the slum was arbitrarily identified and a sample of at least eight ymw was obtained from each direction first household was randomly selected and all the households were visited until the desired sample was obtained for that slum operational definitions slum 8 the slum areas broadly constitute of all specified areas in a town or city notified as slum by statelocal government and ut administration under any act including a slum act all areas recognized as slum by statelocal government and ut administration housing and slum boards which may have not been formally notified as slum under any act a compact area of at least 300 populations or about 6070 households of poorly built congested tenements in unhygienic environment usually with inadequate infrastructure and lacking in proper sanitary and drinking water facilities catchment slum 18 slum in the geographic area defined and served by a health facility which is delineated on the basis of such factors as population distribution natural geographic boundaries and transportation accessibility by definition all residents of the area needing the services provided by the health facility are usually eligible for them urban primary health centre 17 established by government of india under the national health mission to improve the health status of the urban poor particularly the slum dwellers and other disadvantaged groups by provisioning access to quality primary health care services along with strengthening the existing capacity of health delivery systems leading to improved health 17 status and quality of life a uphc caters to a population of 50000 currently there are 52 uphcs in lucknow family planning services 19 it includes services that enable individuals to determine freely the number and spacing of their children and to select the means by which this may be achieved modern spacing methods 20 include contraceptive pills condoms injectables intrauterine devices and emergency contraception modern limiting methods 20 include male and female sterilization unmet need for modern family planningmethods 7 the percentage of women of reproductive age who are not using any modern method of family planning but who would like to postpone the next pregnancy or do not want any more children the sum of the unmet need for limiting and the unmet need for spacing is the total unmet need for family planning unmet need for spacing 7 it includes fecund women who are neither pregnant nor amenorrhoeic who are not using any modern spacing method of family planning and say they want to wait two or more years for their next birth also included in unmet need for spacing are fecund women who are not using any modern method of family planning and say they are unsure whether they want another child or who want another child but are unsure when to have the birth unmet need for limiting 7 it refers to fecund women who are neither pregnant nor amenorrhoeic who are not using any modern limiting method of family planning and who want no more children met need for modern contraceptive methods 21 refers to those currently married women who want to space births or limit the number of children and are using modern contraceptive methods to avoid unwanted or mistimed pregnancies total demand for family planning 21 the total demand for family planning is the sum of unmet need and met need tools of data collection a predesigned and pretested interview schedule see additional file 1 was used for data collection information was collected regarding biosocial characteristics autonomy status of the women knowledge regarding family planning attitude towards contraceptive use current use of contraceptives factors favoring limiting access and utilization of family planning services in young married women religion was based on the belief system followed by the participant and caste category on the official classification of the population of india 8 other backward class is a collective term used by the government of india to classify castes which are educationally or socially disadvantaged 8 scheduled caste and scheduled tribes are officially designated groups of people by the constitution of india 8 ymw above the age of 7 who can read and write in any language with an ability to understand was considered as literate 8 modified kuppuswamys socioeconomic classification a composite scale based on education occupation of the head of the family and the monthly income of the family was used to determine the socioeconomic status 22 autonomy 23 of the women was assessed in three dimensions of household decision making concerning money spent health care and physical mobility and scored accordingly attitude of the women and her husband towards family planning was assessed from the responses given by the women on the pertaining questions the schedule was pretested on a sample of 30 young married women living in urban slums of lucknow inconsistencies and confusions in the pretest exercise including the interview protocol were corrected before actual data collection result of pretest was not included in final study completed schedules were checked weekly for consistency and completeness by the supervisors the collected information was rechecked for its completeness and consistency before entering the data into a computer data management data collection procedure during the visits to the slums the investigator approached the young married women fulfilling the inclusion criteria and after explaining then about the study an informed consent was sought from them for their participation in the study complete confidentiality and anonymity of the respondents was maintained written and informed consent was taken the study included 535 ymw who met the inclusionexclusion criteria for the study data processing and analysis descriptive summary using frequencies percentages graphs and cross tabs were used to present study results univariate analysis was performed using binary logistic regression and the factors which were found significant during univariate analysis were forwarded to multiple logistic regression model in a step wise manner for calculation of adjusted odds ratio a p value 005 was considered statistically significant results the total demand for family planning among the young married women living in urban slums of lucknow was 876 findings demonstrated considerably high unmet need for contraceptives among young married women in urban slums it was found to be present in more than half of the young married women of which in about 409 was for spacing methods and in 144 for limiting methods biosocial characteristics of women the mean age of the study participants was found to be 2128 ± 19 years most of the women were hindu by religion and about 482 of them belonged to other backward classes about 187 of the study participants were illiterate more women in the older age group had high school and above level of education as compared to the younger age group majority of the women in older age group were working outside home for money the mean duration of stay in the city was 272 ± 195 years the mean age at marriage and at the birth of first child was found to be 1787 ± 185 and 1923 ± 167 years respectively more than half of the women in the age group of 1519 years were nulliparous as compared to older age group about half of the older women had ≥2 children teenage childbearing was reported to be about 8 knowledge of contraceptives was significantly low in the younger women as compared to women in the older age group autonomy in family and media exposure was significantly more in the women of older age group contact with health worker was very low in the younger age group as well as with the women of older age group none of the young married women had received any education on family planning before marriage reasons for unmet need more than twothird of the women in the study cited embarrassment hesitancy shyness to be a reason for unmet need for contraception knowledge of family planning methods and place where fp services are available was significantly low in 1519 years age group in comparison to older age group about half of the older women had a negligent attitude towards adopting any family planning method and 456 of them faced opposition to contraceptive use as a consequence of expectation for early child bearing by the husband and family members health concerns and fear of side effects were frequently cited reasons of non use of contraceptives in the older age group factors influencing need of contraceptives among young married womenbivariate analysis biosocial factors age of the respondent majority of the women in the age group of 1519 had an unmet need for family planning services the increase in age group was found to be significantly associated with decrease in unmet need women of the 1519 year age group were about 3 times more likely to have an unmet need than women of the age group religion and caste religion was found to be significantly associated with unmet need for family planning services more unmet need was observed among hindus as compared to muslims majority of the women of scheduled caste scheduled tribe category had an unmet need for family planning services women belonging to the other categories were significantly less likely to have an unmet need than those belonging to sc st category level of education the unmet need of family planning services was found to be significantly higher among the illiterate women women who were literate were less likely of having unmet need for family planning services as compared to illiterate women also women whose husband was educated were less likely of having unmet need as compared to those having uneducated husband socioeconomic and employment status unmet need was high among the unemployed women it was only 189 in the employed women no statistically significant association was observed between working status of women and unmet need for family planning unmet need for family planning services was also found to be high among women from lower and upper lower socioeconomic class in comparison to the women belonging to middle and upper middle class duration of stay in the slum women who were residing for more than a year in the slums were less likely to have an unmet need than those residing in the slum for less than a year and the association was statistically significant fertility related factors duration of marriage women who were married for less than 1 year were significantly more likely to have an unmet need in comparison to women who were married for more than a year total number of pregnancies number of living children number of male children and desired number of children parous women were 222 times more likely to have an unmet need than nulliparous women and this association was found to be statistically significant women who had one or more living children had a high unmet need for family planning services and majority of the women with a male child had an unmet need for family planning services women who had one or more living children were 884 times more likely to have an unmet need than women with no living children and this association was found to be statistically significant the association between number of male children and unmet need was found to be statistically insignificant the number of children desired by the women was found to have a statistically significant association with unmet need for family planning services with higher unmet need in women desiring 2 children women who desired ≥2 children were significantly less likely to have an unmet need than women desiring 2 children knowledge of contraceptive methods and its access women who did not have any knowledge of contraceptive methods had statistically significant high unmet need for family planning services majority of the women who did not have any knowledge of place where family planning services are available near their slum had an unmet need women who had knowledge of availability of family planning services at the uphc were significantly less likely to have an unmet need than women with no knowledge media exposure less than half of the young married women were exposed to family planning message on tv radio the association between media exposure and unmet need for family planning services was found to be statistically insignificant contact with health worker association between contact of anm during household visits in the slums or during hnds and unmet need for family planning services was found to be statistically significant women who did not have a contact with anm were about 3 times more likely to have an unmet need than women who had a contact autonomy status of women women who had no autonomy in their family had a higher unmet need for family planning services women who had some autonomy and those who had autonomy were less likely to have an unmet need than women with no autonomy motivation and opposition to contraceptive use women whose husbands had an unfavorable attitude towards family planning had a high unmet need women with husbands having a favorable attitude were found to be less likely to have an unmet need as compared to women whose husband had an unfavorable attitude also the unmet need was found to be more in absence of any discussion of family planning with husband and with others the association being statistically insignificant on the other hand only 139 of the women who were motivated to use contraceptive methods had an unmet need unmet need was found to be less in those women who were motivated to use family planning methods by husbands by other family members friends relatives by health care providers but this association was found to be statistically insignificant about 116 young married women reported opposition to contraceptive use women having opposition to contraceptive use were 500 times more likely to have an unmet need than women with no opposition and this association was found to be statistically significant multivariate logistic regression factors found to be statistically significant in bivariate analysis were subjected to conditional multiple logistic regression for adjustment and controlling the effect of confounding variables several factors that were found to be statistically significant on bivariate analysis lost their significant on multivariate analysis which could be partly explained due to colinearity and possible confounding observed between predictor variable age of the women educational status of the women duration of marriage number of pregnancies knowledge of contraceptive methods opposition to contraceptive use and contact with anm showed independently significant association with unmet need for family planning women of 2024 year age group were significantly less likely to have an unmet need than women of the lower age group women who were literate were significantly less likely to have an unmet need for family planning as compared to illiterate women parous women were significantly more likely to have an unmet need than nulliparous women women who had any knowledge of contraceptive methods were significantly less likely to have an unmet need than women with no knowledge women having opposition to contraceptive use were significantly more likely to have an unmet need than women with no opposition women that had a contact with anm were significantly less likely to have an unmet need than women who did not have a contact discussion more than half of the young married women living in the slums were having an unmet need for family planning of which 409 was for spacing and 144 for limiting almost all women in the younger age group had an unmet need for spacing methods as compared to older age group this is much higher than the unmet need for family planning as reported by nfhsiv 6 in uttar pradesh and in lucknow the unmet need in ymw is even higher than that reported in rural uttar pradesh 6 shukla m et al 11 in urban slums of lucknow also found a higher unmet need among young married women however pal a et al 10 reported very high unmet need in the urban slums of lucknow about a decade ago in selected slums unmet need is higher than that found by sherin r et al 24 in their study in rajasthan age of the women was found to be a significant predictor for unmet need of family planning in the present study the unmet need for family planning was found to be significantly higher in the age group of 1519 years women of the younger age group are more likely to have an unmet need as women of the age group 2024 years are more educated and have more knowledge and experience of contraception 25 they tend to be more mature and play a role in decision making thereby less prone to have an unmet need 25 similar to these findings the younger women in the present study are reported to have significantly less knowledge and poor access to information lack of decision making power are shy hesitant and are undermined by sociocultural expectations of early marriage and childbearing duration of marriage less than 1 year was found as one of the determinants of unmet need in the study begum s et al 26 perceived that this high unmet need among newlywed couples might be due to sociocultural practice in the bangladeshi community to have a child immediately after marriage socio cultural practices of indian community are more or less similar to the bangladeshi community begum s et al 26 also reported that sometimes the health providers impose barriers in accessing fp services by young women and resulting in increase in unmet need for services among this group education level of the women emerged out as one of the strong predictor for unmet need for fp services in the urban slums majority of the women in the present study with lower level of education were found to have an unmet need for family planning services and unmet need was found to decrease with increase in level of education with only 791 among those who were literate having an unmet need for family planning services similar findings were reported by sherin r 24 wulifan et al 27 and hamsa l et al 28 who also observed that a lower level of education was significantly associated with higher unmet need in our study majority of both the multiparous and nulliparous women expressed no desire for childbirth at present but were still not using any of the contraceptive methods almost all of the nulliparous and primiparous women had an unmet need for spacing whereas twothird of the multiparous women had an unmet need for limiting methods unmet need for family planning services was significantly higher in women with more number of pregnancies but nulliparous women also constituted the major bulk of those having an unmet need this is in accordance to the findings of studies done in developing and developed nations around the world 242728 which reported a lower unmet need among nulliparous women contrary to this imasiku et al 29 and shukla m et al 11 found unmet need to be more in nulliparous women calhoun lm et al 30 found that providers restrict clients access to spacing and longacting and permanent methods of family planning based on parity similar views were echoed by begum s et al 26 unmet need was also found to be significantly associated with the number of children that are desired by a woman which is in concurrence with study done by bhattathiry mm and ethirajan n 31 in concurrence with mosha i 32 and woldemicael g and beaujot r 33 who found that women who had less autonomy in the family were more likely to have an unmet need significant association was found between the autonomy of the young married women and unmet need the study reported that most of the women in the younger age group had no autonomy in the family and hence more prone to unmet need chafo k 21 attributed the availability of an enabling environment in the family helpful for women in implementing fertility desires and fulfilling their contraceptive needs in this study also significant association was found between husbands favorable attitude for family planning and low unmet need however only 161 reported that their husbands were favorable towards family planning methods this is similar to the findings of other studies done in various low and middle income countries among slum women aged 1524 years 10313435 in accordance to other researchers kabagenyi a et al 36 and hall mak et al 37 the present study also found significantly high unmet need among young women who faced opposition to contraceptive use by the husband or families in this study 45 of ymw reported opposition from either husband or other family members this needs to be dealt by utmost attention by the program managers during planning for fp services for this group in the slums a study of reproductive health service providers in urban uttar pradesh highlighted that providers also imposed restrictions to younger clients access to fp methods based on partner consent 30 approximately one quarter of midwives restricted client access to pills and condoms based on partner consent and nearly 75 restricted access to the iucd based on partner consent 30 the pattern that has emerged from the study that a particular profile of clientsunder educated poor having few or no children not having the support of their partner and newlywed women are less likely to receive fp counseling by a provider in the urban uttar pradesh 30 similar to that reported by other studies 283133 who found that women were less likely to have unmet need if they were aware of contaceptive methods and site from where fp can be procured our study also observed significantly high unmet need among women who have low knowledge of contraceptive methods and place for fp services procurement in the present study knowledge of contraceptive methods was found low among the young women and 767 were not aware of place from where they can avail the fp services role of frontline workers is crucial in uptake of family planning services by the community researchers in various parts of the world 21353839 found the met need of family planning to be significantly higher among those women who had a contact with anm similar findings are reported in the present study where unmet need for family planning services was found to be significantly higher among those women who had no contact with anm as compared to those who had a contact with anm in this study only 213 women had any contact with the anm and about 88 women were recommended by health care provider for adoption of fp methods contact with health worker was almost negligible in the case of 1519 years age group wulifan et al 27 stated that though women of reproductive age in low and middle income countries are in favor of birth spacing but they were less likely to engage in family planning discussion with health workers in comparison to the older women this reluctance in actively expressing their fp needs is in parts explained by prevailing stigma shyness hesitation embarrassment myths misconceptions and sociocultural expectations attached to contraceptive use in young as found in the present study it reflects the dire need for the national and regional program managers to take into consideration the favorable effect of contact with anms as a golden opportunity to increase the use of family planning methods especially by young married women living in urban slums recently urbanasha has been deployed under the national urban health mission 17 and it is expected that they will reduce the unmet need in these urban slums the main reasons for unmet need for family planning services among the young married women in the present study were found to be shyness embarrassment hesitancy followed by lack of knowledge regarding family planning method as well as their accessibility about 40 of the women had a negligent attitude towards family planning opposition for contraceptive use was faced by one third of the women in concurrence to the resent study sultana b et al 40 in their study in urban slums of pondicherry also found that client related factors and contraception related factors were the cause for unmet need huda fa et al 41 in the study among married adolescent girls in slums of bangladesh reported that lack of knowledge of the available methods family pressure to prove fertility opposition from husbands and mothersinlaws were the main reasons for unmet need nazish r et al 42 in their study in uttar pradesh found that the major reasons for unmet need for fp were opposition from husband or family poor accessibility of the method and negligent attitude of the women towards family planning the coverage of a large slum population and use of a strong methodology enhances the internal and external validity of the research work however considering the important role men play in the dynamics of family planning their non inclusion in the present study may not reflect the overall perspective of the couple with regard to the use of family planning services therefore further studies can be done for indepth exploration of these factors conclusions unmet need for family planning was found to be very high among the young married women of urban slums the study identifies the focus areas which have to be addressed to achieve reduction in unmet need and there by attainment of the desired goal of population stabilization and better reproductive and maternal health molding the minds of young generation at an early stage by inculcating reproductive and sexual education as a part of routine school health services could go a long way in motivating them to adopt contraceptive use in future and subsequently follow a healthy fertility behavior formation of community based peer system will provide an opportunity for holistic discussion about family planning methods these community based peer groups will help the young women to overcome embarrassment shyness or hesitation and will also give them autonomy to avail fp services a comprehensive approach should be used by the health worker working in these slums to provide counseling services not only to the young married woman but to all stakeholders training should be imparted to health workers to improve their interpersonal behavior change communication skills to tackle the myths misconceptions embarrassment hesitancy shyness and fears regarding contraceptive use among this young population apart from training it is also importance to sensitize the health workers that within this age group there are various vulnerable sub sections with their diverse need for fp services newlywed recently settled in urban part nulliparous less educated woman with no autonomy and with opposition from partners and families warranting a combined and coordinated approach directed towards each subgroup supplementary information supplementary information accompanies this paper at 1186s12905020010109 additional file 1 final questionnaire questionnaire authors contributions ky conceived and planned the study ky and ma analyzed the data and wrote the first manuscript draft jvs and ms provided constructive feedback with regard to interpretation of results and writing of manuscript vks helped in acquisition of data ma helped accessing the study sites in order to collect data ky ma ms jvs and vks contributed to study design and consultation during the ongoing study and data collection all authors read and approved the final manuscript abbreviations competing interests the authors declare that they have no competing interests

background nfhs4 stated high unmet need for family planning fp among married women in uttar pradesh unmet need is highest among age groups 1519 and 2024 years currently few data is available about unmet need for fp among vulnerable section of the community ie1524 years age group living in the urban slums therefore this study was conducted to assess the unmet need for fp services and its determinants among this underprivileged and underserved section of society residing in urban slums of uttar pradesh india methods cross sectional study was conducted in the slums of lucknow india one urbanprimary health centre uphc was randomly selected from each of the eight municipal corporation zones in lucknow and two notified slums were randomly selected from each uphc all the households in the selected slums were visited for interviewing 33 young married women ymw in each slum with a prestructured and pre tested questionnaire to achieve the sample size of 535 analysis of the data was done using logistic regressionthe unmet need for family planning services among ymw was 553 about 409 of the unmet need was for spacing methods and 144 for limiting methods important reasons cited for unmet need for family planning services were negligent attitude of the women towards family planning opposition by husband or others embarrassment hesitation shyness for contraceptive use poor knowledge of the fp method or availability of family planning services among method related reasons health concerns and fear of side effects were frequently cited reasons on multiple logistic regression age educational status duration of marriage number of pregnancies knowledge of contraceptive methods opposition to contraceptive use and contact with auxiliary nurse midwife anm showed independently significant association with unmet need for family planning services conclusions unmet need for family planning services is very high among the ymw of urban slums the findings stress that program managers should take into cognizance these determinants of high level of unmet need for family planning among ymw and make intense efforts for addressing these issues in a holistic manner

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introduction the term millennial was first used in 1the book generations by william strauss and neil howe in 1991 authors coined and named the generation born from the 1980s onward as millennials the term is widely adopted by researchers and popular media to refer to the demographic cohort following generation x and preceding generation z same authors additionally discussed generational traits and characteristics of millennials emphasizing their role in shaping society same authors detected millennials traits and characteristics emphasizing civicminded and idealistic teamoriented and collaborative technologically proficient protected and sheltered upbringing confident and assertive diverse and inclusive and delayed adulthood howe and strauss introduced the concept of extended adolescence for millennials highlighting that they often delayed traditional markers of adulthood such as marriage homeownership and starting a family focusing more on education and personal development our study is aligned with pew research center conducted study with a goal to understand americans experiences with dating sites and apps and their views of online dating generally threeinten us adults say they have ever used a dating site or app according to the same study respondent experiences range from triumphant to troubling as some report meeting a partner online or being excited about prospects while others report facing harassment or scams with the development of technology many social norms have begun to change including the way young people meet for both romantic and physical relationships the propensity for dating apps usage and the millennials interpersonal meeting people the traditional way whether on your night out or through a mutual friend is getting rarer and the internet is slowly taking over and asserting its dominance in this area given the ubiquity of digital technology many millennials have opted to switch their dating life into the virtual world as that is what everyone is doing more and more people are using dating apps in order to find a romantic partner or just a random hook up and its seemingly taking a toll on the development of social skills in younger generations by having dating sites like tinder hot or not or badoo people are not using their social skills as much as they used to another study concluded that millennials are more interested in texting over other forms of communication because it is less invasive more personal and makes them feel values talking to someone is a lot easier when you have time to think about what youre going to say instead of being put on the spot like in a regular facetoface or real time phone conversation lefebvre compared the traditional relationship development model to the process of developing relationships on tinder he found that nearly every stage the process was augmented by digital technology in a way which reduced spontaneous communication this was particularly true for the process of initiating a relationship which traditionally relies on the transmission and decoding of nonverbal messagesin recent years concerns have been raised about the effects of digital mediation on social life some studies have indicated that relationships established and conducted online are characterized by weaker interpersonal bonds than those conducted nonvirtually dalessandro found that online romantic relationships were perceived by millennials to be less authentic as for the croatian research milivojevićs research delves into the psychological dimensions of virtual networking probing its influence on personal balance and integrity within a culture of selfpromotion the study questions how the accessibility of digital interaction along with the ability to hide or adopt false identities might impact disinhibition from social and ethical norms potentially reducing empathy and responsibility in individuals however to date noone has examined the potential relationship between social skills and the use of online dating apps and websites this quantitative study based on premises of social exchange theory which was primarily developed by the american sociologist george c homans and later peter blau and richard emerson social exchange theory provides a framework for understanding how individuals engage in social relationships based on a calculated assessment of the rewards and costs associated with those relationships it has been applied across various disciplines to analyze interactions ranging from economic transactions to interpersonal relationships the study will examine whether or not the development of the technology has facilitated a space where millennials could meet virtually and does the technology help in development of the interpersonal skills and expands the ability of the millennials to date in real life the importance of this research is reflected in the potential correlation between the propensity for online dating and the development of the interpersonal skills literature review the usage of dating apps has increased in the recent years a majority of nevermarried users of online dating platforms have recently used one of these services including those who were currently doing so pew research center 2023 threeinten online daters who have never been married younger people tend to engage in online dating more than their older peers in china 3549yearolds make up 40 of the apps users and for instance 62 of chinese dating app users are under 30 according to hanson the very term dating app is a misnomer mostly because the apps are used for more than just dating like hooking up and making friends the most common response when asked why they use apps is to meet people while the main reason for not using dating apps is because of the lack of trust in people online in a series of indepth interviews conducted with millennials about online dating dalessandro found that the most common criticism that millennials voiced was that digital technology brought out worst in people this included misrepresentations on profiles a lack of courtesy and unkind and cruel comments fake profiles and bots posing as real people are discouraging some people from using the apps according to the urban dictionary the term catfishing is the phenomenon of internet predators that fabricate online identities and entire social circles to trick people into emotionalromantic relationships catfishing has become a big issue when it comes to internet relationships altogether and the fear of it is making it harder for potential users to decide to try dating sites and apps even though both males and females prefer longterm relationships to casual sex a study showed 63 of college students engaging in hookups during their time in college previous researchers argued that hooking up has become the norm on college campuses this is mostly due to the fact that they believe that college is a the propensity for dating apps usage and the millennials interpersonal time for prioritizing selfdevelopment over emotional investment the fact that this study was conducted on college students in a slightly different cultural surrounding isnt a disruptive factor since we can apply the same principle here in croatia where this research will be conducted most college students especially millennials and gen zs want to explore during their time at the university they wish to experience new things and not be tied down with unnecessary obligations due to that amongst other things dating apps have become exceedingly popular in recent years especially among college students interestingly enough even though the majority of the participants in the study prefer to meet their potential romantic partners in person they continue to use dating apps as means of connecting with other people this practice alienates them from being more social and according to sunter and vagenbosch there are 6 reasons to choose using dating apps two relational goals two intrapersonal goals and two entertainment goals since our lives are becoming more and more hurried people are choosing dating apps to find someone to start a relationship with or just simply finding someone to engage in a casual sexual relationship this way they save money that they would usually spend on first dates with people they may not be compatible with texting someone is a lot easier than having to actually talk to them in person you are able to thoroughly think about how you want your text to sound like and what you want it to say which makes it easier to always present your best self according to chin edelstein and vernon people who score higher in anxious attachment are more likely to say that meeting others is their main reason for using a dating app to them meeting others decreases the chance of being single they spend their time on dating apps trying to connect with someone in an attempt to match with just the right person in order to create a connection be it romantic or just physical factors influencing rising usage of online social media and online dating due to the fact that the usage of online social media has risen in recent years millennial teens are utilizing new strategies and techniques to present themselves to others via digital media since teenage years are crucial for the development of the persons character by using social media excessively they augmented their digital identity with visualization symbolism color and designs resulting in more explicit messages offline than online not having an actual person opposite from you lowers persons inhibitions making them more prone to saying something they wouldnt normally say in a facetoface situation according to birger an important factor for the increase in online dating is the fact that in 2012 there was 34 more women graduating from colleges in america which resulted in the average of 4 collegeeducated women on 3 collegeeducated men this in turn allowed for some men to put off settling down while more women are giving up on playing hard to get since educational intermarriage is at its alltime low for collegeeducated women to exclude workingclass men poses an issue since it significantly lessens their dating pool for collegeeducated men however excluding the workingclass women almost has no impact at all on their marriage prospects jessica vascellaro mentions how since most dating apps work based on location of each user and connects users like that those apps are more likely to appeal to users in densely populated areas as opposed to people in rural areas dating patterns of millennials offline vs online dating social skills millennials are changing the dating game and have been prone to wait longer to get married they are less sexually active than both baby boomers and gen x and are prone to have fewer partners according to pennybacker millennials in college are more likely to take a more relaxed approach to dating in order to put focus on their academics and career and claim that social media as well as dating apps encourage superficial and temporary relationships however contrary to the belief that millennials have rejected the institution of marriage the book embracing and transforming marriage suggests that they have embraced and transformed the concept to align with their worldview experiences and aspirations the research indicates that many millennials are highly invested in making their marriages work willoughby bj the croatian qualitative study by lončar šuljug vučica and hržić investigates modern dating scripts and casual sexual relationships among croatian emerging adults revealing a blend of traditional dating and contemporary options like open relationships friends with benefits and onenight stands research also concludes that longterm relationships are viewed as a precursor to marriage or cohabitation often delayed until career stability the propensity for dating apps usage and the millennials interpersonal according to deloitte global 2023 research six in ten millennials believe businesses have no ambition beyond wanting to make money and are responding to financial pressures by taking on side jobs postponing big life decisions like buying a house or starting a family and adopting behaviors that save money such as buying secondhand clothes or not driving a car online dating has become one of the primary ways that people meet partners nowadays according to kate furby in her paper she discusses attraction and how does it affect desirability on dating apps for example study shows that older women are less desirable while older men are more desirable the tricky thing is that when youre studying attraction a lot of the things are very subjective and you have to at some point meet the person face to face in order to actually see if the attraction is present recent croatian study by šutić jelić i krnić a concluded modern dating scripts can have both positive and negative consequences depending on what needs a person tries to fulfill ellie schaack believes that due to the fact that social media has been a part of millennials lives ever since their teen years there has barely been a time when their lives werent broadcasted for everyone to see this made break ups even more complicated since its not only between your partner and you anymore but the whole world having no privacy like this can affect the way millennials process situations like break ups and dealing with loss in general having the constant pressure that everything has to be perfect some create an illusion of their perfect relationships and instead of focusing on actually making it work in private they tend to focus on the exterior hobbs owen and gerber claim that lifelong partnerships have been liquefied due to technological change and that internet dating is transforming modern courtship into a sort of commodified game unlike before single adults in urban areas have an almost endless variety of potential romantic and sexual partners available to them usual places for meeting people like bars cafes universities clubs and work places have almost completely been replaced by dating apps and other websites created for that particular purpose due to the development of technology young people are less likely to be able to properly negotiate their romanticsexual relationship within the context of the new media environment according to zachary zane due to the emerging of the dating apps singles arent going out anymore instead they swipe profiles while sitting at home alone even when they do go out they are too intimidating to approach anyone in fear of being rejected since up to this point the only form of rejection was a lack of response however its not all bad depending on how you approach them dating apps can also be a great selfesteem booster that could help you with your facetoface endeavors for example tinder one of the most popular dating apps works in a way that in order to match with someone both of you need to say that you want to having multiple matches from people that you yourself liked increases selfesteem which consequently increases ones courage to take the relationship to the next level actual physical encounter whilst using dating apps the person is hidden behind their screen making it unable for the other person to see what they look like and act like during texting it makes it impossible to react to their body language since they cannot see it there is no eye contact in online dating which is important when it comes to engaging someones attention displaying our interest and indicating our intent however there is more to body language than simply eye contact things like facial expressions gestures and posture all play a key role in our offline communications such as dating for example furthermore a growing number of researchers have explored how the mobile dating apps and websites have been used and to what extent when users engage in online dating it provides a sense of safety control and comfort the apps offer a sense of exploring the unknown without the strain of facetoface communication according to caplan a persons preference for online versus facetoface social interaction holds an important role in the development of negative consequences associated with excessive use of internet this implicates that peoples social skills can be impacted by the transition to online platforms research design and methodology this research is focused on exploring a correlation between the propensity to use dating apps and the extent of millennials personality type for that purpose the quantitative method of evaluation will be used this research design is applicable because the goal is to find out if millennials with introverted personality type have a higher propensity for dating apps and sites usage the main hypothesis for this research is that the millennials with introverted personality type have more expressed propensity to use dating apps for finding longterm relationships this research will prove whether or not the dating apps have a direct connection with millennials personality type or they simply facilitate those relations that wouldnt otherwise survive a facetoface communication from the start in order to test this hypothesis the following sampling method and research the propensity for dating apps usage and the millennials interpersonal conduct was used an anonymous survey was conducted online through googles google forms service the social network that was used in the research is facebook and the main goal was to get the broader picture of the dating applications users psychological profile and dating habits the survey was administered among 385 millennials born between 1987 and 1994 living in zagreb croatia area even though they belong to the same generation as the ones born between 1980 and 1985 the 8794 population has a lot more in common with each other than with the millennials born earlier therefore the research is intentionally limited to this particular age group because the assumption is that this age group has similar behaviors in many relevant areas among other one being the dating the survey was published in four facebook groups of the predominantly student population and also distributed among the senior and master degree student population at rit croatia enrolled in two different programs of study the survey was conducted over four weeks in february 1 st till february 2 nd 2021 the questionnaire consisted of 18 questions divided into three categories the first part of the questionnaire was a set of nominal scale items demographic characteristics education and online or offline dating preference second part of questionnaire used consisted of sevenpoint sidebyside matrix scale α091 the bipolar descriptions used represent extroverts and introverts based on the myersbriggs type indicator the third part of the questionnaire asked respondents about usage of dating apps and preference towards them as well as frequency of usage and the length of the relationship that developed on the basis of the dating app the questionnaire ends with ten items dichotomous likert scale where respondents were asked to rate the statement and choose between yes or no in response to the statement about feeling more selfconfident after online dating α087 descriptive statistics were used to describe the sample in order for the study to be valid the participants need to be born between 1987 and 1994 and need to be a current student of a higher education in zagreb or have a degree from a higher educational institution in zagreb it is crucial that they have spent their college years living in zagreb since the goal of the research is to see if this correlation is in particular affected by the location culture and lifestyle or is it simply a generation characteristic in order to have credible results the needed sample size is 385 participants at the confidence level of 95 and the margin of error of 5 the independent variable in this study is the millennials interpersonal skills development while the dependent variable is the propensity for dating app usage the survey was administered among 385 millennials born between 1987 and 1994 living in zagreb croatia area via online quantitative anonymous survey constructed of 18 questions the sample was predominantly female 584 and male 416 with the majority of the participant born in 1994 this could also potentially open more questions regarding whether or not millennials born prior to 1994 are spending as much time online and on social media as are those millennials and generation z born after regarding the education level of the participants the 4722 can be classified as the graduate level while 4444 belong to the undergraduate level only 556 stated that they have only finished high school education while 278 stated that theyve finished a phd when it comes to the sexual orientation of the survey participants 8961 identify as straight while 597 identify as gay and 571 as bisexual when asked have they ever used any dating apps or sites 6389 stated that they have whereas 3611 stated that they have never utilized such sites tinder proved to be the most used dating app with 6057 of participants stating that was their preferred app of choice this comes as no surprise as it is the most the propensity for dating apps usage and the millennials interpersonal known dating site in croatia due to its presence in the media tinder is followed by badoo with 2317 while grindr bumble and hot or not are all under the 10 mark results and discussion out of overall 385 participants there were 139 participants claimed they had never used a dating app in terms of personality traits out of these 139 participants 89 participants or 6403 scored as extroverts on likert scale questions this suggests that a significant majority of those who hadnt used dating apps identified as extroverts when it comes to texting preferences participants were given two choices regarding their attitude towards texting 7740 preferred keeping their text conversations superficial transitioning to more depth in person or during a realtime phone call 2260 declared they are more comfortable discussing everything through texts lastly personality traits within the texting preference group within the 2260 who preferred discussing everything through texts 9655 scored as introverts on the survey questions testing personality this suggests a strong association between the preference for discussing everything through texts and introverted personality traits within this specific group in summary the study indicates a relationship between certain personality traits the nonuse of dating apps and preferences in communication methods particularly regarding texting specifically those who hadnt used dating apps were more likely to be extroverts and within the group that preferred discussing everything through texts a significant majority were introverts when it comes to the most appealing feature of dating apps the data reveals that nearly 30 of participants favor digital communication platforms for their perceived ability to mitigate the emotional impact of rejection showcasing a tendency to employ these platforms as a protective buffer about 22 cite convenience as a primary motivator emphasizing the practical advantages of integrating digital communication into their dynamic lifestyles enjoyment emerges as a significant factor with 16 expressing subjective pleasure in their digital interactions additionally 11 appreciate digital communication as a means of alleviating the anxiety associated with facetoface interactions acting as a psychological intermediary over 10 value the capacity to foster social connections without the constraints of physical presence highlighting the transformative potential of digital platforms a minority at 596 expresses heightened confidence in textual communication while 456 appreciate the relaxation associated with nonfacetoface interactions these diverse motivations collectively contribute to a nuanced understanding of individuals preferences in the digital communication landscape the data reveals that nearly 30 of participants favor digital communication platforms for their perceived ability to mitigate the emotional impact of rejection showcasing a tendency to employ these platforms as a protective buffer about 22 cite convenience as a primary motivator emphasizing the practical advantages of integrating digital communication into their dynamic lifestyles enjoyment emerges as a significant factor with 16 expressing subjective pleasure in their digital interactions additionally 11 appreciate digital communication as a means of alleviating the anxiety associated with facetoface interactions acting as a psychological intermediary over 10 value the capacity to foster social connections without the constraints of physical presence highlighting the transformative potential of digital platforms a minority at 596 expresses heightened confidence in textual communication while 456 appreciate the relaxation associated with nonfacerelaxation associated with nonfacetoface interactions these diverse motivations collectively contribute to a nuanced understanding of individuals preferences in the digital communication landscape izvor istraživanje autora the data reveals that nearly 30 of participants favor digital communication platforms for their perceived ability to mitigate the emotional impact of rejection showcasing a tendency to employ these platforms as a protective buffer about 22 cite convenience as a primary motivator emphasizing the practical advantages of integrating digital communication into their dynamic lifestyles enjoyment emerges as a significant factor with 16 expressing subjective pleasure in their digital interactions additionally 11 appreciate digital communication as a means of alleviating the anxiety associated with facetoface interactions acting as a psychological intermediary over 10 value the capacity to foster social connections without the constraints of physical presence highlighting the transformative potential of digital platforms a minority at 596 expresses heightened confidence in textual communication while 456 appreciate the relaxation associated with nonfacetoface interactions these diverse motivations collectively contribute to a nuanced understanding of individuals preferences in the digital communication landscape conclusion the study results supported the hypothesis that the technology has facilitated a space where millennials with less developed interpersonal skills could meet virtually and that technology helps in development of the interpersonal skills however the expansion of the ability of the introverted millennials to date in real life stayed vague what this research has shown is that the original hypothesis that the millennials with introverted personality type have more expressed propensity to use dating apps for finding longterm relationships was not proven in its entirety however it did pose new questions and shed light on the current situation namely it did prove that millennials with introverted personality do have a more expressed source the authors rese izvor istraživanje au conclusion the study results supported the hypothesis that the technology has facilitated a space w millennials with less developed interpersonal skills could meet virtually and that techno helps in development of the interpersonal skills however the expansion of the ability o introverted millennials to date in real life stayed vague what this research has shown is that the original hypothesis that the millennials introverted personality type have more expressed propensity to use dating apps for fin longterm relationships was not proven in its entirety however it did pose new questions shed light on the current situation namely it did prove that millennials with introve personality do have a more expressed propensity to use dating apps as well as to rely on tex for more indepth conversations just not that they use it to establish a longterm relation however that could be connected to the fact that the overall view of the participants is dating apps are not suitable for when you are interested in longrelationships motives and perceived benefit of dating app usage can be summarize emotional protection convenience enjoyment anxiety alleviation social connec confidence in textual communication and relaxation another survey conclusion is tha propensity to use dating apps as well as to rely on texting for more indepth conversations just not that they use it to establish a longterm relationship however that could be connected to the fact that the overall view of the participants is that dating apps are not suitable for when you are interested in longterm relationships motives and perceived benefit of dating app usage can be summarized in emotional protection convenience enjoyment anxiety alleviation social connection confidence in textual communication and relaxation another survey conclusion is that the millennials are using dating apps to meet new people even if it is simply with the purpose of expanding friendships and as most relationship coaches agree friendship is the basis for any good and strong relationship having said that one could argue that using the dating apps for expanding friendships now is an investment into a longterm relationship tomorrow our results are in line with social exchange theory was primarily developed by the american sociologist george c homans later the theory was further refined and expanded upon by other sociologists and researchers including peter blau and richard emerson in the context of the data individuals seem to make choices regarding digital communication platforms based on the perceived benefits such as mitigating the emotional impact of rejection convenience and the enjoyment derived from these interactions the theory also touches upon the concept of rewards and costs where individuals seek relationships or interactions that provide more rewards than costs in this case the rewards may include emotional comfort convenience and enjoyment while the costs might involve potential facetoface discomfort or rejection globally extending this survey and conducting surveys in bigger cities in the united states of america could potentially yield different response as suggested by the literature review additionally this research could also be conducted among the generation z as they show more interest in switching into the virtual world and thus being more opened to taking dating apps as something more interesting when it comes to finding love further research could focus on influence of covid 19 limitation of social contact and consequently increase in usage of dating apps and increasing the propensity to use dating apps for finding longterm relationships for millennials with introverted personality type the propensity for dating apps usage and the millennials interpersonal sklonost korištenju aplikacija za upoznavanje i razvoj međuljudskih vještina milenijalaca lorena rosean jennifer matić jasminka samardžija sažetak istraživanje analizira vezu između tipova osobnosti i sklonosti prema korištenju aplikacija za upoznavanje u kontekstu kreiranje dugoročnih odnosa svrha provedene kvantitativne studije je testirati postoji li korelacija između sklonosti milenijalaca korištenju aplikacija za upoznavanje i njihove spremnosti za izlaske u stvarnom životu glavna hipoteza istraživanja je da milenijalci s introvertnim tipom osobnosti imaju izraženiju sklonost korištenju aplikacija za upoznavanje kako bi se testirala ova hipoteza putem interneta je provedene anonimna anketa korištenjem googleove usluge google forms društvena mreža koja je korištena u istraživanju je facebook a glavni cilj bio je dobiti širu sliku psihološkog profila korisnika aplikacija za upoznavanje i navika upoznavanja istraživanje je provedeno na populaciji milenijalaca u hrvatskoj koji žive na području zagreba nezavisna varijabla je razvoj interpersonalnih vještina milenijalaca dok se zavisna varijabla definira kao sklonost korištenju aplikacija za upoznavanje glavna hipoteza istraživanja da milenijalci s introvertnim tipom osobnosti imaju izraženiju sklonost korištenju aplikacija za upoznavanje nije potpuno potvrđena otkrivajući umjesto toga snažniju sklonost introvertiranih osoba korištenju aplikacija za upoznavanje i slanje poruka kao komunikacijskog alata za kreiranje socijanih interakcija ne nužno za dugoročne veze rezultati istraživanja su u skladu s teorijom društvene razmjene u kontekstu dobivenih rezultata podataka čini se da pojedinci donose odluke u vezi s korištenjem digitalnih komunikacijskig platformi na temelju uočenih koristi poput ublažavanja emocionalnog utjecaja odbijanja praktičnosti i užitka koji proizlaze iz tih interakcija teorija društvene razmjene se također dotiče koncepta nagrada i troškova gdje pojedinci pokazuju veći interes za odnose ili interakcije koje pružaju više nagrada nego troškova u ovom slučaju nagrade mogu uključivati

the research examines the relationship between personality types and the inclination to use dating apps in the context of establishing longterm relationships specifically it quantitatively tests whether there is a correlation between millennials preference for dating apps and their readiness for reallife interactions the main hypothesis posits that introverted millennials exhibit a more pronounced tendency to use dating apps to test this an anonymous online survey was conducted using google forms with facebook as the research platform the study aimed to gain a comprehensive psychological profile of dating app users and their dating habits the research focused on millennials in croatia born between 1987 and 1994 residing in zagreb the independent variable was the development of millennials interpersonal skills while the dependent variable was defined as the inclination to use dating apps the primary hypothesis asserting that introverted millennials have 95

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background the clinical nursing education literature emphasises students experience of belongingness to the workplace as a prerequisite for learning 1 it has thus been suggested that becoming a nurse includes membership and participation in a community of practice of nursing 23 being part of an authentic setting makes learning real as students are able to interact with patients rather independently from their supervisors 4 however making students feel that they belong to a workplace is easier said than done conversely the healthcare environment has been questioned as being favourable learning environments due to eg increasing work load and the challenge of organising supervision 56 further clinical placements have been characterised as a source of stress for students especially when facing moral dilemmas 7 regarding nursing students experiences of clinical learning environments the supervisor relationship seems to be as crucial as it is challenging 3568 clinical placements are however widely recognised as essential for nursing students development into professional nurses in order to utilise learning opportunities in the clinical setting the complexity of clinical learning environments needs to be better understood there is a vast body of literature in health sciences education investigating students perceptions about learning environments with instruments such as the clinical learning environment inventory and clinical learning environment and supervision 910 in this discourse clinical learning environments are addressed as something students can perceive and are therefore understood as measurable 11 however from a sociocultural perspective on learning clinical learning environments can be understood as being constructed in interactions between students and environments and therefore a more situational and dynamic feature than in the former discourse billetts 12 concept of workplace participatory practices offers a framework for understanding learning in the workplace as an interdependent process between workplace affordances and individual engagement in this framework the workplace offers certain affordances for learning that is the available activities and how the workplace invites learners to participate in these activities access to participation is guided by workplace values and norms that build on workplace history and negotiated in interactions between established members of the workplace individual engagement refers to how individuals elect to engage in afforded activities and is arguably guided by personal values and history as well as individuals agency to engage in the workplace agency here relates to how individuals find meaning in participating in the available activities for example an experienced lack of relevance might decrease the likelihood of students engagement in a workplace the potential educational value embedded in available activities might therefore not be fully utilised if learners neglect to acknowledge them as pedagogical rich 13 clinical learning environments are arguably created in interactions between the workplace and individuals as the workplace affords learning opportunities in which individuals can elect to engage 14 the concept of workplace participatory practices thus adopts a bidirectional approach to workplace learning whereby both the workplace and the students are viewed as agents and stakeholders 15 further workplace participatory practices acknowledge the relationship between the workplace and students to be highly relational and interdependent 16 learning in the workplace can from this perspective be viewed as a relational and social act dependent on both workplaces and students and therefore complex by nature 14 applying the framework of workplace participatory practices to nursing students clinical education can offer insights into how they become participating members of a clinical workplace importantly acknowledging both the workplaces ability to invite students and their own agency to engage in the workplace can help us understand how the process of becoming a participant occurs in practice however as clinical environments have a major impact on students 31718 one can reasonably assume that the workplace exercises greater levels of influence on students than vice versa the students are thus at the centre of attention in this study the aim of this study was to explore the interdependence between affordances and engagement in clinical learning environments of nursing students we posed the following research question how are nursing students influenced in their interactions with clinical learning environments methods context the study setting comprised three publicly funded academic hospitals in stockholm county council sweden where nursing students from different universities had their clinical placements the threeyear undergraduate nursing programme in sweden which leads to a bachelors degree in nursing and registration as a nurse combines theoretical courses with clinical placements students attend up to six placements during the programme and placements last approximately foursix weeks usually students have two or more supervisors during the placement period many supervisors are given the opportunity to take educational courses to develop as supervisors and clinical education managers educational and pedagogical issues at the workplaces have usually been extensively discussed with several supervising models being sampled before agreeing on what was perceived as the most suitable one as each clinical workplace decided on the supervisory model the enacted one varied inbetween clinical departments in addition to the supervisors a clinical education manager is responsible for overall administration and communication with teachers in the midand end points of each placement a university teacher and the supervisor assess students as per the intended learning outcomes of the placement in the swedish context students actively participate in clinical practice and are sometimes given one or a few patients to care for under supervision design and theoretical framework we designed an ethnographyinspired qualitative study 19 with data collected through field observations and followup interviews as we drew upon a constructivist interpretative tradition knowledge was viewed as relative and socially constructed 20 furthermore we adopted a sociocultural perspective on learning meaning that learning was viewed as situated in a social world dependent on individuals and the larger community 21 procedure in line with our philosophical orientation data collection and analysis was an iterative process meaning that initial analysis of data guided further data collection further data collection was guided by case study methodology which is understood to be especially beneficial when the boundary between the phenomenon and the context is unclear 22 accordingly we strived for various settings in terms of medical specialty and hospitals also we actively deselected wards designed exclusively for students as we suspected their interdependence between workplace and students to be of another nature then in the regular hospital setting data was collected from three sites during 2013 and 2014 one site at each hospital the sites were purposefully recruited through negotiations between the research team and gatekeepers 23 and approval to undertake ward observations was obtained from the head of each clinical department the sites were diverse in terms of medical specialty but all held great educational responsibilities both on the undergraduate and postgraduate level at each site students with placements at the time of the planned data collection were asked by their supervisor or clinical education manager if they were interested in participating in the study in the researchers interactions with both gatekeepers and potential participants it was clarified that the intention of the study was not to assess clinical education but to explore the clinical environment with all its opportunities and challenges in this way the research team was able to build trust with the sites 24 as the observations were hopefully not perceived as evaluative in addition this approach might have reduced the observers effects on participants as they felt comfortable with not being assessed during observations 19 all students who were asked agreed to participate in the study the first author performed nonparticipant observations 25 shadowing six students during an entire shift and observing students activities and interactions even though only six students were shadowed the observer came across several more during observations extensive observational and reflective field notes were taken 26 during observations ml wore a clinical uniform and introduced herself as a medical student and researcher but did not interact with participants or others if they did not explicitly address her followup interviews with students and supervisors were performed preferably the same day as observations in a few cases this was not possible due to practical reasons and the followup interview was instead held a few days post observation followup interviews adhered to an interview guide based on the literature the research question and the present observation followup interviews were audio recorded and lasted in average 20 min during the observations ml also approached other members of the workplace holding informal interviews with them informal interviews were not recorded ml instead wrote down the main messages from these interviews altogether the study data consisted of six days of observation and ten interviews all observations and interviews were transcribed verbatim resulting in approximately 60000 words of data the analysis took an inductive thematic approach 2728 and was performed in the following steps an initial analysis was performed after collecting data at the first two sites influenced by critical incident analysis 29 significant events were used fig 1 overview of data collection data was collected at three sites where field observations were followed by followup interviews with some of the participants as data analysis was performed iteratively with data collection there is some time inbetween the collection of data at each site as a tool for the initial analysis 30 the first author identified seven significant events from field notes on a specific incident and excerpts from interviews detailing the incident a significant event was understood as a situation involving eg something emotional for the student a conflict of any kind or in interviews with students or supervisors identified by them as a valuable learning situation based on the analysis of the significant events preliminary themes were identified all the data was arranged into a framework of intended incidental and cultural learning activities adopted from the work of hafler 31 the arranged data was subsequently organised in categories within each type of learning activity the previously identified themes were adjusted according to the categories and were based on the analysis of the entire dataset after the data collection at the third site the analysis was finalised through discussions in the research team where themes were critically discussed adjusted and analysed in relation to the literature this study is part of a phd project and the interdisciplinary research team consisted of a diversity of perspectives including nursing medicine and education the entire research process was characterised by continuous and critical discussion on design and analysis both within the research team and in an extended network of researchers with backgrounds including medicine nursing higher education and social science this was helpful throughout the research process and guided decisions on data collection analysis and interpretation results three themes relating to how the interdependence between affordances and engagement influenced nursing students were identified the themes concerned different dimensions of clinical learning environments the clinical learning community the clinical learning design and clinical learning context the dimension of each theme will assist in outlining what was apprehended about the theme we shall now present the three themes with illustrations from field note excerpts and interview quotes theme one being aspirational in taking up the offered role supervisors provided space for students in the workplace making them a natural and desirable part of the health care team this meant that being new or being a beginner was accepted even though activities might take longer than with professional nurses the staff addressed students who seemed unsure and would discretely guide them in terms of how to behave or act in different situations students were actively included in ward traditions and introduced to routines for example taking control of patients was supposed to be performed at specific intervals two students are planning a shift together with their supervisors supervisor one the first 24 h youre supposed to take vital parameters every 8 h but perhaps you do not need it in the to do list supervisor two actually i usually do that since the wards statistics are poor in this way the workplace shared its norms and values with the students for instance that the wards goals for alignment with vital parameter routines were prioritised by the nurses students were invited into the professional community however they were expected to align with the norms in that sense the offer of membership seemed conditional for students it was important to perform tasks in the right way according to ward routines for example a student could stay awake at night wondering whether she had performed her tasks properly in the morning a student poses questions arising from the previous night supervisors and students laugh together with the student at the fact that she could not sleep due to her clinical placement student what was it… the bag to the urine catheter i drained it yesterday am i supposed to tell anyone about that supervisor no you do not have to tell anyone but you can always do that twice during your shift as a habit you can do it during the nursing round student ok how lucky i thought about calling the ward to tell them… this field note highlights how the student besides worrying about the patient also seemed anxious about whether she had done everything right likewise students were eager to be able to answer patients questions perform procedures smoothly and remember all the facts about the patient students thus strived to fill out expected roles as they entered the workplace community i sometimes wonder perhaps obsessively whether ive done everything right have i removed the ivfluid on this patient did i… sort of like did i blow out the candles… and the worst thing i can keep on droning on is whether ive forgotten to say something in this theme students thus demonstrated an ambition to manage the role of a professional nurse taking it up in an aspirational way student i dont like the feeling of insecurity im the kind of person who prefers to know everything precisely before i do something myself theme two being overwhelmed by the responsibility of care the workplace offered a clear structure of clinical education as students learning was taken into consideration in conjunction with ward routines students role responsibility and progression throughout the placement were thought through by the workplace and this usually meant that students were given responsibility and a mandate to care for patients by giving students responsibility the workplace endeavoured to create an authentic environment for them to practice away from the supervisor students were entrusted to receive notifications and supervisors ensured that students had sufficient time to eg come up with an action plan it puts more responsibility on the students since they need to take initiative and do things… and experience responsibility themselves they do not only follow and imitate us they also reflect for themselves as such the workplace entrusted students to provide care for patients students grasped the responsibility they were afforded and appreciated being entrusted even if they identified themselves as novices and unknowledgeable theres a lot that i still cannot manage practically i dont know anything at all but still i am given a lot of responsibility here and i am entrusted despite only being in my second year even if students were allowed to interact independently with patients supervisors clearly demonstrated full responsibility for patients by being available for students at all times and trying to make them feel safe in the following situation a student is about to perform a procedure on a patient the student explains to the patient what is about to happen she is wearing gloves and an apron as is appropriate for bedside working the supervisor is present standing next to the wall but without gloves or apron she looks relaxed does not oversee the student and does not appear perturbed the student starts but hesitates as the patient experiences pain she looks to her supervisor for help who immediately fetches gloves and approaches the bed to help out for students responsibility for patients seemed to be an energyintensive assignment it implied dealing with many issues simultaneously which sometimes resulted in frustration from perceiving themselves as being slow that they would eventually have to manage several patients concurrently was unimaginable to them i feel like im perfectly occupied with two patients thats good enough i wouldnt want more students engaged in their patients wellbeing and appreciated how the relationships they were able to build with them could motivate their learning they took responsibility for patients as they were eager to develop the capability to deliver care in a patientsafe manner however during independent activities with patients students seemed to be fearful of failure assessments and not knowing things they would have liked to know two students are having a brief discussion during the intense morning shift the first student how many patients do you have the second student i only have one the first student i have two and i get totally confused did i serve breakfast to the right person as in this situation students could at times easily forget and become confused over seemingly easy tasks even with few tasks and arguably enough time to solve them students gave the impression of being stressed patient care was thus an exhausting experience and students acted overwhelmed by the responsibility of care theme three being hesitant to negotiate own values with reality the workplace made it possible for students to experience a real clinical setting in the clinical reality students participated in ward activities and experienced the everyday complexity of the clinical ward this could entail finding themselves stuck between the patient and the doctor as patients could have one view of their disease and the doctor an antithetical one for example some hospitalisations might seem unnecessary from the nursing perspective meaning that doctors decision could be understood as incomprehensive from various members of the staff patients were occasionally met with scepticism as they presented with conditions that the health care team found difficult to address a nurse from the night shift is handing over to the day team which includes two nurses and a student one nurse but what caused the dizziness the other nurse well the patient thought it was because he was so angry with the home care service the nurses laugh one nurse puts her hands to her head and pretends she is both angry and dizzy the student notices her charade but fails to smile in this field note the nurses are making fun of the patients explanation of his symptom here the workplace provided an example for students of how nursing could be put into practice in a pragmatic and viable way building on the wards extensive patient management experience students approached their future professional role meaningfully and demonstrated high ambitions and values regarding patient treatment whereas supervisors responded to patients calls as time permitted students immediately sought to help their patients a student helps a patient to the toilet leaves the patient there and returns to make the patients bed upon finishing he goes out into the corridor the alarm system goes off and the student realises that it is his patient he immediately freezes in the corridor turns around and promptly goes towards the toilet to help his patient students highly prioritized their patients in a way that was possible due to their workload but also in a way they viewed as necessary for high quality patient care accordingly students sometimes reacted with deep concerns over actual patient treatment at times strongly disagreeing with supervisors or other health care staff members assumptions about patients notwithstanding they seldom spoke up opting instead to express their disagreement to fellow students a student tells her peer students about a patient encounter when another member of the staff had expressed his mistrust in the patients symptoms the patient said not being able to find your own feet is really hard but it is tough as this is the first time i am meeting her and i have my view of her and then he a staff member comes and expresses his view but i still have my view you know… in this field note the student reflects upon a patient encounter where the student disagreed with a member of the staff this time the student did not speak up the following discussion inbetween the peers went as follows a student perhaps we should ask them why they did like that second student sure but then youre a student and do not dare third student next week perhaps… we might dare then in this way the students confronted their own basic values regarding patient care with the reality of the workplace and even though not openly communicated they demonstrated hesitance regarding their willingness to adjust to the workplace culture one student puts it like this during reporting they make comments like this patient has already returned she was here last week everyone sighs and im thinking is this really necessary … these preconceptions that one can have about patients… i never want to be like that discussion this study explored clinical learning environments of nursing students from a workplace participatory practices perspective we identified aspects of workplace affordances and individual engagement and analysed interdependent interactions between students and the workplace this resulted in three themes on how nursing students are influenced in their interactions with clinical learning environments the first theme implied that students were aspirational in their efforts to take up the roles the workplace afforded them our results suggest that the membership offered to students at the workplace was conditional while students felt welcomed and included the workplace implicitly expected them to align to ward routines and traditions importantly neither supervisors nor managers advocated for conditional membership and worked arduously to include and invite student making them feel at home and safe on the ward the importance of an inclusive approach to students during clinical placement has been variously highlighted 332 however joining a community of practice involves negotiating with existing members even if newcomers tend to initially align to workplace norms to gain acceptance in the community 3334 thus belonging to the group can be of greater importance than following ones own values in this study students endeavoured to fill out the roles offered in an aspirational way noteworthy in this theme students sought to fulfil their roles not only in relation to patients but also in relation to the community of nurses consequently students were eager to perform tasks in the right way which meant that they were exposed to the boundaries of the local practice it was as if the workplace was saying if you do not practice the way we do here you cannot belong to our community students thus sought to align to the expectations of the workplace one can imagine that the fear of failing to fill out a role can hinder learning the precise finding in a study by levettjones et al 3 is that students who experience support from their supervisors could focus on learning instead of being preoccupied with staff relationships further manninen et al 4 advocate that when students experience belongingness to a team they are able to focus on learning and understanding nursing moreover from a sociocultural perspective insufficient experience of belongingness to the community will likely deter learning 3335 indeed including students in workplace communities continues to be crucial for student learning 36 as they to some extent will need to align to the workplace culture nevertheless it is important that they maintain their critical and reflecting approach in order to develop their own professional identity and not simply adjust to existing ones 37 the second theme entailed students becoming overwhelmed by the responsibility of care the results suggest that students were afforded responsibility in line with the educational framework of clinical education and sought to handle the responsibility for patients participating in practice is in line with contemporary educational theories emphasising opportunities for learners to be active as a central feature of learning eg learningasparticipation 38 transformative learning 39 and the theoretical framework of this study workplace participatory practices 1214 here the workplace succeeded in involving students making them active in both practice and their own learning which students previously have highlighted as fundamental to learning environments 17 independently caring for patients was however seemed to be an exhausting and challenging experience for nursing students as previously described in the study by manninen et al 4 in the current study students were occasionally so overwhelmed by the responsibility of care that they for example could forget which patients had been served breakfast their capability to deal with extensive workloads can in this phase of their training be regarded as limited as students in this study could experience stress even during calmer shifts given that students are expected to develop from novices into professional nurses within three years being overwhelmed is perhaps unsurprising it might therefore be of importance for clinical education to facilitate students development of the capability of handling responsibility mcnamara reported on a highly appreciated programme aiming to prepare students for clinical placements including roleplays to simulate clinical processes from admission to discharge 40 which might be one way of exposing students for responsibility early interestingly odland et al showed that newly qualified nurses were overwhelmed by the responsibility as they had not been experiencing that as nursing students 41 clinical education studied here seems in that sense to be successful in preparing students for transition into the professional role as they already as undergraduates experienced responsibility it is interesting to notice here that students did not show any indications of being abandoned on the contrary supervisors were present and accessible for questions and support we believe that this availability was significant for students opportunities to practice responsibility in a safe environment the third theme indicated that students became hesitant regarding their willingness to negotiate their own values with the experienced reality in a metastudy of nursing socialisation price 18 found the paradox of caring as a salient theme connoting students struggle with conflicting notions of nursing poor role models who do not reflect students ideals are known to be a common feature of clinical education 42 however role models are also known to be of strong influence for nursing students 318 manninen et al 43 found that nursing students become increasingly selfcentred towards the end of their training arguing that previous experiences of poor role models might explain this tendency conversely the students in this study did not demonstrate complete alignment to workplace practices but instead resistance to what they saw as poor patient care coherent and strong ideals were found among nurses on qualification in a previous study which support our results 44 in fact students hesitance to adapt to the existing reality might be an indication of their critical and reflective approach however in the aforementioned study the majority of participants could only two years after graduation be described as compromised or crushed idealists 44 this could of course be a reflection of todays health care withstanding your ideals is impossible with the workload and reality of nursing however as mentioned before making students and newly graduates maintain their reflective approach is central for them not to abandon their ideals in terms of belongingness research shows that interactions within learning environments heavily determine the extent to which student feel included and accepted 1336 positive studentstaff relationships are understood to improve student perceptions of their clinical learning environments 3 however the present results suggest that students might not have a desire to belong as this would require them to compromise their own values regarding patient care thus belongingness to the workplace and membership in the community were not dependent only on the workplaces ability to include students but also on students willingness to engage in the workplace from a workplace participatory practices perspective workplace learning is understood as dependent on both the affordances of the workplace and the engagement of individuals in this case students 1215 it might be the case that the impact of students individual engagement when considering learning environments has been underestimated as attention has been on workplace functions and supervisors actions the most important stakeholders in clinical education namely students have been omitted in relation to practice the present results further establish the notion that nursing students are assisted in their learning by being invited into the community and given responsibility for patient care the combination of these factors provides students with favourable opportunities for learning in addition exposure to the reality of health care enables authentic learning and knowledge transferability to the context in which students will eventually practice 10 this study highlights the need to acknowledge students as an important stakeholder in creating clinical learning environments rather than viewing them as consumers of the environments we therefore argue that the concept of workplace participatory practices as outlined by billett 1215 can be suitable in further exploring clinical education as it recognises both workplace affordances and individual engagement we argue that the three themes concern different dimensions of clinical learning environments the learning community the learning design and the learning context the learning community includes the role students are given and concerns how newcomers are made members of the workplace community the learning design entails how activities are structured planned and introduced to facilitate learning and relates to the educational framework of the workplace the learning context involves the setting in which learning takes place and the contextual factors that impact and influence learning due to its established significance clinical learning environments have been extensively researched but theoretical perspectives on learning environments remain scarce 45 the educational environment is arguably a multilayered multidimensional phenomenon that is not easily grasped or measured 11 our results suggest that clinical learning environments contain at least three dimensions community design and context further empirical work is needed to investigate the stability of these dimensions extending the list if necessary methodological limitations as with all scholarly work this study has some limitations ml was a novice observer and despite the methodological support she received from the research team it potentially influenced the quality of the data collected our decision to collect data at three different sites limited the possibility to engage deeply in a single context at the same time dependability was enhanced as themes displayed consistency over the three sites moreover in terms of credibility the three sites also provided us with various perspectives on the phenomenon there might be a risk that field observations influence behaviours of participants referred to as the observer effect 46 in our case the study objectives were made clear for participants limiting potential experience of being assessed additionally as the observer was a student herself she might have been perceived as less threatening however as students were asked to participate by their supervisor they might have felt obligated to take part in the study while field observations and interviews were conducted by a single investigator the analysis was collaboratively performed as the research team comprised a variety of perspectives including nursing medicine education and sociology the research process was characterised by an openminded and critical approach to the results and its relation to previous research and theory although this study drew inspiration from the ethnographic tradition we do not consider it to be an ethnographic study which would have required more extensive field observations 19 field observations might be criticised as subjective and lacking continuity however it can be argued that when performed properly they can contribute to understanding social phenomena 47 although field observations are often performed at a limited number of sites researchers often find that sites share more commonalities than differences implying that the results are likely transferable to similar contexts 48 which we believe was the case also in this study the provided details on context and procedures as done in this study might also increase readers opportunities to transfer the results to their own settings conclusion this study explored clinical learning environments of nursing students from a workplace participatory practices perspective workplaces succeeded in inviting students into both the community of nurses and the practice of patient care however the main message from the results was that nursing students negotiated their belongingness with the community because of strong inherent norms and values in the profession in this negotiation students showed hesitance regarding compromising their own basic values with the experienced reality of health care consequently the challenge for clinical nursing education is perhaps not to increase students experience of belongingness to the workplace but to maintain their critical and reflective approach to health care practice centring on the initial question to belong or not to belong hamlet himself concludes thus conscience does make cowards of us all and thus the native hue of resolution is sicklied oer with the pale cast of thought upon closer examination it appears necessary to upgrade the student as a stakeholder in creating rather than being a consumer of clinical learning environments if students do not have the desire to belong no inclusion whatsoever will incorporate them as members of the workplace this study highlights the significance of students individual engagement in their interactions with clinical learning environments additional file additional file 1 interview guide interviews adhered to the following interview guide authors contributions ml eb and kbl designed the study and together with sp they performed the selection of sites ml collected and transcribed all data ml eb sk sp and kbl collaboratively analysed data and interpreted the findings ml was responsible for drafting the manuscript which eb sk sp and kbl critically revised all authors approved of the final version of the manuscript authors information matilda liljedahl md is currently a phd student at the department of learning informatics management and ethics at karolinska institutet with previous experience in qualitative research she also holds a position as a junior doctor in stockholm county council erik björck md phd is an associate professor in clinical genetics and an experienced medical educator he currently holds a position at the department of molecular medicine and surgery and as a senior consultant in clinical genetics at karolinska university hospital susanne kalén rn phd is a senior medical education researcher currently she holds positions at the department of clinical science and education södersjukhuset karolinska institutet and at the stockholm county council sari ponzer rn md phd is a professor of orthopaedics at the department of clinical science and education södersjukhuset karolinska institutet and a senior researcher in medical education previously she was the dean of higher education at karolinska institutet and currently she is head of the orthopaedic department at södersjukhuset klara bolander laksov phd is an associate professor of medical education with a background in sociology and is an expert in qualitative research she currently holds positions at the department of learning informatics management and ethics at karolinska institutet as well as at the department of education at stockholm university competing interests the authors declare that they have no competing interests

background belongingness has been argued to be a prerequisite for students learning in the clinical setting but making students feel like they belong to the workplace is a challenge from a sociocultural perspective workplace participatory practices is a framework that views clinical learning environments to be created in interaction between students and the workplace and hence are dependent on them both the aim of this study was to explore the interdependence between affordances and engagement in clinical learning environments the research question was how are nursing students influenced in their interactions with clinical learning environments methods an observational study with field observations and followup interviews was performed the study setting comprised three academic teaching hospitals field observations included shadowing undergraduate nursing students during entire shifts fiftyfive hours of field observations and ten followup interviews with students supervisors and clinical managers formed the study data a thematic approach to the analysis was taken and performed iteratively with the data collection results the results revealed that students strived to fill out the role they were offered in an aspirational way but that they became overwhelmed when given the responsibility of care when students basic values did not align with those enacted by the workplace they were not willing to compromise their own values workplaces succeeded in inviting students into the community of nurses and the practice of care students demonstrated hesitance regarding their desire to belong to the workplace communitythe results imply that the challenge for clinical education is not to increase the experience of belongingness but to maintain students critical and reflective approach to health care practice additionally results suggest students to be included as an important stakeholder in creating clinical learning environments rather than being viewed as consumer of clinical education

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introduction and research question people doing full time youth work accompany young people in their sensitive phase of searching for models of a successful life in developing their religious identity young people need people who show them how living a christian life can look like today and encourage them to shape their own lives through discussion orientation and differentiation in this respect youth leaders are prominent and will be observed they cannot not be role models … they are models from whom one learns good or bad through imitation this results in significant opportunities for youth leaders to support young people in the development of their fragile and fluid identity on the one hand on the other hand there are dangers associated with their influence depending on their maturity leaders may face the irresistible temptation to bind people to themselves instead of encouraging them to think and act independently in addition being confronted with their own and others expectations can put leaders under pressure thus leaders perceive their role with its opportunities and dangers as an ambivalent experience the following statement of a youth leader expresses their dilemma i want to shape the young people only in a positive way but lets be honest i will also shape them negatively1 the perceived ambivalence in the sense of an ambiguity arises from the fact that contradictory statements wishes and evaluations are present at the same time the youth leaders statement above refers to her own imprint which includes both positive and negative aspects at the same time according to lüscher experiences of ambivalence occur when people in their search for the meaning of persons social relationships and facts that are important for facets of their identity and accordingly for their ability to act oscillate between polar contradictions of feeling thinking willing or social structures that seem temporarily or permanently unsolvable that is contradictory aspects that are found seem mutually plausible this can be perceived as an irresolvable tension or lead to new options for action the aim of this study was to explore the ambivalent role experience of youth leaders which represents partial aspects of the masters thesis youth leaders as role models2 and continue with the ambivalence experience the research question was how do fulltime youth leaders experience their role as faith role models for youth and young adults this study explored how fulltime youth leaders in protestant churches free churches and ministries in germany experience and shape their role as faith role models to adolescents and young adults by using semistandardised interviews the purpose was to find starting points for further development of the education and training of youth leaders in order to support them and equip them to do their valuable work a technical classification in practical theology follows which includes a presentation of the state of research and a description of the background of the youth work of protestant churches free churches and ministries in germany relevant to the study followed by the research methodology classification in practical theology the review of practical theological german standard literature on faith role models shows that besides god and jesus people from the bible and church history and the reallife environment are recommended as worthy of being imitated the importance of the family is striking in pastoral theology the expected exemplariness of the ministerial person occupies a broad space something similar although in a weakened form can be observed about teachers and leaders fulltime and voluntary workers in general and ultimately every christian the role models influence can occur directly and willingly through educating teaching and proclaiming and incidentally in conversation through observation and examples it is relevant whether someone is noticed as a role model whether mimesis follows the observation and whether the relationship is experienced as appreciative for attitude change it is essential to engage with content not only at emotional level the fact that expectations influence interaction significantly can be deduced from the many ways they are implicitly and explicitly present with reference to power the danger of dependence and thus manipulation and abuse are sensitive concerns these are intensified when a ministry leads to attachment to a person instead of focusing on communicating the gospel in dealing with people and thus with faith role models it is true that you can do a lot for each other but you can also do a lot to each another as a danger to the role model fechtner et al identifies the pathology of helping that is possible selfoverloading this research is located in the field of religious education which is a composite science between theology and pedagogy or education and social sciences and draws on theories from both fields it moves in a zone of tension since faith as a relational event is on the one hand not teachable and therefore not at one s disposal on the other hand it includes learning and understanding learning processes play a dual role in this research youth leaders reflect on how young people learn from them as role models and how they perceive themselves in this role and from this conclusions are drawn for training and mentoring youth leaders the research is located in congregational pedagogy and youth work it encompasses multilayered learning processes in connection with faith models and the reflection of these processes so that the congregation becomes a didactic place church pedagogy as a professional theory plays an indirect role because the employment relationship has an impact on the youth leaders following the classification of the research work in the state of research theology and definitions of the central terms the initial situation of the research is presented to this end the role that learning from faith models plays in the developing a religious identity will be presented first 3 definitions of terms and description of the initial situation developing a religious identity the research work is based on schweitzers understanding of the development of religious identity he postulates that it does not end with adolescence but is a lifelong process identity goes beyond external forms and church affiliations to include a personally adopted religious conviction in a reflected form since it is not finally concluded it is an identity referred to as godrelationship and transcendence since identity is fundamentally and thus olso religious identity a selfdesign its formation can be stimulated and promoted but not brought about from the outside it is not only a matter of conveying content but also of possibilities of identification which can promote the development of ones own identity it is through the encounters and relationships with others that religious identity develops against this background the following section defines what can be understood by a role model of faith and the offer of identification it contains 32 model of faith from the perspective of the psychology of religion faith means an act of the whole person a taking up of a relationship to an encompassing whole in this study the focus was on faith in the triune god based on the revelation in the bible which is closely linked to the person of jesus christ in the new testament 3 in the process of faith man receives salvation through acceptance by god thus faith is a gift from god and at the same time the human response to this gift englert shows a shift in church history from emphasising a decision of faith to developing a faith that is closely connected to ones biography and cognitive and emotional development this research assumes that both aspects belong together even if faith cannot be taught intimate trust can be exemplified and a capacity for judgement in faith can be stimulated with the maturity of the individual as an objective forms of faith can be learned and practised so faith can be expressed and become effective in the individuals life therefore role models play an orienting or even formative role in all complex learning processes depending on the phase of life4 in the following sections the significance of faith role models will be shown from the viewpoints of religious history dogma pedagogy and psychology and practical theology learning from role models has a long history in the judeochristian faith rabbis used them to show the ideal of a person characterized by torah study in the middle ages christian saints were venerated and in pietism there was a preference for biographies dogmatically the role model concept with its normative character is ambivalent although the earthly life of jesus christ is worthy of being imitated an ethically understood role model christology would overstrain the strength of human beings faith manifests itself in accepting the vicarious work of christ for salvation through the indwelling of the spirit mankind becomes a new creature and is enabled and called on in the new testament to follow christ which includes the testimonial way of life paul urges people to imitate him but only in so far as he imitates christ thus following paul … is following christ the question arises who is suitable as a faith role model from a practicaltheological perspective in the current media society and role models are shown to be smooth beautiful and flawless at the same time they are quickly and mercilessly rejected at the first misstep the bible shows a different approach god does not choose the flawless as leaders and role models but murderers like moses or deniers like peter this shows his faultfriendliness he gives fallen human beings a second chance furthermore in experiencing their own weaknesses people acquire a wisdom with which they can help others a role model also proves helpful in dealing confidently with ones weaknesses by faith in justification for human existence remains broken both in role models and in those who imitate a role model it is precisely this brokenness that can lead to disappointment in people who expect virtuous behaviour and a measure of perfection from their role models when aware of limits and dangers learning from a model can indeed trigger positive learning processes as shown by older and more recent learning 4 in this regard the models of the psychology of religion by osergmünder fowler and streib are also important for religious development the affective component of the experience of faith theories neuropsychological findings and pedagogical research künkler 201775 they include cognitive affective and actionrelated aspects the concept of role model in this study is based on that of the religious educator mendl who understands a role model as a person who is chosen as a personal model because of his or her special characteristics or moral actions and stimulates forming ones own life lachmann confirms that a person can lastingly impress another and inspire imitation and identification provided that there is a positive relationship with the role model however preserving the boundary to idealization or even to a veneration of saints is essential however whether a person is perceived as a role model is decided in each case by the recipient in the research field the young people are accompanied by the youth leaders who are characterised by the following 33 youth the age group that youth leaders accompany is an independent phase of life ranging from 11 to 27 schwab divides it into young adolescents teenagers and young adults as a main characteristic he names the ambivalence between growing independence in the cultural sphere and simultaneous economic dependency physical changes take place as well as the psychological and social processing of the processes associated with the transition from childhood to adulthood in postadolescence important life decisions … such as choosing a career or starting a family are made and many imprints of ones own childhood and adolescence are critically questioned adolescence is decisively shaped by school for many young people confirmation is their first more intensive … encounter with church christianity when they ask about the possible significance of the church for their lives and about the credibility of those who represent them as a pilot study among 14 to 19yearolds in the catchment area of the protestant church in westphalia 5 and the empirica youth study 20186 by faix and künkler among highly religious7 young people revealed that faith and community are inseparable for them also typical of young adults in christian settings is the desire for successful relationships both with god and interpersonally even when young people can talk about their faith they choose carefully with whom they want to talk about it because they find the topic very personal more important to them than dogmatic content is the quality of experience and the everyday relevance of faith overall the importance of faith is declining among young people according to the current shell youth study among young people aged 12 to 15 faith is important for only 24 of protestant young people and only 13 of protestant young people pray at least once a week according to the 2016 sinus institute youth study8 membership in a faith community is usually based on family tradition and not a personal decision an exception is young people who join a faith community through active church involvement in denominational youth work by conscious decision this highlights the importance of youth leaders activities also the 2018 youth study9 supports that they take on an essential role and important function for young people almost 90 highly religious young people mentioned that fulltime workers are important as they represent a person of reference and trust the framework in which youth work takes place in protestant churches free churches and ministries is explained below 34 youth work in evangelical churches free churches and ministries in germany of germanys nearly 832 million inhabitants 207 million are members of the evangelical church in germany the latter emerged from the reformation and was divided into 20 different regional churches primarily territorial churches in which elected volunteers and ordained theologians … share the leadership responsibility some 300 000 members of protestant and free churches are united in the association of protestant free churches and almost 600 000 members of other free churches and communities are not fully recorded within the evangelical state church there is also the gemeinschaftsbewegung organised in associations the roots of which besides the reformation include the pietism of the 17th century the revival movements of the early 19th century and the evangelism and holiness movement of the late 19th century in the anglosaxon world the unions work as free ministries within the evangelical church 10 many churches free churches community associations and independent ministries are united in the german branch of the evangelical alliance founded in 1846 as a worldwide association of evangelically minded christians from various groups and congregations a commonly formulated confession of faith with five focal points unites them striving for unity common prayer the importance of the bible evangelism and social responsibility the survey was conducted among youth leaders whose employer was closely associated with the evangelical alliance creating a common orientation ground the respective employment relationships of the youth leaders are discussed below 35 fulltime youth leaders evangelical churches free churches or community associations can directly employ fulltime youth leaders as deacons or youth pastors they work for youth associations and youth organisations independently organised under the umbrella of the evangelical regional church or free churches and offer regional and national events also mission organisations and independent organisations with a specific target group can employ youth leaders the activity profile the education path and the job title within evangelical churches free churches and community associations differ in the regional church context church youth work groups are often led by volunteers the fulltime workers provide support through counselling and training and do important relational work they are usually trained through social pedagogical or religious pedagogical studies at a university or they have been trained as deacons some of their posts include a partdeputation of religious education in a public school at primary and lower secondary level in community associations graduates of bible schools are often employed as ministers for children and youth at district level or nationally and free churches sometimes have their training institutes they often choose the title youth pastor for fulltime youth workers these differences are not significant for the research work the respondents were fulltime youth workers in evangelical churches free churches or independent organisations they are collectively referred to as youth leaders what characterises their work will be examined in more detail below problem and research aim the field of activity of community educators and youth leaders is like that of pastors but far less recognised in addition the very demanding clientele the working hours the sixday week the frequent lack of overtime compensation and a low salary compared to other church employees are further stress factors in an empirical study in the 1990s désirée binder researched how evangelical community deacons experienced their profession she identified the comprehensive demands and influence of the appointing authorities on service and private life sanctions in the case of contradiction between lifestyle and church norms and insufficient opportunities for professional development as stress factors indeed some things have changed in these areas over the last 25 years however leaders are still required to reflect the congregations understanding of christianity through their lifestyle in conservative communities the ministry of youth leaders as such is challenging because according to rieg it encompasses two mandates they are supposed to strengthen and promote the selfinterest and personal responsibility of the young people and at the same time they must fulfil a pedagogical mandate the fact that irregular working hours are difficult to reduce to a life marriageand familyfriendly level and leave too little room for reading preparing working out and catching up is still present brunner even states a high potential for work overload leister also mentions role conflicts resulting from different fields of work and the stress potential in the work environment for example while care is taken to separate professional and private roles11 in professional settings youth leaders often invest holistically in relationships with people with whom they have professional and personal contact particularly noteworthy among the pathogenic factors mentioned by schneidereitmauth are value conflicts which can arise in connection with the faith crises of the fulltime staff this shame factor brings with it taboos in addition to these external factors aspects of personality play a role in the challenges faced by youth leaders one of these challenges is that an idealistic attitude towards the profession … can lead to the selfdemand of permanent presence this is reinforced by permanent accessibility via social networks those working in fulltime ministry and are wellknown nationally are easily stylised as heroes with a large following this can lead to unhealthy dependency for the young people and the youth leaders youth leaders work is based on a relationship of trust this poses the danger of exploiting trust and imprinting can slide into abuse as these explanations have shown the role of youth leaders as role models is exposed to different expectations challenges and dangers unfortunately there has not yet been a study in germany on the proportion of people trained for fulltime youth ministry who continue this profession how long they do so and for what reasons they fail to do so however several churches and ministries have recognised the need to accompany young people in their first years of ministry by assigning them experienced people they are not dependent on12 this is essential in supporting the formative and challenging tasks of young people for the development of these programmes it is helpful to clarify how the selfexperience of youth leaders in their role as faith role models is formed it has already become evident that internal and external causes and theological and sociological aspects are significant here the aim of this study was to determine the quality of experience of youth leaders in their role as role models the focus on the emotional aspects of selfexperience provides an introspective differentiated perception of the professional group this can support the further development of holistic education and training programmes in the following section the methodological approach of the study is explained and the research field and the criteria for selecting the sample is described 5 presentation of the methodology data collection and preparation the research approach was based on qualitative social research problemcentred interviews were conducted online via ms teams between march and may 2020 using a semistandardised interview guide the questions were developed on researchrelevant findings from the respective reference sciences from a social science perspective developmental and religious psychology findings and aspects of the psychology of learning formed the starting point sociologically the generational inclination of the groups of people involved was considered equally fundamental were theological anthropology and the restoration of the image of god through justification and sanctification added to this were biblicaltheological perspectives on role models and the pauline call to be an imitator of christ the interviews were recorded as audio files and then processed as a contentsemantic transcript 13 52 research field all interview participants worked full time in christian youth work they had completed a degree or theological college at a missionary training centre and ministered as youth leaders in an evangelical church free church or independent ministry active within or associated with the evangelical alliance14 these include the protestant churches with their youth associations as well as the ministries such as the gnadauer verband in addition there are the free churches which are conservative evangelical15 or pentecostal the subjects were found with the help of the snowball method to avoid the danger of lumped samples the researcher asked various youth leaders specifically training institutions for further recommendations as to who could be considered as an interview partner this started various chains so that sufficient variance could be achieved among the subjects of the 30 people who returned a completed questionnaire on their field of activity 29 were willing to be interviewed from this group of people 12 youth leaders were selected who were as different as possible in terms of their characteristics to be able to compare the subgroups with one another the researcher wanted both men and women and the two mainly relevant age groups to be represented by at least three test persons16 in this way young professionals and experienced leaders were included unfortunately it was not possible to recruit any interview participants who had studied at an evangelical state university this is because both the personal contacts and the resulting chains led to youth leaders who graduated either from free evangelical universities or missionary training schools the survey included graduates from two different theological colleges and five different missionary training schools one person attended a threeyear leadership community college abroad with reference to basic theological orientations mainly evangelically influenced persons were interviewed the researcher was only able to recruit two respondents from the charismatic pentecostal church movement because she is less wellnetworked in this area the following table 1 shows the features of the interviewees in groups through proclamation at home and abroad and the centrality of christs death on the cross and the bible evangelical groups see themselves as particularly faithful to the gospel and usually represent rather conservative values at the same time they are characterised by a great vitality 16 the age question was asked in the form of decade designations in order to lower the inhibition threshold with regard to this information and to increase anonymity the age limit is near the end of adolescence which according to schwab is 27 years this is also the transition from generation y to generation z which can however overlap by several years which must be taken into account in the evaluation following the presentation of the research methodology and the research field the collected data will now be analysed and interpreted analysis and interpretation of the data the transcripts were analysed using qualitative content analysis according to mayring and kuckartz the analysis tool f4analyse was used as a technical aid for coding the transcribed texts could be captured and text passages could be marked in colour a colourmarked category system was created next to the texts memos and category definitions could be created and texts could be compared by different categories the first coding was deductive and based on the interview guide and additional categories were created inductively then based on four research questions a targeted reduced category system was developed by merging and dissolving categories17 an excerpt relevant to the ambivalent emotional experience of the youth leaders to be researched is presented in table 2 in the following section the subjective experience of the role is first presented in a differentiated way in categories a and b in order to illustrate the similarities and differences between the individual youth leaders a typebuilding procedure is then applied 61 categorybased evaluation youth leaders experience their role ambivalently with reference to their influence on the young people and the impact of the position on themselves the same issues can be found in both emotion domains as the categorybased evaluation shows in table 3 they found their task of accompanying and shaping young people and leading them to maturity emotionally positive and stimulating this had to do with their effectiveness and making a difference in the lives of young people in addition their task matched their passion and talent and therefore gave them joy it gave them a good feeling to contribute to young people becoming mature in faith and life simultaneously their influence and the resulting responsibility were emotionally negative and stressful for them they experienced that negative behaviour on their part could also have a longlasting effect they realised the danger of abusing their influence and that not all those entrusted to them could protect themselves effectively also they were confronted with other values and life stories and sometimes felt overwhelmed in dealing with them beyond their impact on the youth the emotional experience of youth leaders had to do with how their role affected them again aspects of a2 and b2 are considered in parallel because they deal with issues that were experienced ambivalently on the one hand their exposed role as youth leaders and faith models led to manifold appreciation experienced directly through verbalisation or indirectly when young people trusted them sought advice were grateful or imitated them on the other hand both community leaders and young people placed high expectations on their availability and lifestyle youth leaders also put themselves under pressure to live in an exemplary way they experienced inner selfcriticism and selfdoubt in the face of their weaknesses and failures as stressful and experienced a lack of understanding or criticism from superiors they experienced it as deeply meaningful to be able to do what they were passionate about what helped others and thus made a valuable contribution at the same time they were burdened because they did not always see the results of their work or the growth of those entrusted to them took more time and was more unpredictable than they hoped handling this was a challenge for them being seen as role models motivated them to persevere in their faith and critical questions from young people positively challenged their thinking they also experienced growth when they had to disappoint expectations even if they considered it in retrospect as essential and helpful to have learned to set boundaries and to let go such learning was associated with effort sometimes also with pain youth leaders lived their role as role models in a relational way they found it fulfilling when relationships were mutual when they learned from one another and experienced relationships at eye level and when they sensed the young peoples willingness to forgive them however it was burdensome for them that their role made these eyetoeye relationships difficult especially in private even in friendships they were often seen in their leadership role in their ministry they had to motivate themselves and their coworkers and the young people and they felt dependent on their coworkers to some extent this put a strain on them 62 type formation to picture differences and likenesses in the emotional experience of youth leaders a typeforming procedure was used as a further step of evaluation and analysis in addition to the categorybased evaluation the categories emotionally positive or inciting and emotionally negative or stressful emerging from the coding were used as comparison dimensions since the focus was only on the emotional component it was not clear whether the experience referred to their behaviour towards the young people or the effect on themselves much more critical is the subjectively experienced intensity of the feelings which became apparent in the choice of emotional terms such as burden or enthusiasm and the frequency with which the respective category was mentioned to compare the individual cases another function of the analysis tool f4 was used as an aid the display of the frequencies of individual codes in a table m1 to m7 are the male respondents with m1 as the youngest w1 to w5 represent the female respondents in table 4 the assigned text quotations were displayed in a table in the same way thus it was possible to consider quantitative and qualitative aspects in the search for similarities and differences of the experience as exemplified in table 5 by m1 the two comparative dimensions were used to present the experience of the 12 respondents in a cross table thus groups of respondents emerged who shared a socalled feature space slight expression was marked each time that emotions were described without salience respondents were assigned medium level of expression if several expressions contained emotions and strong level of expression if a variety of different emotions including strong ones were mentioned in table 6 of the possible nine feature spaces the respondents represented seven the emerging groups within the characteristic spaces were checked for internal and external heterogeneity thus it became evident that the seven groups could be combined and presented individually in table 7 by using four colours each group was given a short name strong positive feelings medium positive feelings slight positive feelings strong negative feelings the selection of the abbreviations was based on the markedness of the emotional experience but cannot do justice to the complexity of the individual cases the specific types are described below to prevent oversimplification and distortion and to present what the groups had in common the characterisation was done by selecting one person of the group as a prototype who represents the relevant characteristics in a pure way these characteristics can thus typically be sharpened to clarify the reality structure of the experience contents note that with a total sample of 12 people the respective groups in the characteristic spaces are small they comprise two to four individuals each therefore the described types have a hypothetical character the extent to which they are representative of the overall experience of youth leaders in similar contexts would have to be determined with further investigation this limitation must be considered especially for genderspecific aspects for example bearing in mind the limited scope of the statements the types found in the available interview material will now be characterised and referred to the state of research in the literature in addition possible implications for the practice of training and further education and the accompaniment of youth leaders are derived in a typerelated way this is done in a cautiously concrete way as both the contexts of training differ greatly between university studies on the one hand and training centres with four types of emotional experience the balanced one m1 m5 m6 m1 experienced slight positive and negative feelings m5 and m6 were assigned the medium characteristic thus their overall balance of emotions seems even the ambivalent one w2 w3 in w2 and w3 both characteristics were strongly pronounced however this results in them being not so much balanced as having a strong sense of ambivalence because the respective emotional experiences were strongly pronounced the delighted one m7 w1 w4 even though they described mild to moderate negative feelings these seemed minor compared to the solid positive emotions mentioned they were therefore combined in one group the burdened one m2 m3 m4 w5 the opposite is true for the burdened they also described positive feelings however in the described intensity of their expressions the burdensome feelings outweighed the positive ones a shared residential community on the other hand and the further education programmes of the evangelical churches free churches and ministries also vary greatly 63 characterisation of the four types and implications for training practice 631 the balanced one the characterisation is based on m5 and includes statements from m1 and m6 in the sense of an ideal typical intensification the balanced one is a male and belongs to the age group 30 to 39 and already has professional experience he is happy when the young people learn spiritually and practically from him grow in personal faith prepare group lessons and live in a valueoriented way thus he sees that what he has an effect and is noticed at the same time to be permanently seen in his professional role is challenging for him he often feels observed and partly dependent on volunteers this is unpleasant because he does not always act as he would expect of himself he finds it problematic that the learning processes of many young people are unpredictable or take long overall positive and negative emotional experiences balance one another out interpretation and conclusion for the training and accompaniment practice the balanced one has already developed a good routine within the framework of professional experience the role conflicts or stress potential nevertheless remain noticeable for him for the further training or accompaniment of this type a role reflection of the public character and dealing with volunteers seems to be relevant furthermore it seems important to notice the first signs of fatigue and to strengthen resources and attitudes that support longterm professional satisfaction and staying healthy in the profession reflecting on what is meant by success and how and whether it can be measured can be helpful 632 the ambivalent one based on w3 statements from w2 are included the ambivalent one is female and in the age group 20 to 29 she feels honoured and affirmed when young people ask her for advice or imitate her see her as an expert trust her or give positive feedback she is happy when young people think independently and question issues or their actions meeting expectations is essential to her and she has had an arduous learning process about setting boundaries around expectations not being able to give people what they need is painful for her she has a high awareness of her influence and the accompanying danger of idealising her person by the young people or manipulative actions on her part it is striking that she often uses the verb to try when describing her actions which on the one hand shows commitment and on the other hand insecurity about her effectiveness interpretation and conclusion for the training and accompaniment practice the ambivalent has a high awareness of the fact that in learning from role models the boundary to idealisation or even saint worship must be maintained she is in her first years of service and lifehistorically in the middle of postadolescence it is helpful to support their own identity including healthy boundarysetting and inner independence this can be done during training and during guidance in the first years of work theologically relevant seems to be the reassurance in gods gracious action which cannot be stopped even by ones own inadequacy and a conscious affirmation that human existence remains broken both in the role models and in those who imitate a role model 633 the delighted one based on w4 statements from m7 and w1 are included the delighted one finds her ministry fulfilling it matches her passion and heartfelt concerns it makes her happy to see how she can support and shape young people and she has the feeling that she can change a part of the world by doing so at the same time she experiences fulfilment and appreciation in her work and little or not as much observation from her environment as she would have thought before although she is selfcritical and aware that her shortcomings also have a formative effect on the young people this experience does not seem emotionally dominant interpretation and conclusion for the training and accompaniment practice the delighted one seems to be absorbed in her work she is aware of her formative role sch but at the same time she has found a realistic way of dealing with it in the accompaniment of youth leaders her potential can be made fruitful for others for example in the form of intervision groups for colleagues at the same time the exchange with colleagues whose work is currently lined with more obstacles than their own can strengthen her resilience in a preventive way furthermore a high fit between ones passion and the demands of employment seems to be a protective factor in the training of youth leaders the process of finding ones own profile can be supported for example by specifically reflecting on practice phases in this regard 634 the burdened one the focus is on m2s statements supplemented by those of the other persons the burdened person does not yet have much professional experience he is happy to shape and inspire young people but at the same time he feels the associated responsibility as a significant burden motivating himself his coworkers and the young people and caring for all spiritual life result in pressure and overload this is related to his high expectations and those of the young people and his superiors he is aware of his weaknesses and uncomfortable when others see his mistakes on the one hand his dependence on god strengthens his relationship with god on the other hand an inner burden remains perceptible for w5 who differed from the others in her professional experience this related mainly to the longterm adverse effects interpretation and conclusion for the training and accompaniment practice the burdened one seems very responsible in terms of personality type which together with a possible spiritual exaggeration of his role has a burdening effect this shows that an ethically understood model christology strongly apart from the implications mentioned in ambivalence there is also a need for reflection on selfexpectations and the expectations of others which could probably best take place in personal accompaniment during training and the first years of work how can the individual findings on the role experience of youth leaders be summarised and what conclusions can be drawn for training and further education practice conclusion in summary it can be stated that although all respondents mentioned joyous and stressful factors in their role experience these differed in intensity it seems evident that joyful or stressful moments can predominate in the overall experience a more significant finding is that mild to moderate emotional expressions of the experience can lead more easily to a state experienced as balanced than when the respective emotions are pronounced the following an empirical study among protestant youth leaders in germany journal of youth and theology 132 10116324055093bja10043 hypothesis may explain this fact both directions of emotional expressions produce a certain stress level through their intensity they add to the overall experience rather than neutralise it in the introduction it is indicated that the experience of ambivalence was considered in a more differentiated way since postmodernism while initially the stressful aspects and the associated inner tensions were the focus of consideration the expansion of the term in different scientific disciplines has clarified the liberating and creative aspects of ambivalence originally the experience of ambivalence was understood as a basic symptom of schizophrenia nowadays it is considered a sign of inner strength if one can allow ambivalence and contradictory views and deal with them adequately for this reason it is also important in the training and further education of youth leaders to teach constructive strategies that go beyond repressing or accepting and make the liberating and creative aspects of ambivalences fruitful therefore in accompanying youth leaders assistance needs to be provided for example in the modulation of feelings the burdened and the ambivalent persons could benefit from cognitive evaluation systems including examining underlying theologicalanthropological beliefs this raises a resourceoriented question for further research which individual and systemic factors contribute to a youth leader being delighted or balanced the analysis of the four types also showed that training and further education and the accompaniment of youth leaders must on the one hand be oriented to the personality type and on the other hand to the professional experience or the individual development to be suitable for example while it is important to strengthen identity and clarify roles during training and the first years of work it is necessary to strengthen protective factors later to be able to work healthily and happily in the long term summary as has already become clear in the presentation of the categories the emotional experience of the role model is characterised by ambivalences it seems as if the youth leaders in their role as role models are constantly walking a fine line between happiness and excessive demands between taking advantage of the learning opportunities and being frightened by the dangers at the same time joy and concern relate to the same topics being allowed to shape and support young people is both gratifying and frightening for them as is their exposed position including the expectations placed on them by applying the typeforming method it became evident that this could lead to four different patterns of experience depending on individual perception ones own role experience leads to a pleasing burdened balanced or ambivalent overall balance the findings of both analyses categorybased as well as typeforming are summarised in eight theses which underpin the title of the article youth leaders like to be role models of faith yet are afraid of it 1 youth leaders enjoy having influence at the same time they are aware of the danger of manipulation and abuse of power 2 youth leaders are happy to be able to influence young people in the long term but they are also frightened by how longlasting their influence can be youth leaders are happy when young people discover and imitate christianity lived by them but at the same time they are worried that young people will copy things from them that are not worth copying 4 youth leaders enjoy it when young people look up to them on the other hand they do not want to be idealised to spare the young people disappointment later 5 being allowed to accompany the young people gives the youth leaders affirmation but at the same time they feel overwhelmed in some situations the aspects described in theses 15 become visible in a1 in the youth leaders joy in being allowed to accompany shape and lead young people to maturity and in b1 in the responsibility they perceive as burdensome in connection with their influence 6 their role model effect encourages youth leaders in their own development and growth but at the same time they feel under pressure because of the expectations placed on them 7 youth leaders experience meaning and appreciation in their role model effect at the same time they suffer from the fact that their influence remains unavailable and they cannot produce desired processes and results 8 youth leaders value eyetoeye relationships and suffer from being tied down to their role as role models in their private lives the aspects mentioned in theses 68 are described in a2 and b2 as the effects of the youth leaders role model on themselves the theses show the need to equip youth leaders for their responsible tasks through helpful training and further education and support their statements show that they are not primarily insecure in their subject matter but that their challenges lie more in the area of their own personality development relationship maturity roleappropriate action and theologicalpsychological reflection on their own experience these aspects are to be trained less in lecture formats and more in holistic formats the focus here is on promoting relationship skills as a core competence through community lifeforms and guided selfreflection in pastoral care mentoring and coaching experiencing ones role models is a significant learning experience which can be deepened through a holistic examination of the role model offers of roles should be discussed in a differentiated way in the training and introduced openly this includes theological and sociological reflection on the role model including its opportunities and limitations threats and protective mechanisms the backbone of a resilient approach to ones role is the cultivation of a personal relationship with god in which the loving care of the gracious god can be experienced in education and training this can be supported by spirituality lived in various ways holistic approaches to faith and compassionate daily interaction practiceoriented education and further training facilitate the assumption and formation of the role model if the respective internships concerning the experience of the role are also reflected a sensitive phase is the start of the career the youth leaders can be supported by experienced mentors guided selfreflection practicerelevant further training and collegial networking opportunities youth leaders invest their entire personalities in their ministry more reason why they need a stable network of relationships a hospitable environment in the congregation and family and collegial cooperation in the ministry to cope with the diverse challenges in the long term helpful professional and personal counterparts facilitate their further development outlook youth leaders take on a relationshipintensive and holistically demanding role they put their whole being into the task of accompanying young people holistically in a sensitive phase on the one hand they experience the happiness and joy of being able to shape and inspire young people on the other hand they feel the responsibility that comes with it as a challenge the biblicaltheological foundations that can be helpful for experiencing and shaping ones role as a role model were presented as well as social science findings that can be useful in reflecting on ones own shaping activities the extent to which youth leaders consciously draw on these sources and the influence it has on their role a holistic perception of the experience of youth leaders in their role is the starting point for professional development and role design the research results outlined here can inspire further research be it on the genderspecific aspect of role experience possible correlations between a conscious reflection on ones own role and role experience or helpful interventions and counselling concepts in the training and further education of youth leaders author biography monika baumann is responsible for the practical parts of theological education as a practical lecturer at the theological seminary in adelshofen southern germany she also teaches pastoral care and religious education her main concern is to accompany young people in the development of their potential and to stimulate reflective learning processes jaco dreyer is a professor of practical theology at the university of south africa he teaches methodology of practical theology and has a particular interest in public practical theology

this article dealt with the experience of fulltime youth leaders in evangelical and free churches in germany of their role as role models of faith the research was based on a qualitative empirical study in which 12 youth leaders were interviewed using semistructured interviews the evaluation was carried out by doing a categorybased qualitative content analysis according to mayring 2015 and kuckartz 2018 and the type construction kelle kluge 1999 the quality of experience of the interviewees in their role as role models was determined thus a differentiated perception of the professional group can be strengthened and holistic education and training programmes supportedyouth work a role model of faith emotional role experience types of youth leaders education and training programmes

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conclusions the high proportion of hivinfected msm in bamako who are unaware of their hiv infection and the high prevalence of concurrent partnerships could further the spread of hiv in bamako increasing testing through peer educators conducting mobile testing could improve awareness of hiv status and limit the spread of hiv in concurrent partnerships concurrent sexual partnerships or overlapping sexual relationships with more than one person may increase hiv risk by connecting sexual networks and potentially lending themselves to the transmission of hiv during the acute phase of infection most studies on concurrency have been conducted on heterosexuals the relationship between hivand concurrent sexual partnerships among heterosexuals is inconclusive with mixed results yielding varied conclusions 1 2 3 data on concurrent male sexual partnerships among men who have sex with men are limited and come from outside subsaharan africa 4 5 6 the focus on concurrency among msm has instead been on bisexual partnerships that is men who have sex with men and women 7 8 9 10 11 12 and some studies do not clearly indicate the sex of sexual partners involved in concurrent relationships 13 14 15 concurrent male sexual partnerships among msm are especially important because hiv prevalence and acquisition probability are higher among msm than among heterosexual men and women 16 17 18 19 20 as part of malis national hiv surveillance strategy we conducted a respondentdriven sampling survey of msm in bamako mali to learn about hiv risk behaviors and service utilization here we identify correlates of concurrent sexual partnerships among these men and discuss their implications for malis epidemic methods we used rds to survey msm in bamako mali from october 2014 to february 2015 21 22 23 eligibility criteria for participation included 18 years or older history of oral or anal sex with another man in the last 6 months residence in or around bamako in the last 6 months ability to communicate in french or bambara and to provide written informed consent and possession of a valid rds recruitment coupon a target sample size of 550 people was calculated based on an estimated hiv prevalence of 20 a 95 confidence with a width of 10 and a design effect of 2 potential seeds were identified during the formative assessment and were purposively selected for age neighborhood of residence education marital status hiv status and engagement in prevention and clinical services data collection began with 6 seeds one additional seed was added during data collection in an effort to reach older msm participants were given 3 coupons to recruit peers coupons expired 2 weeks after being issued individuals could participate in 1 of 2 study sites on different sides of the niger river that divides bamako the sites alternated operating days and the same staff worked at both sites an excelbased rds coupon management system was used to track recruitment coupons included unique codes to facilitate tracking the recruiterrecruit relationship participants undertook an electronic facetoface interview and were tested for hiv after the national algorithm of screening with determine reactive specimens were confirmed with clearview and oraquick was used as a tiebreaker the interview covered demographics alcohol consumption using the auditc scale sexual behaviors including number of sexual partners in the last 6 months according to type condom use at last sex with each partner type access to hiv services and other topics high social cohesion and high internalized homophobia were defined based on higher than mean responses to 5 questions concerning social cohesion and 5 questions reflecting on their feelings about their sexual attraction to men those testing positive for hiv were referred for care and treatment they also received condoms lubricants and hivrelated information in addition to a reimbursement of 4000 cfa for their time and transportation at a second visit they could receive up to 1000 cfa for each successful recruit and 2000 cfa for transportation we defined concurrent sexual partnership as engagement in overlapping sexual relationships where sexual intercourse with 1 partner occurs between 2 acts of intercourse with another partner or belief that the participants last sexual partner probably did or definitely did have other sexual partners between two acts of intercourse with the participant 24 data were analyzed in sas93 and rdsanalyst 054 using giles successive sampling estimator to weight results 25 network size was based on a series of questions that together produced the number of msm living in bamako aged 18 years or older that the participant had seen in the last 2 weeks survey logistic procedures were used for bivariate and multivariate analyses to identify associations with concurrent sexual partnerships age and variables significant at the 010 level in bivariate analysis were included in the multivariate model participants provided written informed consent before engaging in survey activities the protocol received approval from the malian ethical committee of the facility of medicine pharmacy and dentistry the united states centers for disease control and prevention and the columbia university medical center institutional review board results we enrolled 552 msm into our survey over 18 waves of the people who came to the survey site 56 were not eligible for participation recruitment homophily for sexually active msm in bamako was 13 consequently 830 of the msm network component our survey represents is younger than 30 years msm were also relatively well educated with 637 completing secondary school or university students comprised 433 of msm and 127 were unemployed nearly all msm were malian muslim and had never been married and 988 identified as gayhomosexual or bisexual according to the auditc scale alcohol consumption was a problem for 198 of msm over half of msm had more than 1 male sex partner in the last 6 months and 525 had 1 or more female sex partners in the same period the last male and female partners were main partners for 752 and 766 of msm respectively concurrent malemale sexual partnershipseither having a secondary partner or believing a sex partner has onein the last 6 months were common over a quarter of msm had a secondary male partner and believed that their last partner had their own secondary partner suggesting that at least four people ultimately engaged in concurrent partnerships additionally 308 of msm had a concurrent male partnership and at least 1 female sex partner in the last 6 months condom use was inconsistent with 760 of msm using a condom at last sex with a male partner 190 had condomless receptive anal intercourse and 169 had condomless insertive anal intercourse in contrast 433 used a condom at last sex with a female partner the majority of msm did not discuss hiv status with their most recent partner and 318 learned the status of their partner furthermore 137 of msm were hiv positive of whom 867 were unaware of their hiv infection in multivariate analysis msm with at least a primary education were less likely than those with less than a primary education to have had a concurrent sexual partnership with other men in the last 6 months msm who have only told other msm of their samesex behaviors were nearly twice as likely to be in a concurrent relationship than those who had told nonmsm men who have sex with men with lower than average levels of social cohesion were less likely to be in a concurrent relationship and those who did not know someone with hiv were more likely discussion concurrent sexual partnerships have been shown to be a key factor in the spread of hivamong the general population as it speeds the rate at which sexual networks are connected 32627 although heterosexual behavior among msm has been widely reported the literature contains little about concurrent malemale partnerships among msm 457 28 29 30 our survey reveals that not only do msm in bamako mali have sexual relationships with women but they also engage in concurrent partnerships with other men given the high prevalence of hiv among msm and the large proportion of msm who are unaware that they are living with hiv the potential for the rapid spread of hiv among msm and on to their female partners is ever present in bamako few studies have documented that individuals may themselves have a concurrent partnership whereas one of these partners has their own concurrent partnerships 28 this could be the case for over a quarter of msm in bamako whose sexual networks may consequently include up to 4 people in a given period our finding that approximately 606 of msm have engaged in a concurrent sexual partnership in the last 6 months is similar to some findings and higher than others 2830 multiple sex partners are associated with hiv infection 1131 however in bamako the number of sex partners is not associated with engagement in concurrent malemale sexual relationships thus targeting msm with the largest number of partners may do little to reduce concurrent partnerships neither hiv status nor symptoms of sexually transmitted diseases were associated with concurrent malemale partnerships like many rds surveys of msm our survey is representative of the network component of msm in bamako who are largely younger than 30 years old 11303233 that such a large share are students and have never been married is therefore not surprising as hiv is a chronic condition and prevalence increases with age it is reasonable to assume that hiv prevalence is higher in the broader msm population our analysis is limited by exploring concurrency with the most recent sexual partner rather than all partners in the reference period the majority of msm in bamako had not tested for hiv in the 12 months before the survey although peer educators do not provide hiv testing in bamako interacting with a peer educator in the last 12 months was strongly correlated with hiv testing 34 the impact of peer educators could be enhanced by training them to conduct mobile hiv testing including couples testing 3536 limited data on couples testing for msm in africa suggest that it has substantial potential 37 more frequent hiv testing and couples testing in particular could help limit risks of hiv acquisition and transmission among msm engaging in concurrent partnerships peer educators could further boost hiv testing by tailoring their messaging to build community and strengthen social cohesion among msm factors that have been associated with hiv testing in bamako 34 peer educators have a pivotal role in facilitating hiv couples testing in bamako and their numbers should be increased to reach additional men author manuscript author manuscript hakim et al

background concurrent malemale sexual partnerships have been understudied in subsaharan africa and are especially important because human immunodeficiency virus hiv prevalence and acquisition probability are higher among men who have sex with men msm than among heterosexual men and womenwe conducted a respondentdriven sampling survey of 552 men who have sex with men in bamako mali from october 2014 to february 2015 eligibility criteria included 18 years or older history of oral or anal sex with another man in the last 6 months residence in or around bamako in the last 6 months ability to communicate in french results hiv prevalence was 137 with 867 of msm with hiv unaware of their infection concurrent malemale sexual partnerships were common with 606 of msm having a concurrent male sexual partnerships or believing their sex partner did in the last 6 months and 273 having a concurrent male sexual partnerships and believing their sex partner did in the last 6 months over half 525 of msm had sex with women and 308 had concurrent male partnerships and sex with a woman in the last 6 months concurrency was more likely among msm with limited education telling only msm of samesex behaviors high social cohesion and not knowing anyone with hiv

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présélectionnées pour quils fassent partie des interventions durgence de la ville en faisant de leurs oc des postes de rassemblement durgence un organisme de hamilton voué à la protection de lenvironnement a exploré les moyens pour ses réseaux existants de se rassembler pour résoudre des problèmes locaux de résilience sociale et un organisateur de quartier de toronto a constitué un réseau pour aider principalement les populations de nouveaux arrivants dun quartier déshérité du centreville tous les projets pilotes ont procédé selon un mélange de démarchage téléphonique dateliers de présentations aux élus municipaux et de participation aux animations publiques et aux programmes locaux deux ont constitué des groupes de travail locaux résultats à la fin du projet pilote le bureau de la gestion des situations durgence de brampton avait établi une relation contractuelle avec une oc et ses bénévoles à hamilton un réseau multilatéral est né pour aider les organismes locaux de services aux populations vulnérables à se préparer aux changements climatiques à toronto on a établi un groupe de travail composé de résidents dune tour dhabitation pour soccuper du bienêtre entre voisins et des interventions durgence le travail se poursuit dans les trois villes conclusion lappui dun large éventail dacteurs aux organismes associatifs et aux bénévoles locaux peut rendre possibles des partenariats pour la résilience climatique au niveau des quartiersavant pendant et après des événements météorologiques extrêmes la santé publique bien quelle ne vienne pas immédiatement à lesprit comme étant un allié essentiel dans ce genre de travail est bien placée pour apporter une contribution conformément aux approches fondées sur le lieu un plan de développement de proximité émergent a permis à des animateurs socioculturels de chaque ville de faire naître des collaborations adaptées à la réalité sur le terrain introduction as the climate warms extreme weather events will continue to be increasingly frequent and severe over the coming decades many urban dwellers believe that should weather events impact them directly government agents or 911 emergency responders will help however government emergency managers ask all residents to prepare their own kits and plans for the first 72 h of an emergency people managing low incomes may be less likely to have emergency plans or supplies and be unable to remove themselves from a hazardous situation due to lack of resources social networks limited mobility mental or physical health challenges and other constraints resilience is the capacity of individuals organizations and socialecological systems to adapt or transform in response to unfamiliar unexpected and extreme shocks it is about the capacity to bounce back from adversity but also to embrace change and bounce forward into new ways of thinking and doing increasingly civil society is recognized as having an important role to play alongside government and the private sector in building local resilience indeed social networks and social capital are widely recognized as key to the creation of community resilience equity must be a key consideration in all resiliencebuilding activity while public health agencies are uniquely placed to build community climate resilience there are few published examples of such work beyond that of los angeles although the resilience of public health itself has received some attention it is also clear that public health cannot build community resilience alone there is increasing recognition of the importance of community engagement the need for participatory governance and the significant contributions that local citizen organizations and community groups make to urban resilience of course calls for public health to engage more fulsomely in community development and to work with unusual allies outside the health sector to address issues of climate adaptation and the ecological determinants of health are not new case studies of the role of civil society organizations active in postdisaster recovery following hurricane katrina in new orleans and hurricane sandy in new jersey usa illustrate the pivotal role of community groups in disaster resilience this empirical work suggests that more centrally coordinated processes for emergency response typically undervalue the considerable prior ontheground work of community groups and their capacity to lead or colead disaster resilience and community resiliencebuilding processes with few exceptions very little has been written about the actual or potential role of faithbased organizations in this process while there is much discussion about the role of fbos in climate change education and advocacy very little has been written about public health collaboration with fbos on any issue and the literature on citizen engagement for local resilience and climate adaptation rarely includes more than passing mention of fbos setting faith the common good a national interfaith network received an ontario trillium foundation seed grant to explore how local initiatives to build urban extreme weather resilience could be created in marginalized neighbourhoods of one large and two midsize southern ontario cities toronto brampton and hamilton fcg asked community resilience to extreme weather a grassroots volunteerdriven organization that promotes multistakeholder networking to increase awareness of local climate change impacts and enhance local resilienceto manage the lighthouse project a pilot that ran from the winter of 2017 to november 2018 funding paid for one experienced parttime animator in each city animators in hamilton and toronto used an assetbased community development approach that recognizes and builds upon existing local assets and strengths responsible for forging relationships and catalyzing change animators developed their own customized approaches in each setting the lighthouse pilots in hamilton and toronto sought to engage a wide variety of allies including fbos a key goal was to discover how the community would rally around this issue and what strategies might be employed to raise awareness of and prepare for extreme weather and related safety and health impacts also of interest was how fbos could be a catalyst for community engagement or whether mistrust of religious organizations would present a barrier peel public health was not recruited to participate in bramptons lighthouse pilot which continues to be led by the citys emergency management office this paper therefore refers only to the two pilot sites where public health was involved emergency management participated in both hamilton and toronto pilots but its focus on emergency preparation strategies meant that its interest in contributing to the community development that builds enduring resilience was limited in this regard ph proved to be a stronger ally the lighthouse project illustrates how even though public health is encouraged to work with unusual allies to address the social and ecological determinants of health they are not always topofmind as a potential ally among those other agencies or groups when the focus is not explicitly on health intervention members of fcgs nationwide network have a history of engagement with environmental sustainability initiatives and are concerned about climate change as they struggle with aging congregations and growing maintenance costs many are reorienting to become more relevant in their neighbourhood their innate impulse to gather and to help in times of need make them natural community allies in resilience fcg wanted to learn how community might form around fbos as resilience hubs and whether mistrust of religious organizations would be a barrier to community engagement working with public health was not an explicit lighthouse goal emergency management however had always been considered a natural municipal ally the lighthouse pilot builds on findings of an earlier toronto pilot neighbourhood extreme weather resilience whose goal was to learn how fbos could provide refuge in direct response to emergency and to understand how local partners such as food retailers could support those efforts community animators deployed by lighthouse in hamilton and toronto used an emergent community development approach that has been identified as central to building community resilience in ways that reflect local needs capacities and interests both animators began with an assessment of the communitys and local faith groups level of preparedness for extreme weather emergencies prior awareness of projected climate impacts and level of emergency planningindividual or communityturned out to be minimal the only activity that all three animators were required to deliver was either or both of a pair of interactive resilientville canada exercises designed by san franciscos neighbourhood empowerment network and customized by crew to simulate community problemsolving during extreme weather and other shock scenarios the exercises advance multistakeholder and local resident participant awareness of the shortand longterm benefits of planning ahead for local emergencies by strengthening existing social relationships creating new ones and establishing close links to municipal supportall crucial to resilience toronto torontos animator had extensive grassroots environmental community development experience especially with newcomers and had established local relationships through crews earlier work in st james town one of the most dense and diverse neighbourhoods in north america most of st james towns residents live in 19 highrise apartment towers there are relatively few service providers on site despite its generally lowincome demographic it has never been designated a neighbourhood improvement area that would have flowed needed resources and partnerships to address pressing community issues crew was first invited to work in st james town alongside a longestablished community group this proved to be an obstacle to engagement with other local stakeholders understanding the degree of collaboration among local organizations and stakeholders before undertaking this work is a key learning it should also be noted that initial partnership with any other local ally might have surfaced similar barriers staff turnover at torontos office of emergency management early in the project meant that the animator was left for a period with no municipal support a toronto public health officer previously known to crew brokered a meeting with the neighbourhoods largest service provider in order to expand local stakeholder engagement but it did not produce results this person also agreed to join an advisory council for the project but without broad representation from local stakeholders this became irrelevant in response to these unanticipated barriers to interagency collaboration the animator focused on the residents who had attended early planning meetings together they formed a lighthouse steering committee participated in workshops and received training on hazards risks and preparedness from oem along with guidance from crew on building social networks as volunteers they conducted extreme weather awareness outreach at community events and distributed emergency preparedness materials some of which were customized for use in adult english language classes and childrens homework clubs the social justice committee of the local anglican church fully committed to the project and wished to contract with oem as a formal resilience hub partner the local catholic church also hosted meetings and observed with interest hamilton beasley is a gentrifying downtown neighbourhood around 57 of residents live below the poverty line and nearly 40 identify as a visible minority the animators fulltime employer was environment hamilton a wellregarded ngo the animator convened a lighthouse working group whose founding members were critical to the success of the project hamilton public health played a close and supportive role from the outset the focus on building capacity in climate adaptation and extreme weather responseparticularly for those from more vulnerable communitiesdirectly aligned with hph objectives they understood that the working group and an advisory network would expand the climate conversation to new audiences other members of the working group brought wide experience to the planning these included st johns lutheran church which hosted regular meetings community workshops and a large public event the beasley neighbourhood association local service agencies and a public health nurse multiple faith groups were represented and graduate students provided support working group members met with leading service providers in beasley following several site visits they redefined their initial concept of a resilience hub they understood that sites such as a local mens shelter would be goto places for people in urgent need during an emergency what staff at these sites lacked was knowledge of projected climate impacts that would affect their clients neighbours and internal operations most did not have emergency supplies or generators the working group considered how a network of service providers community organizations fbos and others could be organized to support each other and to leverage city and other supports in the provision of resources including expertise training and materials as well as participation in emergency communications channels outcomes toronto by pilot end a strong working group of 14 members comprised of mostly st james town residents with strong representation from the anglican church was well established in september 2019 crew received funding to maintain the animators lead role for an additional 17 months nearing pilot completion a fire in the basement electrical room of one of the neighbourhoods apartment towers led to the evacuation of over 1500 people subsequent flood events in several other towers caused lengthy water and power losses exposing current levels of preparedness and resilience crews preparedness materials were subsequently modified to include information on responding to building infrastructure failure the working group focused its attention on one highrise building that was home to three of its members following extensive outreach they are implementing a buddy system for neighbourtoneighbour wellness checks the anglican church is preparing to partner in the training of highrise residentsespecially its own congregantsto be emergency responders ready to open their building prepare hot drinks and manage communications between residents and the church the working group is also seeking to train volunteer community responders who could collaborate with oem in the event of a neighbourhood emergency and be included in oem communications channels residents valued the project and volunteered their time to various pilot initiatives in the absence of support from municipal stakeholders and other influential actors the work continues to rely on the ongoing commitment of the steering committee and other local volunteers the local faith group was an enthusiastic and important ally it did not appear to be a barrier to engagement although further study would need to confirm this hamilton the working group continued with regular meetings after the pilot ended and collaborated on a purpose statement for funding in order to meet the critical need for a paid parttime coordinator as well as further project work underscoring the relevance of community climate adaptation work to public health it contributed guidance to a research project on vulnerable seniors and heata partnership between mcmaster universitys department of sociology hamilton public healths healthy environments division crew and environment hamilton this partnership produced a survey intended to be selfadministered by seniors and other vulnerable populations in the fall of 2019 hph established a partnership with citylab an innovation hub that convenes students faculty and civic leaders to work with citysupported projects to produce digital resources and other materials for the working group individuals who gathered around the project generally had a professional interest in the project outcomes beasley service agencies and other stakeholders had strong relationships with hph and readily engaged with the pilots emergent community development approach the local faith group was an important collaborator from the outset and did not appear to be an obstacle to community and stakeholder engagement implications lighthouse project pilots sought to intentionally enhance community resilience through local initiatives and what contribution faith groups might make the extreme weather resilience focus attracted immediate interest in each of the pilot sites and fbos were enthusiastic allies none of the initiatives can be considered completed work will evolve and respond to community climate concerns as varied as food security and pressures of environmental migration the literature and our experience in the lighthouse project suggests that where municipal governments get involved they should champion initiatives that seek to enhance local social infrastructure as part of disaster preparedness and building community resilience including unusual allies such as faithbased organizations and social agencies that already have a footprint in the neighbourhood and a mandate that includes community the path subsequently taken by the toronto resilience office in the development of the toronto resilience strategy is exemplary in this regard including as it did a connected community approach championed by the centre for connected communities who was a key collaborator in the community engagement component of that work emergency management in toronto and hamilton had only tentative relationships with the lighthouse initiatives community preparedness planning may be perceived as a possible hindrance rather than an advantage in an emergency event a barrier that is noted in the wider literature emergency management is a hierarchical structure whose actions must focus on a moment in time and too often excludes the individuals and grassroots organizers who are typically their own communitys first responders public healths concern with enduring health and wellbeing suggests that it would be a more productive partner in local organizing around extreme weather and climate adaptation it could also act as a bridge between emergency management and local organizers resilientville workshops illustrated the importance of building local social networks that include a place of temporary refuge often an fbo and creating a community planbefore an emergency happens public health was rarely considered a potential ally by community participants in these exercises which suggests a public misunderstanding of their role that may now be shifting as a result of covid19 which has thrust public health into broader visibility hphs direct engagement with the beasley working group demonstrates that the expansion of climate awareness to larger audiences and support for the climate preparedness of agencies serving local marginalized populations could potentially expedite city and public health objectives public health staff in toronto were individually supportive but played no formal role a lack of engagement from public health departments in brampton and toronto likely reflects the reality that where public health is not in the lead their involvement is invited when other stakeholders see the relevance and opportunity and also that public health cannot realistically be everywhere and in everything that could be seen as relevant in some cases it may also reflect residual ambivalence on the part of authorities regarding the role of citizens in emergency response jurisdictional quandaries that often leave public health out of the conversation andor the unevenness with which climate change is championed by public health departments as a key public health issue in a resourceconstrained environment whereas most of the published literature on public health collaboration with civic organizations is written from the perspective of public health and profiles examples where public health is in the lead this paper complements other work that explores such collaborations from the experience of fbos and nonhealth sector leadership the lighthouse initiative however shows the potentially important role of public health that sometimes goes unrealized despite its experience in emergency preparation and ministry directives that encourage collaboration with other sectors and community groups municipal and regional public health departments and emergency management should champion initiatives that seek to enhance local social infrastructure as part of disaster preparedness and building community resilience including unusual allies such as faithbased organizations and social agencies that already have a footprint in the neighbourhood and a mandate that includes community service and social inclusion interestingly in toronto it is the citys resilience strategy that has brought together emergency management public health fbos and others to enhanced community resilience in the face of extreme weather events and this occurred after the initial lighthouse pilot project period the lighthouse pilots demonstrated the need for flexible community and civic partnerships that encourage communityled innovation as well as the inclusion of marginalized groups and frontline service providers adequate funding shared expertise and equitable partnerships with emergency management and public health could meet both government and community objectives for the proactive building of community resilience those initiating this work outside this sector may need to be reminded of the potential contribution that public health can play more consistent support within public health for frontline staff to engage on an ongoing basis in placebased collaborative community development would also go a long way to cultivating the social ecology of relationships that would be fertile ground for such collaborations the latter requires a flexible emergent approach that is responsive to communitydefined needs and priorities rather than a onesizefitsall approach to community development building the social networks and social capital that are critical to community development takes time patience flexibility and ingenuity many fbos are enthusiastic allies in building local resilience to climate change impacts with support from community volunteers along with expertise and financial assistance from their municipality fbos could become valuable resilience hubs we offer our experience with the lighthouse project and this paper as an appeal for more participatory communityengaged public health in light of the persistent gaps in its approach to climate change preparedness compliance with ethical standards

objective the lighthouse project 2017 2018 explored the role that faithbased organizations fbos might play as resilience hubs for climaterelated stresses and extreme weather emergencies in disadvantaged urban environments of three cities this paper discusses the role that public health played in these initiatives and makes an appeal for more participatory communityengaged public health in light of the persistent gaps in its approach to equitable climate change preparedness methods pilots were initiated in the greater toronto and hamilton area gtha bramptons emergency managers offered preselected fbo volunteers specialized training to be part of the citys emergency response in establishing fbo sites as emergency muster stations an environmental organization in hamilton explored how its existing networks could rally around a local social resilience challenge and a community organizer in toronto undertook network building to support mostly newcomer populations in one innercity neighbourhood all pilots used a mix of cold calling workshops municipal presentations and participation in local programming and public events two convened local working groups results by the end of the pilot bramptons emergency management office had made one contractual relationship with an fbo and its volunteers in hamilton a multistakeholder network emerged to support the climate preparedness of agencies serving local vulnerable populations in toronto a residents working group was established to address neighbour wellbeing and emergency response in one apartment tower work in all three communities is ongoing conclusion multistakeholder support for community organizations and local volunteers can enable partnerships in neighbourhoodlevel climate resiliencebefore during and after extreme weather events public health while not typically topofmind as a key ally in this work is well positioned to make a contribution consistent with placebased approaches an emergent community development design enabled community animators to catalyze collaborations to suit the ontheground realities of each siteobjectif le projet lighthouse 20172018 a exploré le rôle de « carrefours de résilience » que peuvent jouer les organisations confessionnelles oc face aux perturbations climatiques et aux situations durgence météorologique extrême dans les milieux urbains défavorisés de trois villes notre article porte sur le rôle que la santé publique a joué dans le cadre de ces initiatives et exhorte la santé publique à être plus participative et plus engagée localement vu les lacunes qui persistent dans sa démarche de préparation équitable aux changements climatiques méthode des projets pilotes ont été amorcés dans la région du grand toronto et de hamilton rgth les gestionnaires des mesures durgence de brampton ont offert une formation spécialisée à des bénévoles dorganisations confessionnelles

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background summary longitudinal macrolevel data on demographic and socioeconomic trends are an important source of information for researching and monitoring human development worldwide for example related to poverty eradication advances in education or improvements in living conditions while extensive data are available at the national level eg through the world bank open data repository 1 only limited comparable data exist at the subnational level such data are particularly important for examining the often significant differences between regions within countries information on regional heterogeneity also enables better targeting of policy efforts and supports inclusive policy planning and implementation in particular there is a dearth of comparable subnational data that accurately reflect womens living conditions and the specific gendered challenges they face 2 for example national data on domestic violence is available for 106 countries in the world bank open data repository but the information for each country is available only for one year making it difficult to explore trends and underlying drivers of change development does not benefit all parts of a population equally and women and girls often face disadvantages and discrimination highquality longitudinal data on womens status and living conditions both at the national and subnational levels are therefore critical to understanding how improvements can be achieved in an inclusive and sustainable manner the global data lab provides selected subnational data on women 3 including in form of the subnational gender development index here we build on these efforts further extending the available range of subnational indicators with a particular focus on issues related to gender equality womens wellbeing and key demographic outcomes in this article we present livwell 4 a global longitudinal dataset at the subnational level which is mainly derived from demographic and health survey data 5 livwell is based on the answers of millions of women and collected in 199 dhs surveys in 52 countries the microdata were aggregated to the subnational regional level the resulting macrolevel dataset covers 447 harmonized subnational regions over a 30year period from 1990 to 2019 it includes 114 indicators on womens status and wealth education household characteristics health fertility and infant health in addition we included 20 indicators on domestic violence and decisionmaking power which are particularly difficult to obtain from other sources our dataset provides added value through the extensive harmonization of region boundaries over the past decades changes in the dhs administrative subdivisions frequently occured which limits the comparability over time for the construction of the subnational data we have manually harmonized the dhs regions by accounting for changes in countries administrative subdivisions based on the ipums international 6 geographic files and the dhs spatial repository 7 ipums international has made considerable efforts to harmonize dhs regions yet only 28 out of 90 dhs countries were harmonized so far limiting the possibility to analyze data at a large geographical scale over time in our manual harmonization we matched the regional boundaries of an additional 24 countries to derive longitudinal information about regional changes and trends using the spatial boundaries of the harmonized regions we complemented the aggregated dhs data with additional external information about the climatic and socioeconomic conditions in the regions as climatic factors we obtained monthly information on temperature and precipitation from the climatic research unit of the university of east anglia 8 which we used to identify anomalies and extreme events in the years prior to the dhs data collection as external socioeconomic indicators we included information on the regional gross domestic product per capita and human development index which are based on kummu taka and guillaume 9 in addition to the dataset we have created the companion r package livwelldata that makes it easy to use the dataset in r and subset it by selecting indicators of interest the package and instruction can be found on the git repository of the r package the resulting dataset offers a variety of opportunities for policyrelevant analysis by enabling researchers to explore demographic trends and underlying drivers of socioeconomic developments and changes at the sub national level with a focus on womens living conditions and wellbeing the data could be used for example to study the role of policy interventions for socioeconomic and demographic outcomes the relationship between access to household assets and womens decision power the effect of climate change on health 10 fertility or household wealth or the role of environmental and socioeconomic conditions for genderbased violence 11 a preliminary version of the dataset was recently used to study the effect of access to modern energy on fertility and reproductive choices in 44 countries 12 methods overview the livwell dataset 4 consists of 265 indicators which capture womens living conditions as well as the broader socioeconomic demographic and environmental conditions in a region it covers 447 harmonized subnational regions in 52 countries from 1990 to 2019 to construct the dataset we used information from 199 dhs surveys as data sources which we combined with climate data from the climatic research unit of the university of east anglia 8 and socioeconomic background data from kummu et al 9 to construct the dataset the dhs microdata were aggregated to the subnational level and combined with gridded data on the climatic and socioeconomic conditions in the regions the derived subnational regional data were validated using data derived from the dhs stat compiler 13 the world bank open data repository 1 and the subnational human development database 3 the livwell dataset 4 is an expansion of a dataset that was originally developed for an earlier study on access to modern energy and fertility 12 the earlier version of the dataset covers 42 countries 403 subnational regions and 27 indicators the livwell dataset consists of 5 groups of indicators the first group of indicators is based on individual level dhs data and contains fig 2 countries and waves of dhs surveys represented in livwell the blue dots correspond to waves represented in livwell the pink dots correspond to waves that had to be excluded from livwell because it was not possible to harmonize the regions information on womens living conditions decision making power reproductive health fertility and issues related to domestic violence the second and third group of indicators are also based on dhs data and reflect composite measures of child mortality and household wealth the fourth group of indicators includes regional socioeconomic indicators derived from external gridded data provided by kummu et al 9 finally the fifth group of indicators reflects the environmental and climatic conditions in a region and is derived from the gridded climate data provided by the cru of the university of east anglia in addition to the raw version we provide a version of livwell with linearly interpolated data as dhs surveys are collected in every country on average only every five years the original version of livwell entails gaps between the years of data collection with the interpolation we create a seamless yearly dataset that allows for the analysis of trends at a finer temporal resolution all steps of the data processing and aggregation were carried out in r 14 with the exception of harmonization of the regional boundaries over time and the harmonization of four dhs variables which both required a manual step for each group of indicators a corresponding r function transformed the raw data into the final indicators at the subnational level to interpolate the data we used the r package imputets 15 figure 1 summarizes the different data processing steps the harmonization of the regional boundaries was central for the aggregation and the computation of the indicators and is described in detail together with the other processing steps below data sources the livwell dataset was compiled from three main data sources which were combined at the subnational regional level providing comprehensive information on the demographic socioeconomic and environmental conditions and trends in a region the demographic and health survey 5 represents the primary source of data since its creation in 1986 the dhs program has collected hundreds of surveys in over 90 lowand middleincome countries focusing on population issues and health the dhs program typically adopts a twostage cluster sampling design that ensures representativeness of the data at the national and subnational level 16 most dhs variables are the same across countries and time enabling the comparison over space and time livwell includes 52 countries out of the 90 countries covered by dhs countries had to be excluded either because they had only one dhs wave or because the harmonization of their regions over time was not possible in addition two surveys india 2015 and turkey 1998 had to be excluded because it was not feasible to load the files on our system it is possible however to calculate the indicators in livwell also for single dhs survey using the tutorial addingcountrylivwellrmd on the git repository of this article for each dhs survey information is collected using different types of questionnaires a household questionnaire is used for general questions about the characteristics of the household and its usual residents and visitors adult members of the households are then interviewed using a womens or mens questionnaire collecting information on a range of topics including fertility mortality family planning marriage reproductive health child health and nutrition dhs data are also a key source of information on domestic violence in lowand middleincome countries many recent dhs surveys include a domestic violence module that collects information on womens experiences with physical sexual or emotional violence in their lifetime and during the past 12 months to construct the livwell dataset we relied on data collected using the dhs womens and household questionnaires the information provided in these two questionnaires is typically stored in several dhs datasets that are accessible for data users we used the women dataset the household dataset and the birth dataset the microdata collected among women allow us to gain a unique picture of the status of women and their livelihoods around the world the data collected at the household level provide additional insights on wealth levels and disparities housing characteristics and household demographic composition which shed further light on the demographic and socioeconomic conditions and trends in an area like other surveybased data sources the dhs data are prone to sampling and nonsampling errors the latter type of errors is inevitable in population surveys these errors can be due to nonresponse coverage and measurement issues the dhs implements different procedures before during and after the data collection to reduce the effect of these errors 17 to account for sampling errors the livwell dataset provides standard errors for all indicators which allows users to gauge the uncertainty of individual data points as a second data source we used the global gridded data compiled by kummu et al 9 to obtain measures for the socioeconomic development level of the subnational regions this dataset provides information on gdp per capita in purchasing power parities and hdi for the whole world at 5 arcmin resolution for the 25year period of 19902015 to obtain the grid level datasets the authors made use of available subnational data whenever possible combined with national data temporal interpolation and extrapolation approaches were used to fill missing values over time we combined this gridded data with the spatial shapefiles of the regional boundaries to calculate average gdp per capita and hdi level for the dhs regions included in our data to obtain information about the climatic conditions and extreme events in the dhs regions we used data from the cru of the university of east anglia 8 as a third data source the cru data are provided on a 05° latitude by 05° longitude grid over all land domains of the world except antarctica the data are based on interpolations from weather station observations and provide information on monthly temperatures and precipitation in addition we used data from the global spei database 18 which provides information on the standardized evapotranspiration index at a monthly level the database is based on monthly precipitation and potential evapotranspiration data from the cru again using a 05° spatial resolution the livwell dataset can be easily expanded by adding information from other spatial datasets following the procedures outlined later in this section and the code located on the data record 4 or on the git repository with the increasing availability of high resolution spatial datasets users can answer a broad range of research questions by combining livwell with other data sources for example gridded data are now available at a high resolution for global population counts 19 and density 20 built up land 21 and nighttime lights which have been proposed as a proxy for electrification and economic development in addition to the crubased climate indicators provided in the livwell dataset a number of sources provide access to further environmental indicators including on global forest loss 22 terrestrial gross carbon dioxide uptake 23 water bodies 24 agricultural production 25 and disaster locations 26 harmonization of subnational regions the harmonization of the regions over time was a crucial step to maximize the available number of dhs survey waves per country the official administrative subdivision of countries changes from time to time which is also reflected in the geo admin 1 regional boundaries of the dhs survey waves for example in the surveys used for livwell 30 of countries did not change their administrative boundaries 40 changed their boundaries once and 13 changed them twice the goal of the harmonization was to identify the smallest common spatial denominator to allow for comparisons over time the approach being similar to the ipumsdhs international region harmonization the harmonization of subnational regions was done in three steps first we collected the region names and indices of all dhs surveys as a second step we assigned each region a unique harmonized identifier for example one country had 4 regions in the first three dhs waves but in the last dhs wave the region r was split into r1 and r2 the new splitoff regions r1 and r2 were then assigned the same identifier as the original region r and each respondent was assigned the identifier that corresponds to the harmonized region where she or he resided when the individual data were aggregated at the subnational level in the third step the indicators could then be calculated at the level of the harmonized regions to assign the identifiers we used two sources first when available we used the ipumsdhs international region harmonization which was available for 28 countries if this information was not available we used the dhs spatial repository which shows on an interactive map the region boundaries of dhs data for the different dhs waves based on these two sources we obtained a dataset that maps the raw and harmonized region names and indices of 204 dhs surveys once the assignment of harmonized indices was done we collected the harmonized boundaries using the function downloadboundaries from the r package rdhs 27 and whenever necessary merged the region boundaries using the function stunion from the r package sf 28 supplementary fig 3 and the file methodologyharmonizationrmd on the data record 4 and the git repository provide a complete description of the mapping of the raw and harmonized regions and the steps involved in the harmonization harmonization of dhs variables over time and across countries four of the householdlevel variables used were multicategorical variables whose categories varied across countries type of floor type of toilet source of drinking water and type of cooking fuel to create consistent indicators across all countries we first collected all the possible values of each of these variables across all dhs surveys then we assigned each of these values to a broader category for variables like type of floor type of toilet and source of drinking water we assigned three categories high middle and low quality following the methodology used for the construction of the international wealth index 29 for example for the variable source of drinking water the value piped to dwelling was assigned to the broader category high quality drinking water source the value in the nile which was specific to egypt was assigned the category low quality drinking water source for the variable reporting the type of cooking fuel used by the household we assigned two categories modern cooking fuel and traditional cooking fuel we included electricity liquefied petroleum gas natural gas kerosene and biogas as modern fuels for cooking all traditional biomass namely firewood charcoal agricultural crops animal dung as well as coal was counted as nonmodern cooking fuels calculation of indicators on womens living condition using the dhs data we calculated 134 indicators that provide a picture of womens living conditions and the level of socioeconomic development at the subnational level for 52 countries over 30 years to create these indicators for the harmonized regions the individual dhs data were aggregated to the level of the harmonized subnational regions note that for some dhs surveys the data are also representative at the admin 2 level but we kept the admin 1 level to remain consistent across surveys three types of indicators were calculated using the dhs data indicators representing womens living conditions and fertility child mortality indicators and household wealth indicators to calculate these indicators we wrote and the following r functions calculatewomenindicators calculatefertilityindicators calculatechmortindicators and calculatehouseholdindicators which are located on the data records 4 as well as the git repository of this article for the creation of each of these indicators whenever possible we followed the methodology outlined in the guide to dhs statistics 30 in addition we calculated indicators that are not typically published in the dhs final reports or stat compiler for those indicators we describe their construction in supplementary table 1 all indicators were fig 4 harmonized dhs regions in bangladesh the regions of dhaka and mymensingh as well as rajashahi and rangpur were combined to a larger spatial entity to account for boundary changes and splitups of the regions over time weighted by the relevant survey weight we also calculated standard errors for all indicators using the r package survey 31 to account for the stratified twostage cluster design of the dhs data for complex indicators like the total fertility rate or child mortality we used the r package dhsrates 32 to calculate the indicators and their standard errors as dhs surveys are typically collected over several months they can sometimes comprise two calendar years in these cases the survey year reported in the livwell dataset was the year in which most interviews were conducted as reported by the dhs program we also calculated the average month of interview which was necessary to merge dhs indicators with the climate data typically within the same region interviews were conducted within one to two months time windows prior to aggregating the data at the regional level the dhs microdata had to be preprocessed first within each dhs sample the region identifiers were harmonized for this we merged the survey microdata with the dataset that maps the raw region identifier with the harmonized region identifier this way the microdata could be aggregated to geographical regions that are consistent over time second for the survey files in which the units of analysis are women of fertile age we removed cases corresponding to women younger than 15 and older than 49 third for dhs variables with country specific variable labels we added their corresponding harmonized categorization last some of the multicategorical variables were recoded and simplified into variables with two or three categories for example the dhs variable main type of cooking fuel contains several categories firewood coal electricity etc we created a binary variable taking the value of 1 if the cooking fuel used was modern and 0 otherwise based on this information we derived the composite indicator percentage of women cooking primarily with modern fuels the first group of dhs indicators obtained reflect womens living conditions and fertility these are based on the dhs ir files in which the units of analysis are women aged 15 to 49 while most dhs surveys interview women regardless of marital status some dhs surveys are restricted to women who had ever been married these surveys are referred to as evermarried surveys as opposed to the typical allwomen surveys to calculate indicators from evermarried surveys that can be compared to indicators calculated from allwomen surveys we followed the recommended dhs approach and applied allwomen factors released in the ir datasets to account for the proportion of women who were never married in a region see the guide to dhs statistics 30 for more information about using the allwomen factors the fertility indicators were calculated using the r package dhsrates 32 the fourth and last group of dhs indicators are the householdlevel indicators about household characteristics assets and wealth these indicators are based on the dhs household recode files most of the household indicators are standard and follow the guide to dhs statistics 30 for example the average household size or the proportion of households having a computer figure 5 provides the user with an overview of the availability of dhs indicators across different subcategories of indicators in the raw version of livwell and in the interpolated version international wealth index to provide a comparable measure of the level of wealth in a region the livwell dataset includes the international wealth index which was proposed by smits et al 29 the iwi is an assetbased index of households material wellbeing which can be compared across countries and time periods the construction of the index is similar to other wealth indices including the dhs wealth index 33 to construct the measure we use the results of a principal component analysis conducted by smits et al 29 considering different variables on households asset ownership access to basic services and housing characteristics based on the pca weights were derived for each of these variables to conduct the pca the authors used data from 165 surveys which were conducted between 1996 and 2011 in 97 low and middle income countries of these 99 were dhs surveys 36 multiple indicator clusters surveys 16 world health surveys and 14 from other surveys and censuses to obtain comparable values for the variables type of floor type of toilet and source of drinking water we recategorized the original variables into low medium and high quality categories using the iwi methodology 29 to obtain indicators at the region level based on the iwi we first calculated for each dhs survey and for each household its iwi using the variablespecific weights based on the household information we then calculated the average the standard deviation and the gini coefficient of the iwi for each region to calculate the value of the iwi for each household we followed the procedures described in the original paper by smits et al 29 we summed up the different variables on asset ownership and housing characteristics here each variable was weighted with the first factor of the pca as described above the resulting weighted sum of indicators represents the nominator of the wealth index which was divided by a normalization factor to scale the wealth index to a range from 0 to 1 as some dhs surveys had missing information for some of the wealth variables we used as normalization factor the maximum possible value the wealth index could take given the variables available to derive the maximum possible value we summed up all the positive weights of the nonmissing indicators the formula of the iwi writes iwi d fpca fpca if 25 004470 25 004470 i item item item item item i ∑ ∑ with • iwi i the value of the international wealth index of household i • the value of 25004470 reflecting a constant adjustment factor provided in the original paper 29 • d item j a dummy variable measuring whether the household possessed an item or not the items are listed in supplementary table 3 • fpca item the weight corresponding to the first factor of the pca for a given item the values are shown in supplementary table 3 regional socioeconomic indicators based on the gridded global datasets for gdp and hdi over 19902015 9 we obtain the regional socioeconomic background indicators gdp per capita and hdi which we combine with the aggregated dhs data the gdp captures the monetary value of all final goods and services in a region in a year 934 the hdi is a composite index measuring achievements in key dimensions of human development related to health education and economic development the values of the gdp per capita are given in constant 2011 international us dollars thus enabling comparisons between years to produce the original gridded datasets kummu et al 9 used a combination of national and subnational data sources for gdp they used a previously published subnational gdp per capita dataset compiled by gennaioli et al 35 together with national information from the world bank development indicators database 36 and the cias world factbook 37 to collect subnational hdi data they relied on various sources including censuses and undp reports for countries outside of europe as well as the subnational eurostat database for countries within europe nationallevel data on hdi was obtained from undp 38 for the construction of the datasets the authors created a seamless administrative raster file covering the global land area based on the national and subnational information available they constructed yearly datasets using temporal interpolation and extrapolation for missing data at the national level information was derived using regional data we used the information on the spatial boundaries of the regions to crop the gridded data and calculate average gdp per capita and hdi values for each of the dhs regions the boundary information was saved as a multipolygon geopackage and is available for download together with the other materials on the data record 4 and on the git repository of the paper the r package raster 39 was used for the data transformation first the raster data over time is clipped to the spatial boundary data to obtain a multilayered rasterbrick object containing information on the dhs region each raster grid falls into based on this an aggregate regional value was derived using the extract function which returns the mean value of all raster cells whose center lie inside the boundaries of a region the resulting dataset contains information on a yearly basis from 1990 to 2015 by joining these data to the aggregated dhs data we obtain information on regional gdp per capita and hdi values for each of the dhs waves until 2015 the data on the regions socioeconomic conditions come with certain limitations which were reported by kummu et al 9 in their article the accuracy of the data can vary between regions and over time depending on the available source data also many of the data sources used for the construction of the gridded dataset report only average value which may not reflect the possible heterogeneity within an area in addition the availability of source data over time is an issue especially the subnational data on hdi were available only for a single year changes in subnational hdi in relation to national hdi may hence not be well captured in the dataset and finally the interpolation and extrapolation approaches used come with certain assumption and uncertainties which may affect the results climatic indicators indicators on environmental and climatic conditions in a region were derived from the cru monthly highresolution gridded time series dataset 8 and the spei database which also uses cru data the cru time series is based on global observations from weather stations the individual observations are transferred to a 05° regular grid using angular distance weighting for interpolation an overview of climate indicators can be found in supplementary table 2 the spei database provides information about drought conditions globally at a 05° spatial resolution it combines information on monthly precipitation and potential evapotranspiration and uses a standardized intensity scale with higher values indicating more humid and lower values indicating drier conditions the spei can be calculated for different time periods from 1 to 48 months reflecting the time scale over which the water balance in a region is measured here we provide indicators based on spei03 data as previous research has suggested that a 3month spei is wellsuited to monitor drought impacts on vegetation 40 users can flexibly adjust the temporal scale by replacing the spei03 data with other datasets in a first step we derived gridded information on monthly average temperatures in °c precipitation in mm and spei03 from the different data sources in a second step we once more used the spatial boundaries of the regions to crop the gridded climate data and calculate the mean monthly temperature precipitation and spei03 per region following the same procedure as outlined in subsection regional socioeconomic indicators this gives us a long monthly timeseries with climate information from 1900 to 2020 to derive indicators that can be used in statistical analyses we calculated a number of composite climate indicators on local climatic conditions anomalies and changes over time we created climate variables as first composite climate indicators we calculated the average minimum and maximum temperature precipitation and spei03 in a region 12 36 or 60 months prior to the dhs survey for precipitation we additionally calculated the total rainfall in mm for the different time periods considered as a second type of indicators we calculated standardized anomalies in the region for this we calculated the longrun mean and standard deviation for each of the measures over the reference period 19002020 in a region i for a given month m we then calculated for each month in a year y the deviation from the longrun mean and standardized it using the longrun standard deviation for the entire reference period using the following formula anomaly x x sd imy imy i m im where x imy represents the temperature precipitation or spei03 in a region i in month m and year y and x im and sd im the average value and standard deviation of x for region i in month m calculated over all years the derived monthly anomaly measures are standardized and can be interpreted as monthly deviations from the longrun mean in terms of standard deviations of the local distribution based on these monthly values we calculate the mean temperature precipitation and spei03 anomaly as well as the mean absolute anomaly 12 36 and 60 months prior to the dhs survey while the first of the two measures averages over both the positive and negative anomalies the second one takes only the absolute deviation from the mean into account reflecting the intensity of the fluctuations over time in addition based on the calculated anomalies we derive a third set of composite indicators which summarize the share of months share in the past 12 36 or 60 months where the climatic conditions have deviated from the longrun mean by 1 sd 1sd 15 sd 15sd 2 sd 2sd or 3 sd 3sd allowing to comprehensively capture anomalies of different intensity here we again distinguish positive anomalies anomp with a climate value exceeding the longrun mean and negative anomalies anomn with a value below the longrun mean this way we can for example distinguish periods with extreme temperatures above or periods with rainfall below the longrun average based on the share measures it is also possible to calculate the total number of months with an anomaly by simply multiplying the share with the considered time window of 12 36 or 60 months using the monthly spei03 data we additionally calculate the share of months in the past 12 36 or 60 months which experienced drought conditions with spei03 values below different absolute thresholds here we distinguish between months with an spei03 below 1 15 and 2 reflecting different levels of drought intensity the different types of climatic indicators provide a comprehensive picture of the climatic conditions and anomalies in an area and can be used for a wide range of environmentpopulation analyses the climate data were calculated on a monthly basis in contrast indicators based on dhs data are reported for one year when merging the dhs indicators with the climate indicators we used the average dhs interview month as reference to merge the relevant climate information the climate data assigned to the dhs indicators thus accurately reflects the climate conditions that respondents experienced during the 12 36 or 60 months prior to the interview data records the data and codes to reproduce the dataset are hosted on zenodo which is a generalpurpose open data repository developed under the european openaire program and operated by cern the data are hosted at the permanent doi 4 there are three csv files and one gpkg file in the repository the first file livwellcsv contains the livwell dataset itself with all 265 indicators for 52 countries 447 subnational regions over 30 years the livwellcsv file also contains the standard errors for each indicator based on dhs data the second file livwelllininterpolatedcsv contains the livwell dataset including the linearly interpolated data the third file indicatorscsv includes the metadata and description of indicators the fourth file harmonizedboundariesgpkg contains the harmonized boundaries of the subnational regions used in our dataset together with the indices and names of regions the dataset livwell may be shared and adapted under the conditions of the ccby 40 license in addition the records contain a folder codelivwell with all the codes and intermediary data to reproduce the dataset or to add new indicators or new surveys we also included two tutorials name addingindicator livwellrmd to add a new indicator and addingcountrylivwellrmd to add a new country or survey however this is a static version of the code we encourage users to use the git repository to have the latest version of the code technical validation to validate the livwell dataset we proceeded to an internal validation using data from the dhs stat compiler 13 and an external validation using data from the world bank open data repository 1 and from the subnational human development database 3 the stat compiler is a user interface application developed by the dhs program that allows to visualize indicators based on dhs survey data indicators are also available at the subnational level if the code to produce livwell is sound and if the logic to calculate indicators follows the dhs standards the values of the indicators in livwell should match the values in the dhs stat compiler since the regions boundaries are not harmonized over time in the stat compiler we could only compare the countries for which the definition of regions did not change over time this resulted in 35 comparable surveys covering 14 countries we were able to compare 55 out of the 134 indicators based on dhs data since not all livwell indicators based on dhs data are available in the dhs stat compiler all indicators we compared for the 35 surveys matched the values from the stat compiler we provide a more detailed example of this comparison for 10 domestic violence indicators for the dhs survey ethiopia 2017 in fig 7 for evermarried surveys the stat compiler does not produce indicators for all women by applying the allwomen factors therefore we were not able to validate the indicators for the evermarried surveys for some indicators that we were not able to compare with the stat compiler data we proceeded to an external validation to do so we used countrylevel comparable indicators from the world bank open data repository 1 and from the subnational human development database 3 and plotted these values against the corresponding values from our dataset at the region level we can see the withincountry variability for each country along the xaxis in addition to the international wealth index data five indicators had comparable definitions with world bank data and could be validated through this process overall the relationship between the countrylevel indicator and the regionlevel indicator from livwell is highly linear suggesting a good fit for some indicators there is a slight difference due to differences in the definition of indicators for example for the variable percentage of women using modern contraception the country level data tend to be higher than the region level data because they are calculated based on married women only for the indicator on cooking fuels the relationship is not as linear as with other indicators because the country level is based on clean cooking fuels whereas our indicators on modern cooking fuel excludes wood the gdp indicator from the world bank that had the most available data was in 2017 constant while our measure of gdp was calculated in 2011 constant which probably explains the lower correlation finally since not all indicators could be validated through the internal and external validation we also made sure that all values of indicators included livwell had realistic summary statistics eg that all proportions range between 0 and 1 and that continuous indicators have realistic averages usage notes the livwell dataset is provided in csv format so it can be easily used in any data processing software the file with harmonized boundaries is provided as a gpkg file and can be opened and processed using for example r python or qgis we also created a r package named livwelldata allowing to easily use the dataset in r the package contains four functions the function livwelldata allows to load the whole dataset or a subset based on a selection of countries years andor indicators it contains a parameter interpolated allowing to load the data including interpolation the function livwellindicators allows to extract the list of all available indicators the function livwellcountries allows to extract the list of countries in the dataset the function livwellharmonizedregions allows to extract the list of harmonized subnational regions the r package livwelldata as well as the instruction to use it can be found on this git repository 1 the red dotted line corresponds to the 1 to 1 ratio code availability the processing steps to obtain the dataset were carried out in r and rmarkdown and are reproducible all the code is available on the git repository of this article the source code for the companion r package livwelldata is available on the git repository of the package the following r packages were central to the development of livwell tidyverse 41 knitr 42 rdhs 27 dhsrates 32 and survey 31 competing interests the authors declare no competing interests

data on womens living conditions and socioeconomic development are important for understanding and addressing the pronounced challenges and inequalities faced by women worldwide while such information is increasingly available at the national level comparable data at the subnational level are missing we here present the livwell global longitudinal dataset which includes a set of key indicators on womens socioeconomic status health and wellbeing access to basic services and demographic outcomes it covers 447 regions in 52 countries and includes a total of 265 different indicators the majority of these are based on 199 demographic and health surveys dhs for the period 19902019 and are complemented by extensive information on socioeconomic and climatic conditions in the respective regions the resulting dataset offers various opportunities for policyrelevant research on gender inequality inclusive development and demographic trends at the subnational level

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now big data refers not only to large data volume but also to our increasing ability to analyze and interpret those data including data collection data storage and management data processing and analysis data privacy and security etc the technologies involved mainly include extensible storage systems distributed file systems databases cloud computing data mining tools technologies etc big data applications involve many sectors bringing unprecedented convenience to our life such as in the fields of health care smart grids government systems logistics systems etc in recent years some scholars have explored more applications of big data such as big data management in the mining industry big data and the ethical framework of smart city big data analysis of social media application of big data in the emotional analysis of tourism as a multidisciplinary and interdisciplinary research field big data research requires cooperation from various disciplines scholars from different disciplines have contributed their efforts and created the glory of big data in recent years the research on big data mainly focuses on the following four aspects firstly it focuses on the technology of big data itself concentrating on the improvement and innovation of technologies methods and tools related to big data for example taleb et al proposed a quality evaluation model to deal with the quality of unstructured big data sun and wang put forward a possible mathematical theory as the basis of big data research secondly it focuses on the application of big data in different industries for example alhussain introduced how to use big data tools and methods to analyze medical big data caesarius and hohenthal explored how can ordinary enterprises adopt big data technology to make changes and pointed out the challenges they will face thirdly it focuses on opportunities and challenges brought by the development of big data for example ashabi et al conducted research on the current challenges and future development of big data gupta and rohil pointed out that big data has hidden dangers such as privacy leakage and he proposed some critical solutions to problems related to big data security and privacy fourthly it focuses on standards and policymaking in the big data industry jia and jia put forward the data model of information construction to promote the construction and implementation of information construction in colleges there are many interdisciplinary studies in the field of big data but very few studies are about the interdisciplinarity of big data research interdisciplinary research refers to the practical activities involving two or more disciplines that cross the boundaries of known disciplines such as the interdisciplinary research of big data and wireless channels however research of interdisciplinarity takes interdisciplinary research as research subjects and conducts research about the characteristics of interdisciplinary research through bibliometric methods there are already some studies about the interdisciplinarity of big data research for example hu and zhang concluded that by 2015 there are 109 disciplines involved in big data research big data research is highly interdisciplinary involving multiple disciplines but unevenly distributed using bibliometrics and visualization tools lv and wang compared and analyzed the interdisciplinary development of chinese and american big data research from 2009 to 2016 zhang et al put forward a method of extracting subject classification based on the address of coauthor institutions to measure the interdisciplinary degree between different institutions in scientific collaboration research on interdisciplinarity has been going on steadily jang et al concluded that qualitative or quantitative research methods can be used to analyze interdisciplinarity the limitation of the qualitative approach is that only smallscale case studies can be carried out while the quantitative method can be used in interdisciplinarity research from three angles authorship subject matter and citation literature bibliometric analysis citation analysis network analysis and other methods can be chosen for analysis in quantitative research objectives of this study at present only a few articles are about the interdisciplinarity of big data research and the timeliness of these articles is not enough most of these studies focus on exploring the scope of disciplines involved in big data research and the core disciplines of big data most conclusions are general without clarifying the collaboration pattern between disciplines and the spacetime characteristics of interdisciplinarity in big data research in this paper quantitative research methods will be used to analyze the interdisciplinarity of big data research from three aspects traditional bibliometrics single index and social network combined with previous scholars experience and methods to get better results especially this paper addresses the following problems 1 what disciplines are involved in big data research what are the main topics and countries in the field of big data 2 what are the characteristics of discipline variety balance and disparity in big data research 3 from the perspective of a codiscipline network what is the relationship between disciplines involved in big data research 2 data and methods data acquisition and processing many records contain big data in abstracts and author keywords only as general research background we restrict title and author keyword to big data to ensure that the retrieved records are related to big data as much as possible at the same time the types of documents are restricted to article proceedings and review the time range is from 2007 to 2021 with 14081 documents full records and references of these documents are exported from the core collection of web of science in plain text format to avoid the deviation caused by frequent updating of the database all searches and data downloads were completed on january 10th 2022 in this study we select the sc as the subject classification method for papers for social network analysis in web of science the sc indicates the research direction called the subject category while the wc indicates the category defined by web of science which is called the web of science category when searching on the web of science we know that the sc of all papers belonging to the same journal is the same and so does the wc generally speaking the sc used as a discipline category is an accurate and straightforward analysis unit to describe the disciplines involved in the research field it can be proven by previous studies like the research of rafols and meyer and the study of taskin and aydinoglu since each paper belongs to one or more disciplines a codiscipline network can be built according to the cooccurrence relationship between disciplines the nodes in the network represent disciplines the number of occurrences of disciplines determines the size of nodes and the thickness of lines between nodes is determined by the number of cooccurrences between these two different disciplines according to the codiscipline network in the field of big data we can know what disciplines are involved in big data research and the relationship between these disciplines methods and tools to analyze and visualize the spatial and temporal distribution characteristics of the big data research the tools mainly include sci2 pajek vosviewer and wc19exe among them wc19exe is used to calculate the indexes of discipline variety balance and disparity sci2 and pajek are applied when making network analysis and vosviewer is used as a visualization tool steps of social network analysis firstly convert the text data exported from the core collection of web of science into isi format data then import it into sci2 secondly analyze the subject category field and get the codiscipline network in big data research thirdly time slice the network and remove the isolated nodes at the same time the fourth step is to export the codiscipline network from sci2 and then import it into pajek for social network analysis such as cluster analysis and analyzing the degree centrality betweenness centrality and closeness centrality of the network finally export the network from pajek to vosviewer for visualization steps to calculate the indicators of discipline variety balance and disparity step 1 divide the text data derived from the core collection of web of science by year and form data sets in five time periods of 20072012 20132015 20162018 20192021 and all years step 2 change the name of the data to something that wc19exe can recognize step 3 analyze the data and export the result table by wc19exe which includes raostirling diversity true diversity div div giniindex simpson shannon entropy h shannon variety disparity perc h n of wcs n of wc u etc step 4 select appropriate indicators results and discussions this part mainly shows the research situation in big data from macro meso and micro levels firstly we analyze the growing trend in the number of research papers in big data and extract the involved disciplines based on the sc then according to the citation topics classification system and coauthorship network of countries we grasp the distribution of research topics and the collaboration among countries in big data research from a macro level to ensure that a comprehensive and correct basic understanding of big data research can be established first secondly by analyzing the variety balance and disparity of disciplines in the field of big data research we know the distribution characteristics of these disciplines such as whether the number of disciplines is monotonous or diverse whether the contribution of each discipline is uniform or unbalanced and whether the distance between citing and cited disciplines is far or near we summarize the relationships among disciplines involved in big data research from an intermediate level mainly describing the whole discipline network last but not least we obtain the key disciplines in the codiscipline network by analyzing the network indicators such as degree centrality betweenness centrality and closeness centrality then we analyze the characteristics and evolution process of each collaboration community in the codiscipline network these summarize the relationships among disciplines involved in big data research from the microlevel mainly to depict key nodes and important cooperative groups in the network these three parts respectively answer the questions raised in the rationale for this study overview of big data research 311 the growth trend of research papers in big data and the distribution of disciplines figure 1 shows the growth trend of the number of disciplines and papers in big data research from 2012 to 2021 it can be seen that the published papers have been growing continuously reaching the highest level in 2018 and then starting to decline slowly which is consistent with the findings of qiu junping in his research he concluded that it was an initial exploration period in big data during 20082011 while the period from 2012 to 2020 was a period of rapid growth the growth trend is in line with the facts the early 20th century was a turning point in big data research in china during this period the ministry of science and technology listed big data in the 973 basic research plan and the ministry of industry and information technology also listed four technologies of big data as critical objects in the 12th fiveyear plan big data has gradually become a research hotspot for scholars in various fields in foreign countries the successful convening of the big data world forum in 2011 and the official publication of big data written by british expert viktor mayer in 2013 both promoted and stimulated the research upsurge of big data research in big data covers a wide range of disciplines according to the statistics from 2007 to 2021 there are 141 disciplines involved in big data research only the data from 2012 to 2021 are shown in this section due to the small number of papers published before 2012 before 2017 the number of disciplines involved in big data had been increasing and gradually stabilized from 2017 to 2021 basically around 102 which shows that the research in big data has stabilized after the outbreak and the development of the whole field is relatively mature table 1 lists distribution of research topics in big data most existing classification models are periodicallevel classification systems while incites has developed a classification algorithm based on citationscitation topics it is an articlelevel classification system focusing on citations among documents the intensity of these citation relationships will bring related documents together to form discrete related document clusters citation topics builds a threelevel hierarchy of macro meso and micro topics including 10 macro topics 326 meso topics and 2444 micro topics in this section using the citation topics classification system the topics of related papers in big data research are classified into three levels macro meso and micro to reveal the distribution of main topics in big data research step by step macro micro topic distribution based on citation topics figure 4 shows the micro topic distribution in big data research based on citation topics classification from 2007 to 2021 which is a finergrained representation than meso topic and macro topic the micro topic is named according to the most important author keywords by algorithm tools with the socalled importance determined by the number of occurrences and cooccurrences since the term cloud computing emerged in 2012 it has been the hottest topic in big data reaching its climax in 2017 while the popularity of cloud computing has been declining since 2018 it remains a critical topic in big data in addition the internet of things syndromic surveillance knowledge management and industry 40 have become hot topics in big data in recent years qiu used the lda model to cluster the literature on big data he found that the research hotspots of big data in china mainly focus on the application level that is library services smart city construction and intelligent urban transportation education ecommerce network marketing etc which is consistent with the conclusion of this section looking at the topic distribution at three levels in big data research it is evident that the development and breakthrough of big data technology and the application of big data are still constant topics despite the changing research hotpots in addition the differences in the number of papers among research topics are also shrinking which means that the distribution balance among topics is constantly improving collaboration among countries in big data research to understand the collaboration among countries in big data research we make a network of coauthorship of countries in big data research from 2007 to 2021 and set a minimum number of papers published at 10 with 80 countries meeting the requirements table 2 shows the top 10 countries in big data research from 2007 to 2021 and figure 5 is an overlay visualization of coauthorship of countries in big data research from 2007 to 2021 in figure 5 nodes represent countries with a corresponding number of occurrences the more occurrences the larger the node the connection between nodes indicates that the two countries have cooperated in publishing posts the more articles published in cooperation the thicker the line between the two nodes years from far to near are indicated from blue to yellow the closer the color is to yellow the later the publication time as the top three countries in terms of publications from 2007 to 2021 there is a significant disparity in the number of papers published between china the united states and india the top three countries accounted for 607 of all research at the same time china took possession of 346 which shows a highly uneven distribution of the number of papers published among countries in big data research in addition more than 400 articles have been published in england australia south korea italy spain canada and germany china works most closely with the united states in big data research with 484 articles coauthored accounting for about 10 of the articles published in china and about 20 of the articles published in the united states followed by 168 articles with australia 120 articles with england and 114 pieces with canada besides saudi arabia pakistan iran brazil united arab emirates switzerland and other countries have also been active in big data research in recent years over time the scale of the international collaboration network is constantly expanding and gradually transformed into a multidominant mode china the united states india and england occupy the core position in the international collaboration network and play the role of a bridge chinese authors are highly dominant in the global collaboration network using social network analysis and scientific map lv revealed the collaboration mode of countries in big data research and drew more profound conclusions global big data research focuses on domestic cooperation especially intrainstitutional collaboration with a low proportion of collaboration between countries and institutions international collaboration and crossinstitutional collaboration are possible directions to promote the leapforward development in big data 32 three dimensional index evaluation of discipline variety balance and disparity variety the definition of interdisciplinary emphasizes integrating the knowledge of two or more disciplines so the variety index measures whether the disciplines involved in interdisciplinary research are various table 3 is the result of analyzing the variety in the field of big data using wc19exe a tool measuring interdisciplinarity created by professor loet leydesdorff simpson div and variety are three indicators used to measure the variety of research the researchers papers are divided into five stages from the time dimension as can be seen from the analysis results the variety of big data research is constantly improving with time and the three indicators all show an upward trend specifically the simpson index was 089 in 20072012 rising to 095 in 20192021 the div index increased from 0003 in 20072012 to 012 in 20192021 and the variety index increased from 010 to 086 which shows that with the deepening of research in the field of big data more and more disciplines are involved and the variety index naturally increased these also show that the coverage of big data research is constantly expanding and many researchers in other disciplines have begun to apply big data to interdisciplinary research looking at all years the variety index accounts for 09 in all years indicating that the disciplines involved in the research of the big data field account for 90 of all disciplines in wcs the results of the analysis fully demonstrate the variety of disciplines in the study of the big data field it can be seen that interdisciplinary research is quite common in big data research and most disciplines have cross research with big data table 3 simpson div and variety index over time balance the balance index measures the difference between disciplines involved in a research field and reflects the contribution of various disciplines for the interdisciplinarity of a field the higher the balance index the more uniform the distribution of disciplines and the stronger the interdisciplinary characteristics figure 6 is the result of analyzing the balance index of big data research by using wc19exe professor loet leydesdorff used the gini index to measure the balance of the interdisciplinary research the value range of gini index is 01 the closer the result is to 1 the more uniform the distribution of disciplines therefore according to figure 6 the gini index of big data was 096 from 2007 to 2021 and it became 086 from 2019 to 2021 which shows that the uniformity of discipline distribution in the big data field is on the rise with the deepening of research in the big data field the participation of various disciplines and the uniformity of disciplines are rising during 20072012 the research on big data might be limited to computer science with few research results from other disciplines and a large gap between disciplines with the deepening of interdisciplinary research the variety of disciplines is increasing the influence of main disciplines is constantly improving and the cooperation with other disciplines is also increasing which shows that the interdisciplinary research in the field of big data is continuously becoming more balanced on the whole however the gini index is very close to 1 which shows that the distribution in big data is very uneven with the main disciplines still dominating and the interdisciplinary with other disciplines only serving as auxiliary research figure 6 gini index disparity the disparity is the degree to which the categories of the elements are different the disparity index measures the situation in which researchers cite the disciplines quite different from their own disciplines when conducting research the discipline of big data research is computer science researchers cite the more disciplines that are very different from computer science the more pronounced the interdisciplinary characteristics are the intersection of disciplines is reflected by measuring the degree of overlap in the scope of research involved in the discipline over a continuous period the stronger the dissimilarity the more pronounced the interdisciplinary characteristics table 4 is the result of analyzing the disparity in the field of big data using wc19exe according to table 4 it can be concluded that the disparity in big data research is gradually increasing over time which was 079 in 20072012 and 090 in 20192021 this shows that with the deepening of research in big data researchers tend to cite the disciplines which are more different from big data fields for crossdisciplinary research network analysis of interdisciplinary collaboration in big data research overall network characteristics table 5 shows the annual basic information of the codiscipline network in big data research from 2012 to 2021 the overall refers to the total value from 2007 to 2021 since the data before 2012 are too small to be used for network analysis only the data after 2012 are considered here before 2017 the nodes and lines of the codiscipline network are constantly increasing which shows that the scale of the network is expanding every year the scale of the network gradually stabilizes from 2017 to 2021 which shows that the codiscipline network has taken shape the average degree of nodes in the network has been kept at around 5 with little change table 5 descriptive statistics of interdisciplinary collaboration networks figure 7 shows the evolution of network indicators of the codiscipline network in big data research from 2012 to 2021 and the overall refers to the total value from 2007 to 2021 network density is the ratio of the number of edges existing in the network to the upper limit of the number of edges that can be accommodated which is used to describe the closeness of interconnection between nodes in the network the larger the value the closer the connection the maximum density that can be found in the existing network is 05 the density of the codiscipline network in big data research is just more than 005 which indicates that the density of the codiscipline network in big data research is low the network clustering coefficient is used to describe the probability that two adjacent nodes of a certain node are also adjacent to each other which is often used to indicate the degree of node aggregation the higher the clustering coefficient the more likely two nodes will be divided into a cluster the clustering coefficient of the codiscipline network in big data research has been kept at around 03 which means that the nodes in the network are likely to be divided into clusters louvain method is adopted in the community division of big data research it can be seen that the number of community divisions fluctuates significantly from 2012 to 2021 but all of them are around 8 among them in the community division supported by all data from 2007 to 2021 the codiscipline network of big data research is divided into 5 communities 2017 has already explored the data before 2016 in his study to ensure the timeliness and novelty of the study we mainly calculate the degree centrality betweenness centrality and closeness centrality of the codiscipline network from 2016 to 2021 we list the top five disciplines and corresponding indicators degree centrality betweenness centrality and closeness centrality are indicators to measure the position of nodes in the network but they follow different standards degree centrality holds that if a node is connected with many nodes the node is in a relatively central position in the network betweenness centrality holds that the more times a node appears on the shortest path of any two nodes the more important it is if the betweenness centrality of a node is high it plays a key bridge role in the network closeness centrality believes that the less a node depends on other nodes when transmitting information the more important it is the correctness of these indicators has been verified in many studies by analyzing the degree centrality of each discipline in the codiscipline network in big data research from 2007 to 2021 the top five disciplines are computer science engineering business economics environmental sciences ecology and social sciences from figure 8 it can be seen that the degree centrality of computer science and engineering has been far higher than that of other disciplines in the past six years which shows that the collaboration between disciplines in big data research has always been dominated by these two disci as can be seen from figure 9 the betweenness centrality of engineering and computer science has always been in the top two it shows that the two disciplines play a vital and stable bridge role in the codiscipline network compared with degree centrality the ranking of disciplines in big data taking betweenness centrality as the indicator from 2016 to 2021 except for the two disciplines of engineering and computer science changes greatly every year the top ten disciplines with high betweenness centrality are more diverse but less focused as can be seen from the figures the differences in degree centrality betweenness centrality and closeness centrality among disciplines are gradually decreasing it shows that the collaboration mode among disciplines in big data research has changed from the leading role of several important disciplines to more extensive and universal collaboration interdisciplinary collaboration communities in this study the louvain community discovery algorithm is used to divide the codiscipline network of big data into communities after the community division the nodes within the same community have a relatively strong correlation while the correlation between nodes in different communities is weak under this division disciplines with close collaboration will be divided into one community so finally discipline groups based on collaboration will be formed figure 7 shows the number of communities divided by the louvain algorithm from 2012 to 2021 the number of communities is basically around 8 indicating that the collaboration among disciplines in big data research has become mature and stable as hu has analyzed the data before 2016 in his research figures 11 to 16 only show the community division of the codiscipline network in big data research every year from 2016 to 2021 figure 17 shows the community division of the overall codiscipline network in big data research from 2007 to 2021 in these diagrams each node represents a discipline and the color of the node represents the community to which the discipline belongs the size of the node is determined by the number of occurrences of the discipline and the thickness of the connection between the nodes is determined by the number of cooccurrences of the two disciplines we mainly analyze the five crucial communities in the codiscipline network of big data research there are three central communities in the codiscipline network namely community 1 represented by computer science and engineering community 2 represented by business economics and community 3 represented by science technology these community representatives are the most important disciplines in the whole codiscipline network and also the skeleton of the entire network they lead their respective communities while other disciplines are in a relatively secondary position community 1 is the core community in the whole codiscipline network its number of occurrences and cooccurrences is huge and it is also a community with the most stable composition of discipline members the disciplines belonging to the community mainly include computer science engineering telecommunications automation control systems and operations research management science as we can see at the beginning of 2016 the number of disciplines occurrences in community 1 was polarized and computer science was the absolute leader however as time goes by the number of occurrences of engineering and telecommunications is increasing and the gap with computer science is narrowing by 2021 we can find that computer science engineering and telecommunications within community 1 are in a threepronged trend therefore we can conclude that the two disciplines engineering and telecommunications developed rapidly from 2016 to 2021 and gradually became the core disciplines in big data research the importance and stability of community community 4 and community 5 cant be regarded as the supporting communities of the codiscipline network in big data research but their number of occurrences is increasing s yang 17 from 2016 to 2021 in addition the cooperation among disciplines within the community 4 and 5 has become mature and stable community 4 mainly comprises materials science instruments instrumentation chemistry and physics we can find that the members of community 4 are always changing for example materials science belonged to community 1 in 2016 and instruments instrumentation belonged to community 1 in 2017 and 2021 however over time the nodes within community 4 have changed from small and changeable at the beginning to large and few the leading members of community 5 are health care sciences services psychology neurosciences neurology and medical informatics which didnt become stable until 2020 before that disciplines in community 5 were attached to other communities in addition to the above five communities disciplines such as remote sensing geography and physical geography also formed a community in 2021 but the collaboration among these disciplines is unstable disciplines close to one another are more likely to be in the same community because they cost less to collaborate therefore we find that each community represents one major research direction in big data research collaborations in community 1 are related to techniques in big data which are always the center of the whole codiscipline network connecting with and supporting other independent communities community 2 and 3 are also framework of the whole network and collaborations in them are usually about applications of big data we can find that the scale of communities is unbalanced while the scale and stability of communities are improving yearly the gap between communities is also shrinking social science in big data was still in its infancy in 2016 but now it has become mature according to the number of published papers from 2007 to 2021 we can know that big data research reached its peak in 2018 and then began to decline slowly nevertheless big data research is still a critical topic at present in recent years the microtopics in big data research mainly focus on the internet of things syndromic surveillance knowledge management industry 40 and so on from 2007 to 2021 china the united states and india were the top 3 countries in terms of the number of papers and the collaboration between china and the united states was the closest big data research involves a total of 141 disciplines based on the number of papers published computer science engineering telecommunications and business economics are the four most important disciplines with more than 1000 published papers in each discipline the four disciplines account for 64 of the total occurrences of all disciplines which shows that the distribution of disciplines in big data research is highly uneven from the perspective of variety balance and disparity it can be concluded that the interdisciplinary characteristics of the big data field are becoming more and more apparent the variety index is constantly improving and more and more disciplines are getting involved in big data research then the discipline balance is continually rising the participation of each discipline is gradually deepening and discipline uniformity is on the rise regarding discipline disparity researchers in the big data field are more inclined to cite the disciplines that are quite different from their disciplines generally speaking the interdisciplinary of the big data field is increasing by analyzing the codiscipline network of big data we can know that before 2017 the nodes and lines of the discipline network are constantly increasing which shows that the scale of the network is expanding at the same time the scale of the network tends to be stable gradually from 2017 to 2021 which shows that the codiscipline network has taken shape then from the three indicators of degree centrality betweenness centrality and closeness centrality we find the critical nodes in the codiscipline network of big finally focusing on the five communities in the network communities 1 2 and 3 are the most important communities in the network the collaboration among disciplines within them is relatively stable while communities 4 and 5 are slowly forming developing and stabilizing in recent years besides other communities are still in their infancy generally speaking the research in big data has entered a relatively stable stage and the number of disciplines involved has gradually become stable by analyzing the whole codiscipline network we can know that more and more disciplines are involved in big data research the variety of disciplines is constantly improving and the balance and disparity between disciplines are constantly rising although the discipline balance in big data research has been continuously improved the fact that big data research is still led by several major disciplines will not change in the short term computer science and engineering are still the main undisputed contributors with the deepening of research the collaborative communities in the codiscipline network are slowly expanding and maturing at the same time with the addition of new disciplines there will be more collaboration among disciplines and more new collaborative communities implications firstly big data is an emerging field this study provides a clear and comprehensive understanding of the collaboration pattern and distribution characteristics of interdisciplinarity in big data research secondly this study points out five communities of interdisciplinary collaboration in the big data field for example community 1 is represented by computer science and engineering these can provide valuable references for people to understand the field of big data in depth furthermore this study introduces not only the characteristics of discipline variety balance and disparity but also the perspective of a codiscipline network the methods and framework can serve as a reference for interdisciplinarity studies in the future limitations and prospects this study analyzes the interdisciplinarity of big data research from three aspects the results are intuitive and the conclusions are meaningful however this study only obtained the characteristic of the interdisciplinarity of big data research by using descriptive statistics and is weak in theoretical contribution it could not precisely measure the interdisciplinarity from the semantic perspective nor did it analyze the interdisciplinary knowledge flow of big data in the future these aspects deserve further exploration first pay more attention to the characteristics of the dynamic development of interdisciplinary second introduce new methods such as artificial intelligence and text mining techniques third explore the knowledge flow and influence factor in big data research

data as big data is a term that describes a large number of highspeed complex and variable data which requires advanced technologies and processes to capture store distribute manage and analyze information techamerica foundations federal big data commission 2012 big data can also be defined as a vast data set with increasingly diverse and complex structures iqbal et al 2020 characterized by mass rapidity diversification and lowvalue density furht villanustre 2016 however the term has now been extended big data is worthless in a vacuum and its potential value will only be released when it is used to promote decisionmaking gandomi haider 2015

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introduction in 2009 the world health organization classified ultraviolet radiationemitting tanning devices as class i carcinogens 1 indoor uv tanning has been shown to increase the risk of developing squamous and basal cell carcinoma and melanoma particularly among people who start at an early age or tan frequently 1 2 3 4 5 fortunately indoor tanning has declined over the past decade among adolescents and young adults who have traditionally represented a population with a high prevalence of this behavior 67 however among the highest adolescent risk group of white nonhispanic females indoor tanning rates remained above 10 in 2017 which is nearly twice the overall rate of tanning among adolescents 89 previous studies have identified several factors that influence an adolescent or young adults decision to pursue indoor tanning these include beliefs about tanning contributing to beauty 10 social factors such as peer tanning behaviors 11 and positive attitudes and intentions toward tanning 1213 the role of media in promoting positive attitudes and intentions toward indoor tanning remains understudied previous studies have examined traditional media and found that watching reality television was associated with tanning 14 and that exposure to tan models in magazines promoted positive attitudes toward tanning 15 in todays digital world messages promoting indoor tanning may be shared through social media 16 which has nearly ubiquitous use among adolescent and young adults 17 previous studies 1819 support social media as a platform in which comparison to others appearances is positively associated with body dissatisfaction and even as a risk factor for eating disorders social media content related to tanning behavior is common a previous study 20 examined twitter and found 77 mentions of indoor tanning per minute with only a small percentage mentioning health risks while studies such as this have illustrated how users generate and share content about tanning on social media less is known about the content shared by tanning businesses researchers in related fields such as alcohol research have hypothesized that the engagement and interaction that can occur with businesses via social media influence how marketing effects progress from awareness to encouraging behavior 21 the spread of misinformation through social media can be particularly influential as it is tied to emotions identity and ones social network for this study we define misinformation as inaccurate or false information indoor tanning salons business profiles on social media may increase exposure to misinformation among adolescent and young adults the purpose of this mixed methods study was to evaluate health misinformation promoted by indoor uv tanning salons via social media and to understand adolescent and young adults perceptions of this misinformation methods overview this mixed methods study included social media content analysis and qualitative interviews content analysis was conducted on the social media platform facebook between the dates may 1 2015 and april 30 2016 this data collection received an exemption for observation of public information from the seattle childrens institutional review board participant interviews were conducted after content analysis was complete in order to include observations from content analysis in the interview these data were collected between may 8 2017 and july 7 2017 this data collection was approved by the seattle childrens institutional review board social media content analysis design at the time of this study facebook was among the most popular sites used by the adolescent and young adult population 22 facebook also offered business profiles that allowed development of a freestanding multimedia profile with capacity to connect to and interact with users given its popularity among our target population and the robust content available for coding this platform was selected for evaluation for this study purposeful sampling the focus of this study was content posted on social media by businesses that provide indoor uv tanning our goal was to identify social media profiles created and maintained by indoor tanning salons we focused on profiles that were popular among users and had both current and historical content to evaluate our goal was to evaluate 1 year of content retrospectively for each of the 50 states we evaluated 3 tanning business profiles to capture range and variation across businesses we used purposeful sampling to identify profiles a strategy used for description and investigation into social processes of particular groups search strategy to identify potential profiles for evaluation we conducted a search on facebook for each of the 50 states using search terms in the form tanning salon state where state was replaced by each state name we set the search criteria to deliver responses by relevance from the list of search results we reviewed the first 10 business profiles listed and from those profiles we selected the 3 business profiles that had the largest number of followers we then evaluated each of the 3 profiles to ensure that they were publicly available profiles and that they prioritized uv tanning services to confirm that the business prioritized uv tanning services the business profile needed to meet a minimum of 2 of the 3 criteria include the word tanning in name of the business or business category selected on facebook was tanning salon describe the provision of uv tanning services in the about me section of the profile and have 25 or more of the posts by the profile owner in the past month refer to uv tanning additional inclusion criteria were that the business must have had the profile for at least 1 year and that the business must have made at least 1 post during 2015 facebook profiles that were labeled as unofficial pages were excluded facebook profiles have the option to indicate whether they are an official page sponsored by a busines or an unofficial page which often represents an individual who is a fan or supporter of the business furthermore because of our statebased approach to coding tanning salon chains that extended to multiple states were excluded though tanning chains located within single states were included if inclusion criteria were not met by a given profile we selected the profile with the next highest number of followers we developed a list of all salons that met inclusion criteria and the link to the facebook page codebook development and variables through a previous study 23 we have created various codebooks containing keywords and image interpretation used in evaluating facebook profiles for references to other health risk behaviors such as substance use and risky sexual behavior through a review of the literature 132324 and pilot coding we developed and tested a codebook focused on tanningrelated health misinformation we also recorded basic information about the tanning business including the name location and number of followers interrater reliability we conducted interrater agreement assessments at the beginning and end of the coding process interrater agreement ranged from 84 to 99 at the beginning to 91 to 100 at the end of coding across the health misinformation variables procedure trained coders reviewed 1 year of content on each business social media profile assessing a full year of content allowed us to capture data to represent events and seasons pilot data collection illustrated that most tanning business profiles posted multiple times per day and frequently duplicated the same post during a given day or across a given month thus our content analysis strategy was to evaluate 1 post per day selected as the final post of that day every third day of the month this strategy allowed us to ensure that both weekdays and weekends were included in each months evaluations and to vary the day of the week evaluated over time furthermore if that post was identical to the post evaluated from a previous day that post was skipped and the prior post for that day was evaluated this allowed us to diversify the content evaluated we recorded data for each selected post as follows for text posts we recorded verbatim text for usergenerated photos we recorded a thorough description of the photo and for popular public images such as memes or other downloadable icons we copied and pasted the image into the data set we also recorded the date that the post was uploaded to the social media profile each social media post was considered the unit of analysis and was thus categorized and coded based on which constructs were represented in that post data were extracted to a customized database and saved into a secure data file that was password protected qualitative interviews design a qualitative approach was best suited to investigating young womens experiences and perspectives 25 the goal of this inquiry was to understand individual experiences and allow participants privacy in their responses to questions thus individual interviewing was selected as the method participant sample and recruitment given the qualitative approach the goal sample size was 40 participants with experience with both indoor tanning and engagement with a tanning salon on social media with purposeful sampling and this sample size we estimated we could achieve theoretical saturation we conducted purposeful recruitment to target participants who were among the demographic most likely to engage in tanning white nonhispanic females ages 16 through 23 years 26 our purposeful sampling also included focused recruitment efforts on participants who were likely to have engaged with indoor tanning salon content on social media thus we recruited participants via facebook advertisements a facebook advertisement was created and targeted to a national sample of women ages 16 through 23 years the advertisement was posted for a total of 3 weeks the advertisement described an interview study about indoor uv tanning experiences interested participants were directed to a website to complete eligibility screening to ensure they met inclusion criteria these potentially eligible participants then underwent phone screening to confirm eligibility and complete informed consent we obtained informed consent from participants over the age of 18 years and the parents of minors we obtained informed assent from participants under the age of 18 years interview guide development and training during interviews we asked about perceptions and experiences viewing content from indoor tanning businesses on social media questions were designed to invite sharing of perspectives without judgment interview questions were designed to be semistructured and openended allowing participants to expand their comments with followup prompts interview questions included asking participants about their indoor tanning experiences as well as their social media usage example questions included in what ways do indoor tanning salons use social media interviewers then provided a brief overview of the study findings regarding observations of health misinformation on social media participants were asked about thoughts experiences and reactions to this shared information data collection interviews were conducted by phone the interviewer confirmed that the participant was in a private and comfortable location prior to beginning the interview data were recorded in a customized online platform during the interviews interviews lasted between 20 and 40 minutes participants received a us 40 incentive upon completing the interview analysis three investigators with experience in qualitative analysis were involved in the analysis process the investigators utilized a constant comparative approach to categorize responses 25 two of the 3 investigators first individually reviewed all transcripts and then met to discuss data categorization the goal of the first cycle was to collaboratively develop and apply a coding schema the 2 investigators then independently coded 5 interviews after coding the transcripts they reviewed the codes unblinded all 3 investigators then met and discussed and reached consensus for any additions or revisions to coding categories the third senior investigator served to resolve unclear areas or disagreements between investigators the coding process was then applied to a second set of interviews with 2 investigators the purpose of this second review was to evaluate reliability and validity of the initial classification criteria after coding review discussion and achieving consensus on the coding categories the coding approach was applied to the remaining interviews using the same constant comparative approach results social media content analysis of a total of 147 indoor tanning business facebook pages that were evaluated across 50 states 3 businesses closed prior to coding initiation this sample of indoor tanning business facebook pages yielded 4956 posts among 8 health misinformation topics identified the most common were posts promoting misinformation about vitamin d this misinformation typically focused on tanning as a safe and healthy way to get vitamin d the american academy of dermatology notes that tanning beds are not a safe way to get vitamin d given the cancer risk 27 furthermore since bulbs in tanning beds mostly emit uva light vitamin d can only be generated via uvb light thus tanning beds do not provide sufficient exposure to create adequate doses of vitamin d 27 an example post was stop by body and sol to get your daily dose of vitamin d most indoor tanning businesses that displayed misinformation about vitamin d did so infrequently many businesses had only 1 vitamin drelated post within the 1year sample though 3 businesses had 5 or more of this category of posts a second category was misinformation about tanning as a medical treatment for example the flu is not a season its an inability to adapt due to decreased sun exposure… some of these posts were consistent with described inaccuracies in an investigative report provided to the us house of representatives these inaccuracies mainly center on promoting tanning as having health benefits or as a health treatment there is no evidence to support tanning as a safe health treatment for illness including mental illness inflammatory diseases sleep problems or pain disorders 28 most businesses that displayed misinformation about tanning as a medical treatment had only 1 of these posts within the 1year sample there were no businesses with more than 3 posts of this type in the 1year sample another category of misinformation was promoting misinformation about the benefits of a base tan the posts often argued that a base tan would prevent sunburn or was a protective measure to take prior to a vacation there is no evidence that a base tan is protective against sunburn or against cancer risks from sun exposure 27 most tanning businesses displayed only 1 of these posts in the 1year sample and many were posted in late winter prior to spring break season table 1 displays the 8 categories of health misinformation and table 2 displays example social media posts table 1 health misinformation displayed on facebook posts by businesses across 50 states over a 1year period approximately half of participants acknowledged that indoor tanning businesses likely used social media to draw people in and influence tanning behavior some participants who followed tanning businesses on social media specifically noted that social media posts may normalize tanning behaviors or promote tanning benefits table 3 includes the most common topics that participants described viewing on indoor tanning salons social media pages businesses n misinformation category and number of posts just over half of participants expressed that social media influenced their friends or people in general to go tanning more often and 522 mentioned that social media influenced them personally to tan more some participants stated that posts on social media by indoor tanning salons led them to see tanning as safer than the sun or the business as trustworthy as vitamin d was the most common category of social media misinformation posts we asked participants whether they had seen indoor tanning businesses post on social media about vitamin d approximately half of participants reported seeing social media posts from tanning salons about vitamin d i have seen that a few times participant among those participants approximately half believed it was safe to get vitamin d from indoor tanning stating for example i think it is a valid benefit to uv tanning participant table 3 qualitative interviews with white nonhispanic adolescent and young adult women about indoor tanning and social media example quotations participants n topic type of content posted by indoor tanning salons on social media reported by participants they post 4 tan weeks come tan for 5 promotions and deals mainly 38 deals and sales they post sales on lotion and promotions trying to get new people to come in on twitter for retweets they give away free lotion and tanning minutes 12 lotions …they also give tips for what is good for your skin and what isnt 3 tanning tips how tanning salons use social media they are trying to get customers or potential customers 20 attract new customers to promote brand recognition and specials they are running that month…they also promote employment for that salon if you work at the salon you get free tanning 18 showcase deals or promotions there is also the psychological aspect to it where they post motivations like everyone looks good tan to try to get more people to start tan 7 remind andor motivate people to tan advertising their prices and different lotions they have for their clients 6 sell lotions they probably want to decrease the stigma in tanning to make it look more beneficial 4 promote tanning benefits to reach their target market or to target those who are younger 3 target young people what role does social media play in you or your friends tanning i think it would make us tan more than we actually do want to or intend to 25 influences people to tan more it has made me want to tan i used to be against but then facebook drew me into it and now im doing it 24 influence the participant to tan more if theres a deal more people will be inclined to do it even people that dont regularly tan will go to take advantage of the deal 18 motivate to go tanning by deals when you see your friends on facebook and theyre tan it makes you want to be tan as well 14 seeing friends post about tanning not tanning salons is influence to them i definitely see that it affects it when you see people that are tan on social media you wish you were that tan 13 motivate to go tanning by pictures of tan people i definitely thinking that seeing it a lot on social media makes it very normal since you see everyone else on social media it makes it very acceptable 7 normalizes tanning makes it seem like a safe thing to do you dont think about the risks 4 influences viewers to see tanning as safe discussion general this mixed methods study included social media content analysis and qualitative participant interviews we found an overall low frequency of social media posts promoting health misinformation however many of our participants actively followed tanning businesses on social media and participants commonly reported remembering misinformation posts such as those promoting tanning as a safe way to get vitamin d our first finding was that social media posts related to health misinformation were uncommon most of the content posted by tanning businesses was related to other topics such as deals or sales as described by our participants these findings are consistent with a previous study examining hashtags related to tanning that found that most tanning salon posts were related to price reductions 29 we found that the most common category of misinformationindoor tanning as a safe way to get vitamin dcomprised less than 2 of posts recorded across the year it is important to clarify that our data did not represent that uv tanning could provide vitamin d but that posts described uv tanning as a safe way to achieve vitamin d which identifies these statements as clear misinformation as there is no evidence that the body can achieve adequate vitamin d levels safely or adequately 27 furthermore in many categories of health misinformation most tanning businesses displayed only 1 post in that category across our 1year evaluation period given these findings it is even more striking that many participants reported recalling these posts this finding suggests that these health misinformation posts while uncommon were memorable and may have been influential our findings from participant comments clearly support that the practice of following social media tanning businesses contributed to reminders to participants to go tanning through deals and specials and reminders about motivations to tan it is also important to note that a social media platform is interactive whereby users and businesses can interact bidirectionally thus while the frequency of these health misinformation posts displayed by tanning businesses was xsl • fo renderx uncommon these posts can be shared or distributed across an individuals own social media our second finding was that among our purposeful sample focused on those who engage in indoor tanning as well as social media participants commonly engaged with social media related to tanning as nearly half participants followed a tanning business on social media this supports the potential reach and influence that tanning salons have among young social media users participants described that indoor tanning salons social media pages provided them reminders nudges and information about special deals and sales participants described the influence of tanningrelated social media on their own tanning attitudes as well as on their behaviors this finding suggests that of the approximately 10 of young white females who continue to engage in indoor tanning social media may be a viable platform to reach this atrisk population with education or intervention approaches limitations our study is not without limitations this study focused on tanning businesses that were present on facebook and we did not examine other platforms such as snapchat or instagram we were interested in how popular tanning businesses utilized social media to engage with customers thus our purposeful sampling strategy prioritized selection of tanning businesses that were popular on social media we excluded tanning salon chains that extended across states which allowed us to focus on individual businesses within states however tanning salons within chains may reach more viewers compared to individual businesses furthermore our facebook data were from 2015 however the role of facebook as a platform to connect to businesses remains relevant today and no new laws or regulations governing tanning business content on social media have arisen since that time finally our qualitative interviews were purposeful in order to target the atrisk population for indoor tanning thus evaluating external validity of our sample was not appropriate for this study implications despite these limitations our study has implications in the area of health misinformation while the overall reduction in indoor tanning behaviors among women and adolescents 67 is a public health triumph a significant atrisk group of white young women remain engaged in this health risk behavior 89 our study findings suggest that some of these women who tan are also connected to indoor tanning salons on social media while misinformation may not be common or a significant motivator for adolescent and young adult tanning social media connections between businesses and adolescents and young adults are very common and may provide ongoing engagement with and encouragement of tanning behavior that is this social media connection may foster ongoing relationships with tanning businesses and behavioral nudges to go tanning through deals and reminders about motivations to tan an initial strategy to prevent adolescents from following these businesses on social media may be to consider requiring agegating for indoor tanning businesses agegating would block access to indoor tanning social media pages for youth under age 18 the agegating approach is currently used by alcohol companies on social media and youth are supportive of applying this restriction to other businesses on social media 30 additional strategies may include creating regulations about health misinformation directed at indoor tanning businesses similar to strategies used to limit health misinformation about tobacco and marijuana finally strategies to reach atrisk women may include placing targeted educational campaigns on social media similar to the facebook advertisements that we used to recruit for this study which were successful in identifying the population at risk for consequences of indoor tanning our study focused on health misinformation messages shared on social media by tanning salons however the implications of our findings may contribute to a critical conversation about how health misinformation shared via social media may reach vulnerable populations and potential prevention strategies first agegating may present a valid approach to limit youth access to content from businesses based on minimum age limits such as alcohol tobacco ecigarettes marijuana and tanning second regulations that clearly define allowable messages on any medium are critical to consider enhancing efforts around surveillance of social media would be an important part of such regulations it is possible that funds from tax revenues related to these sale of these products could support regular and ongoing monitoring of industry compliance challenges to monitoring social media content include its potentially ephemeral nature as well as the ability in social media to target content behaviorally geographically and temporally while surveillance may not capture all businesses that post misinformation for example many of the businesses that posted vitamin d misinformation did so only once during our data collection time period however ongoing surveillance may be likely to identify businesses that repeatedly post misinformation for example we found that 1 tanning business displayed 13 posts promoting misinformation about benefits of a base tan finally our study illustrates that it is possible to create a sampling strategy to evaluate posts over time and to develop a codebook to identify content and achieve interrater reliability for such content the content and keywords identified in this study may inform other social media surveillance methods using machine learning or automated text analysis for more widespread evaluation it is also possible that partnering with adolescents and young adults who are often at the forefront of the learning curve for digital media may lead to creative prevention approaches conflicts of interest none declared abbreviations uv ultraviolet edited by g eysenbach submitted 101120 peerreviewed ©megan andreas moreno marina c jenkins deann lazovich originally published in jmir dermatology 19052021 this is an openaccess article distributed under the terms of the creative commons attribution license which permits unrestricted use distribution and reproduction in any medium provided the original work first published in jmir dermatology research is properly cited the complete bibliographic information a link to the original publication on as well as this copyright and license information must be included

background indoor ultraviolet uv tanning is common and consequential increasing the risk for cancers including melanoma and basal cell carcinoma atrisk groups include adolescents and young adults who often report beliefs about benefits of tanning adolescent and young adults are also among the most ubiquitous social media users as previous studies support that content about tanning is common on social media this may be a way that young women are exposed to influential content promoting tanning including health misinformationthe purpose of this study was to evaluate health misinformation promoted by indoor tanning businesses via social media and to understand young womens perceptions of this misinformation methods this mixed methods study included 1 retrospective observational content analysis of indoor tanning salons content on facebook over 1 year and 2 qualitative interviews with a purposeful national sample of 46 white nonhispanic women age 16 to 23 years who had recently tanned indoors we assessed experiences with tanning businesses posted content on social media through interviews we used the constant comparative approach for qualitative analyses results content analysis findings included data from indoor tanning businesses n147 across 50 states yielding 4956 total posts among 9 health misinformation topics identified the most common was the promotion of uv tanning as a safe way to get vitamin d n73 15 an example post was stop by body and sol to get your daily dose of vitamin d another misinformation topic was promoting tanning for health benefits n31 062 an example post was the flu is not a season its an inability to adapt due to decreased sun exposure… a total of 46 participants completed interviews age mean 20 years sd 2 almost all participants 4546 98 used facebook and 435 2046 followed an indoor tanning business on social media approximately half of participants reported seeing social media posts from tanning salons about vitamin d an example of a participant comment was i have seen that a few times among the participants approximately half believed it was safe to get vitamin d from indoor uv tanning a participant stated i think it is a valid benefit to uv tanning conclusions despite the low frequency range 05 15 of social media posts promoting health misinformation participants commonly reported viewing these posts and their perceptions aligned with health misinformation health education campaigns possibly using social media to target atrisk populations may be an innovative approach for tanning prevention messages

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introduction although the impact of military service on service members has long been the subject of scientific study 12 the indirect impact on their spouses has received considerably less attention over half of active duty sms in the us military are married 3 military spouses play a critical function in supporting sms 4 thus their experiences may have a significant effect on the readiness of the military force within the limited available literature studies suggest that military spouses experience unique stressors as a result of military life 5 6 7 8 including financial pressures geographic instability because of frequent moves shortand longterm spousal separations and concern for their partners safety recently the office of military community and family policy commissioned a report from the national academies of sciences engineering and medicine that reviewed key issues related to the wellbeing of sms and their families in order to strengthen programs and policies 9 the report highlighted that exposures may vary systematically in relation to sociodemographic factors and that each family experiences a unique configuration of risk and resilience factors partially impacted by these structural forces our study sought to describe the experiences of certain subgroups of military spouses categorized by military and demographic information obtainable through dod records and identify differences in perceived support and militaryrelated stress among the subgroups in our sample we selected those that have historically been understudied or underrepresented in previous research such as dualmilitary spouses and spouses of reserve or national guard sms the majority of existing military family studies have focused on the female spouses of active duty males 10 as this is the majority group among military spouses however a number of other subgroups are growing in the military community and receive less attention and potentially less support for instance approximately 5 of personnel are in dualmilitary marriages including 20 of female personnel 3 suggesting a need to better understand this distinct subgroup dualmilitary couples have historically reported more marital strain and less career and relationship satisfaction compared with militarycivilian couples 11 12 13 14 although not all studies have supported these findings 11 civilian male spouses are another understudied subgroup that may be under unique levels of stress and simultaneously underserved 14 male military spouses have reported poorer employment outcomes and may be more vulnerable to social isolation and other negative outcomes compared with female military spouses 10 raceethnicity and cultural factors also may play a role in how people perceive and respond to stress in the dod community however most research on this subject has focused on differences in treatment seeking 1516 which is important but does not address how militaryrelated stress is experienced in daily life and if these experiences differ meaningfully between raceethnic groups thus there are important research gaps in our understanding of the experiences of military life among different raceethnic groups finally despite the fact that reserve and national guard sms have been called into active service and deployed far more frequently over the last decade than they have historically 17 reservenational guard spouses remain understudied reservenational guard spouses face unique potential stressors associated with military life including uncertainty about future involvement with the military less deployment preparedness and poorer integration into the military community 18 19 20 further research on how the experiences of these subgroups may relate to the perceptions and effects of military stressors and support could help inform the focus and delivery of military support programs by examining differences in military spouses perceptions of military life experiences and support our study aims to identify families at higher risk and in more need of support services the study was designed to take into account characteristics of the military spouse and the sm offering a unique opportunity to comparatively examine the experiences of multiple understudied subgroups we examined several indices central to quality of life among military families including exposure to potential military stressors perceived level of support from the military and perceived social support in order to understand how these may vary across demographic subgroups we expected that reservenational guard and male spouses may experience heightened stress and less perceived social support compared with their counterparts and that raceethnicity and dualmilitary status may predict variation in key outcomes this research could provide practitioners policymakers and stakeholders with empirical data to help guide resource allocation and targeted prevention and treatment initiatives for vulnerable military families methods measures the primary independent variables comprised demographic and military population characteristics including selfreported sex and age groupings spouses were asked to identify their raceethnicity from among six options white nonhispanic black nonhispanic asianpacific islander hispanic native american or other for analytical purposes participants were categorized as white nonhispanic black nonhispanic hispanic or other spouses also reported their personal military service history service member military characteristics included service branch component and pay grade additional covariates in the models included spouses selfreported education level employment status number of children and duration of marriage the key outcome domains were militaryrelated stress including deploymentrelated experiences and perceived social support and perceived support from the military military stress reported by the spouse was operationalized using the mean of three items in each of three domains deployment injury and family stress each of the items was scored from 0 to 4 the number of months the sm was away from home in the past year was used to further characterize recent militaryrelated stress perceived social support was measured using the mean of two items both items were scored on a 5point scale ranging from 0 to 4 perceived support from the military was measured with one item overall how would you rate the militarys efforts to help you and your family deal with the stresses of military life all multiitem outcome measures exhibited good internal consistency statistical analysis we first generated descriptive statistics on the demographics and the spousal stress and support outcomes next we estimated bivariate associations with a simple linear regression model evaluating all possible pairs of demographic characteristics and outcomes finally we estimated a multivariable linear regression model for each outcome including key spouse and military characteristics these models were additionally adjusted for spouse education spouse employment status number or children and duration of marriage all of the spouse and military characteristics were analyzed as unordered categorical measures with the group considered most typical for a military spouse chosen as the reference category all analyses were weighted to account for sampling design and nonresponse the weights allow the findings to be generalized to the population of married spouses of sms with 2 to 5 years of military experience 22 results the sample included 9872 dyads the majority of spouses were female and between 25 and 34 years of age and nearly three quarters were white nonhispanic most of the spouses had no history of military service but some were currently serving in the military and others were veterans half of the spouses partners served in the army followed by 174 in the air force 153 marines 142 navy and 28 coast guard the majority of sms were active duty vs reserve or national guard personnel additionally most spouses were either homemakers or students or employed full time the majority had some college experience or an associate degree had at least one child and had been married 2 to 5 years table ii provides descriptive information for each of the spouse outcomes overall spouses reported fairly low levels of militaryrelated stress m 131 between 1 not at all moderate levels of perceived social support and good levels of perceived support from the military bivariate and multivariable results are presented in table iii the multivariable results are organized by outcome and described below supplemental tables show crosstabulations of all the predictor variables as well as the full set of bivariate analyses spouse military stress in multivariable modeling spouse sex age raceethnicity and military service history as well as sm branch component and pay grade were significantly associated with militaryrelated stress male spouses reported less militaryrelated stress than female spouses spouses with either current or former military service reported less military stress than spouses who had never served in the military reservenational guard spouses reported less military stress than those with active duty partners and spouses of officers reported less military stress than spouses of enlisted sms older spouses reported more military stress than those in the 25 to 34 age group hispanic spouses reported experiencing more military stress than nonhispanic white spouses but no other racial differences were found spouses of sms in the army marines and navy reported more military stress than those with partners in the air force whereas those with partners in the coast guard reported less stress finally spouses who were unemployed also reported more military stress 015 p 013 service member months away spouse sex age raceethnicity as well as sm branch component and pay grade were independently associated with sm time away from home male spouses reported that their sm partners spent an average of 1 month less time away from home in the past year than female spouses whereas older spouses reported their sm partners spent more time away from home than spouses between the ages of 25 and 34 years both black nonhispanic and hispanic spouses reported that their sm partner spent more time away from home compared with white nonhispanic spouses compared with air force spouses all other service branches except the coast guard spent more time away from home reservenational guard spouses reported their partners spent less time away from home than active duty sms and spouses of officers reported that the officer spent more time away from home compared with enlisted sms spouse perceived social support in multivariable modeling spouse age and military service history as well as sm branch and pay grade were statistically significantly associated with spousal perception of social support dualmilitary spouses perceived of significantly more social support than spouses who had never served in the military spouses of officers perceived of significantly more social support than spouses of enlisted sms older spouses perceived of significantly less social support than younger spouses aged 25 to 34 years spouses with partners in the army perceived of less social support than air force spouses but no other differences by service branch were found finally spouses who were unemployed also reported less perceived social support 027 p 001 spouse perceived support from the military spouse raceethnicity and history of military service as well as sm branch component and pay grade were significantly associated with spouses perception of the militarys efforts to help the spouse and their family deal with stresses of military life all minority race groups perceived greater effort from the military compared with white nonhispanic spouses spouses who were currently serving in the military perceived of greater military support compared with civilian spouses who had never served and spouses who were veterans reported perceiving less support from the military compared with civilian spouses reservenational guard spouses perceived greater support efforts from the military than spouses with active duty partners and spouses of officers reported greater perception of military support than spouses of enlisted sms spouses whose partners were in the army perceived less effort from the military providing support compared with air force spouses there were no other differences by service branch discussion the current study expands upon the literature by evaluating the experiences of a large cohort of military spouses including many subgroups that are difficult to engage and are frequently excluded from such research we identified spouse and sm characteristics associated with greater perceptions of the militarys efforts to provide support and less perceived military life compared with female spouses male spouses reported experiencing fewer stressful military experiences and less time away from their sm partner but they did not report significantly different perceptions of military or social support this finding ran counter to the hypothesis that male military spouses may perceive less formal support suggesting that gender may not impact the spouses perception of support an alternative explanation is that men and women may differ in terms of their perceptions and reporting of stress and time away from their partners it is also possible that female sms participating in the millennium cohort study spent less time deploying andor had fewer occupational exposures compared with male sms when the data for these analyses were collected in between 2011 and 2013 dod policies prohibited women from serving in certain direct combat roles however there is also evidence that most female sm deployed during operation enduring freedomoperation iraqi freedom had been exposed to some form of combat 25 further research is needed to better understand gender differences in deploymentrelated experiences and occupational exposures for both males and females this is of particular significance given that dod policy on females in combat changed in 2016 26 after these data were collected and females may experience heightened exposures in future years dualmilitary couples reported experiencing less stress associated with military life and greater perceived social support and support from the military compared with spouses who have never served in the military although spouses with former but not current military service also reported less military stress they also perceived less support from the military compared with spouses who had never served these findings are in contrast to our hypothesis that dualmilitary couples may experience heightened stress and feel less supported by the military despite the demands of balancing two military careers it is plausible that dualmilitary couples have more aligned expectations about what military service entails for the family or that they benefit more from military support services compared with other dualcareer spouses for instance dualmilitary spouses may be more aware of military services and have higher utilization rates than civilian spouses former military spouses also reported greater perceived military support than their civilian counterparts it appears that spouses currently serving in the military perceived greater social support and less social isolation suggesting that the military community and occupational duties may provide a substantial support network not as readily available to civilian spouses or to spouses who had previously served but were now veterans service branches have differing policies on colocation of dualmilitary married couples during deployment which may explain differences in perceived support from the military by sm service branch 27 contrary to our hypothesis reserve and national guard spouses did not appear to have systematically lower support or higher stress than active duty spouses reserve and national guard personnel generally have more geographic stability so these spouses may experience fewer occupational disruptions and fewer disruptions in their social networks another possible explanation is that stressful military experiences specific to reservenational guard spouses were not adequately captured in the military stress measure reserveguard spouses perceived greater support efforts from the military than their active duty counterparts which was another surprising finding many formal support programs such as family and community support centers are based on military installations 17 although reservenational guard families are less centrally located to military installations they have access to extensions of formal and informal support programs 17 in addition programs such as the yellow ribbon reintegration program offer specific resources for families based outside military installations 28 national guard and reserve families may also have access to information and support systems outside of the military context based on their other employment or external networks reservenational guard families may also have lower expectations of military support and thus perceive greater levels of effort from the military in providing support relative to active duty families who may experience more disruption because of military life and thus expect higher levels of functional support spouses over the age of 35 compared with those ages 25 to 34 years reported more military stress more sm time away and less perceived social support this unexpected finding is important to interpret in the context of the study design our sample is comprised of spouses of sm with 2 to 5 years of service and couples with an average age over 35 were less common the military has a unique culture that emphasizes uniformity and core values structures and rules that differ from civilian life 29 adapting to this culture may be more difficult for relatively older couples who are more accustomed to civilian life conversely it is possible that older sms entered service with more professional experiences and thus had greater operational demands in addition their spouses may be more experienced in handling competing family demands such as raising children or maintaining a household independently which could create an opportunity for these sms to take on more demands at work such as deploying more often in terms of covariates couples with two or more children compared with none reported more military stress and less time away for the sm which is likely because of increased familial demands both black nonhispanic and hispanic spouses reported that their sm partner spent more time away from home compared with white nonhispanic spouses more research is needed to determine the root cause of this difference such as whether deployment patterns 30 service assignmentpositions and greater operational demands could be linked to race ethnicity or other sociodemographic factors in terms of military service characteristics results were as expected spouses of sms in the army fared worse across outcomes compared with those in the air force spouses of sms in the marine corps and navy also reported more stress and sm time away from home but not less perceived social or military support conversely spouses of officers compared with enlisted personnel did better across outcomes even after controlling for age spouse education and employment number of children and duration of marriage this finding may be because of rank serving as a close proxy for education and income financial security can secure enhanced support resources that may help reduce stress importantly each branch of service is characterized by a different mission widely divergent staffing requirements and unique recruitment policies resulting in diverse subcultures the air force in particular targets a smaller and more highly skilled workforce 31 especially in contrast with the army which may account for the findings of less perceived stress among this group in our sample furthermore sms in the army navy and marine corps deploy on average for longer lengths of time and over multiple deployments for cumulatively longer periods of time compared with the air force and the coast guard 32 thus these personnel and their families may be exposed to more operational stress there are several notable limitations of this study foremost because the study was crosssectional we cannot determine causal mechanisms or the direction of effects we relied heavily on selfreports from a single respondent for key outcomes of interest it would have been helpful if we had parallel information on these topics from both respondents andor more objective measures of these outcomes however for many of these variables selfreport is the optimal data type the generalizability of our findings is limited to young married couples relatively early in their military careers as of 2011 younger married couples in the military may differ systematically from those who have served in the military for longer periods of time additionally this study included only married heterosexual couples therefore it does not represent the full spectrum of families serving in the military the study also has several strengths including representative sampling of military spouses across branches and the reserveguard and assessment of a multitude of key military and sociodemographic predictors and covariates across the dyad the complex pattern of results highlights the need for further study of these and other understudied subgroups to determine how best to channel limited resources and programs to those most affected and in need of particular services for example studies that focus on the differential patterns of deployment for black and hispanic sms and studies that explore gender differences in spouse reports of stress over time could help elucidate the drivers for risk and resilience among these groups moreover studies that examine the impact of frequent moves on rates of spousal unemployment financial uncertainty and stress could be instructive in developing programs to improve overall quality of life and reduce barriers to employment and financial stability including limited child care options and labor market conditions such findings may be used to inform culturally relevant and sensitive programming and tailor initiatives to enhance social support and connectedness among particular atrisk groups of military spouses

military spouses play a critical role in supporting military service members and thus their experiences may have a significant impact on the wellbeing readiness and resilience of the us armed forces research suggests that military spouses experience unique stressors as a result of military life but few studies have assessed demographic factors associated with their experiences of military life and perceived supportusing data from the millennium cohort family study a nationwide survey of 9872 married spouses of service members with 2 to 5 years of military service this study examined differences in experiences of military life and perceived support across multiple understudied subgroups of military spouses key outcomes included militaryrelated stressors eg deploymentrelated experiences perceived social support and perceived military efforts to provide supportmilitary life stress and perceived support differed across military spouse service member and family characteristics results indicated that spouses who are older than age 35 or are married to enlisted service members in the army navy or marines are more likely to experience heightened military stress or less perceived social support dualmilitary couples reported experiencing less stress associated with military life and perceiving more social support and support from the military compared with spouses who have never served in the militarythese findings may help guide effective channeling of resources and outreach to potentially vulnerable military families

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introduction indigenous language also known as native language or the mother tongue is one of the cultural heritage in nigeria there is the standard language which is the official language of nigeria nation used by newspapers textbooks in schools on the radio and television programs the existence of the standard language according to adeyinka the existence of the standard language makes it possible for people of different dialectic groups to converse meaningfully to this end the importance of a language in any society cannot be overemphasized religion an encounter or a relationship between the supernatural and human beings is also another element of culture presently three main religions are practiced in the southwestern nigeria these are christianity islam and traditional religion culture that entails all aspects of human life incorporate language and religion as an inseparable entity of culture however a contending issue is raised by the cultural diversity has the cultural diversity helped to promote a progressive development among the people of southwestern nigeria this further provokes another question does the culture of southwestern nigerian people exist despite their experiences in the hands of their colonial masters who came to rule them with their culture however the southwestern culture exists with a lot of changes but they are typically southwestern culture of the southwestern people why do we study african religion today the answer to this question is not farfetched the value of studying african language today holds a moral sense of justice and truth along with the knowledge of the existence of good and evil in human society generally the aim of this research article is to investigate the use of language religion and culture in generating peaceful coexistence among the people of southwestern nigeria hence the sociology theory of social exclusion is used in this research article the adopted theoretical framework of exclusion approach is applied on the other hand attention is directed at the role of language religion and culture in conflict resolution in southwestern part of nigeria the study will significantly help to reduce ethnic violence and create room for peaceful coexistence and tolerance among the people of the selected area and nigeria at large some of the identified conflicts that occurred in nigeria particularly in southwestern part the states those involved causes and consequences are presented in table 1 11 2000 osun modakeke versus ife communal clash people unknown theoretical framework there are different approaches to the study of society some of these include functionalism marxist feminism social action postmodernism conflict perspective interactionists perspective and social exclusion among others each of these approaches has its strong and weak points however a critic can make use of any of the approaches since each offers unique insight into the same issue nonetheless no one approach to a particular issue is correct it is assumed that the broadest understanding of a society can be gained by drawing on the adopted approach in the study the exclusion approach is the adopted approach under sociological theories which was used for analysis in this research article this approach cannot be ignored because the society is a high organism and each part contributes to its survival this is evident in the research topic for this research article it is clear that the adopted approach will give us richer fuller and detailed understanding of not only living together in a yorùbá community but also in nigerian society the term social exclusion was coined in france in 1970 by red lenoir social exclusion is defined by red lenoir as a process by which certain individuals and groups are systematically blocked from their rights opportunities and resources that are normally available to members of other groups within a society according to durkheim social exclusion is termed as anomie which he viewed as a breakdown of social bonds between an individual and the community thus resulting to social alienation and the fragmentation of social identity social exclusion according to him theoretically emerges at the level of four correlated factors deprivation of material resources denial of social rights prevention from social participation and cultural integration social exclusion focuses on how to understand the society as well as the responsibility of the society to ensure equal opportunities for all this includes equal access to the labour market education health care judicial system rights and decisionmaking among participation this theory places emphasis on the process of improving the terms on which individuals and groups take part in the society statement of the problem with the increasing state of migration and the right of free movement of citizens there are growing waves of conflicts in southwestern and other parts of nigeria the research article acknowledges from literature that the concept of culture has been over flogged nonetheless the attention of this research article is directed at the role of language religion and culture as tools for peaceful coexistence among the people of southwestern nigeria ie oyo ogun ondo lagos osun and ekiti state one of the main challenges facing the southwestern state is the problem of conflicts and violence especially during political periods this has generated the following questions what is the role of language religion and culture in conflicts resolution why has religion failed to guide the human spirit to fulfil its appropriate role what are the disadvantages of the frequent conflicts and violence in southwestern part of nigeria significantly language religion and culture play a vital role in the society especially in a multiethnic society like nigeria hence there is the need to explore the potentials of these three siblings language religion and culture 1 literature review there are several scholarly works on conflicts and violence resolution like community conflict in nigeria management resolution and transformation otite 1999 ethnic conflict and democracy in nigeria the marginalization question anugwom 2000 ethnic violence and national development in democratic nigeria a historical analysis adeyemi adebisi 2015 mechanisms for conflict management in plural and divided societies the nigerian experience ethnoreligious violence in nigeria garba 2007 ethnoreligious conflicts in nigeria causal analysis and proposals for new management strategies conflict between traditional and western culture a case study of soyinkas death and kings horseman atunpa ero lori iṣatunto irinṣẹ fun aabo ni awujọ yoruba and language use in conflict resolution nigeria and south africa xenophobic attack furthermore studies such as tempo centered on ethnic and violence yusuf and alighazzali survayed islam and religious tolerance the quranic input and salahudeen and adeleke examined conflicts of culture and its implications on muslim students of emmanuel alayande college of education oyo the critical works of these scholars are stimulating encouraging and educative however this research article is prompted by the need to further examine the reasons for the failure of language religion and culture to impact on peaceful coexistence among people findings of previous studies will contribute to the knowledge and understanding of this research article 2 conceptual framework 21 language according to adeyinka language begins right from the cradle and the importance of language in any society cannot be over emphasized it can be regarded as an instrument or a tool which mankind uses to communicate with one another this is because language is considered indispensable in communication and is at the vanguard of everything people do it is sufficiently clear that human beings language and the society revolve around one another the components of the society can help contribute to unity promote good governance and assist to solve political and religion differences corroborating this aristotle as cited in awobuluyi asserts that language and society are inseparable 22 concept of culture chika defines culture as a learned behavior which each person acquires as a member of a group or society to her each character is a product of its unique history sanni describes culture as the beliefs customs practices and social behaviour of a particular nation or people to ajibade culture refers to features of life of a society prevailing modes of dressing routine living habits food preferences the architecture of houses and public buildings the layout of fields and farms and system of education government and law to lebron culture is an allencompassing term that identifies not only the whole tangible lifestyle of a people but also their prevailing values and beliefs culture in this research article focuses on a complete societal heritage it is the pivot around which the life of any society revolves culture welds the past and the present synthesize achievements and aspirations in other words culture connotes the total ways of life of southwestern people of nigeria concept of religion religion in line with king as cited in isiramen is viewed as an encounter or as a relationship between the supernatural and human beings isiramen asserts that religion is expressed in the form of human passion belief of their creator and to whom they absolutely depend on for their sustenance and fulfillment of their destiny it is on this basis that there is belief in supernatural powers or power that the believers accept to have influence on their existence this scholar further stresses that this helps believers to comport themselves in their sociocultural life in a manner they belief will please the object of their worship there are many different religions each with a different set of beliefs the beliefs are about the world and the people in it how they came into being and what their purpose is in nigeria christianity islam and african traditional religion are the three main religions being practiced with christianity and islam being the dominant religions for instance churches in nigerian society is a major source of social services inspiration for art and culture as well as an influential player in politics the most important contributions of islam to the society according to islamic scholars is to promote justice equality and respect for others to africans the value of african religion holds moral sense of justice truth and knowledge of the existence of good and evil in the society according to caudwel and ogunṣina religion laws and taboos exist are for social cohesion in traditional society interaction and politics in the precolonial background was predicted upon the primary goal to root a firm political and economic order as well to sustain and maintain the moral and religious order in worldview abdulraheem states that these religions have certain things in common as they teach that god is transcendent and independent of the world therefore people depend upon him pray to him worship him and people engage in activities that would make their services accepted by god the three religions teach people moral behaviour and how to be good members of society in addition adekunle asserts that the most famous set of rules for moral behaviour are the ten commandments in the bible some important functions of religion in society include the following providing mental peace inculcating social virtues promoting social solidarity social control psychological and physical wellbeing 3 interrelationship of language religion and culture looking at the above definitions of language and culture along with the various functions of language in human society it is very clear that language is a very vital tool for promoting culture ajibade asserts that language can be used to sooth anger excite intimidate energize stimulate create destroy or immortalize sanni states that whatever acts that is being practiced from time to time or from one generation to another becomes their culture this implies that culture expresses how humans experience and understand the world religion on its own is a fundamental way by which human beings experience and understand the world the relationship between culture and religion is revealed in the motivation and manifestation of cultural expression therefore it is imperative to affirm that religion and culture cannot be discussed without language as the three are interwoven thus it is evident that people are influenced by the cultures and regions they are from or practice 4 southwestern nigerian society lebron defines society as a group of human beings bound together for selfmaintenance and selfperception sharing their own institutions and culture members of any society cultivate certain social behaviours similar to common brotherhood faithfulness responsibility patriotism and the life that fosters peaceful coexistence they are united by common aims and objectives as well as values and interest the southwestern nigerian society constitutes the majority ethnic group in west africa identified as yoruba speaking society according to abdulraheem the term yoruba is used to describe a cultural and linguistic group of people most of these people are found in southwest of nigeria they are the indigenous inhabitants of the present oyo ogun ondo ekiti osun and lagos states of nigeria also they constitute the majority single ethnic group in kwara and kogi state of nigeria in their expansion they could be found in bendel state the royal line of benin city which is their claims of ascendance from oduduwa in ife it is known as the spiritual cradle of yoruba centre of dispersion for the various yoruba social groups including the itshekiri language of the same state to abdulraheem the claims seems to be a dialectical of the school of yoruba nevertheless it has been considerably influenced by its immediate linguistic neighbours a number of yoruba speakers could also be found in sporadic locations along west african coast such as senegal ghana and a host of others however when reference is made to yoruba in this study it concerns those that still occupy their ancestral origin in south west nigeria english is the official language of the yoruba people alongside different dialects the people share so many things in common including road water market and electricity among others since the beginning of the 20th century the yorubas were followers of traditional religions but british colonial policies discouraged to a great extent at the time of independence in 1960 majority of the people were classified as muslims or christians at the beginning of the 21st century about half of the population were muslims slightly less than that were christians and only a small number claimed to follow traditional religions however many of those professing to be muslims and christians also openly performed certain rites or ritual of traditional religions that were no longer condemned especially during the colonial period while a supreme god is central to many of the traditional religions the deity is worshipped through a number of intermediaries or lesser gods religious freedom is guaranteed by the constitution and muslims and christians live and work together this does not negate the conflict that exists between them and adherents of traditional religions the yoruba society existence is defined and founded on divine terms its sociopolitical development is forged by religious and political leaders at the helm of affairs in the past hierarchy of power is traced from the supreme being to the divinities and the kings example of the traditional yoruba cultural practices is the dresses that shows the status of the yoruba kings the yoruba ways of greetings dressing ways of showing feelings to their loved ones and their togetherness is a symbolic and a very important aspect of yoruba culture before attainment of independence farming was the major occupation of the yoruba people this is identified in the song below iṣe ̣́ àgbe niṣe ̣́ ile ẹ wa farming is our national occupation ẹnikò ṣiṣe ̣́ á mà jalè whoever does not work will steal furthermore awolu and dopamu assert that the interactional politics in the precolonial background was predicted upon the primary goal to root a firm political and economic order as well to sustain and maintain moral and religious order in world view the southwestern nigerian society is full of myths and rituals there are revelations of how the yoruba leaders in the past seek help from the deities to protect their lands peaceful coexistence according to hamzat adeyẹmi and adebisi peaceful coexistence is a term that defines the relation that takes place between two parties or entities especially with regard to moderating and containing their idiosyncrasies from spinning out of control peaceful coexistence is an obligating term that restricts parties or entities from violating the agreed and defined space where the parties or entities live the term connotes the selfmoderation from arbitrarily interfering in the internal affairs of others parties or entities to which one has not been invited to take part in the term is an equating term in the sense that equality and mutual benefit characterizes relationships of parties or entities especially economic and political relationships it is the abhorrence to any threat to peaceful living while encouraging healthy competition among parties or entities that will help enhance general living condition to bovin peaceful coexistence is a type of relation between states with different social systems the underlying principles of peaceful coexistence include the renunciation of war and the adoption of negotiations as a means of resolving disputes between states equal rights mutual understanding and trust between states as well as consideration of each others interests noninterference in the internal affairs of another state and recognition of the rights of people to freely choose their own socioeconomic and political system he further stresses that peaceful coexistence presupposes a rigorous respect for the sovereignty and territorial integrity of all countries including the development of economic and cultural cooperation based on full equality and mutual benefit bovin asserts that a policy aimed at establishing and developing a good relation between states is identified as a policy of peaceful coexistence significance of the study this study will be of great significance in order to understanding the impact of ethnic violence on democratic consolidation in nigeria furthermore the study aims to motivates the policy makers to further emphasize the design of strategies of peace operations that will encourage diverse local actors as a way to better address their needs likewise those involved in conflicts resolution will learn that tolerance and respect for one another is the central pillar for generating peaceful coexistence similarly it will serve as a useful tool in all the states of the federation as a means of creating awareness about the importance of embodying the spirit of unity and solidarity in the society it will further assist the government in promoting sustainable and peaceful coexistence which requires coordinated and integrated multilateral responses this in turn will reduce the factors responsible for ethnic violence in the society obtaining large information from a large population it gathered more accurate sample and target results which were used to draw conclusions and make important decisions in the research article the research article is a mixed method of qualitative and quantitative method because it involves a questionnaire with indepth scalable answers this study employed a survey research design to investigate the use of language religion and culture in generating peaceful coexistence among the people of southwestern nigeria the research article includes the total number of residents drawn from the selected cities in southwestern nigeria through satisfied random sampling techniques using krejcie and morgan ikeja city in lagos state the information for the study were collected through administered questionnaire to ascertain the use of languagereligionculture in generating peacefulcoexistence among the people of southwestern nigeria they were given options through which they could state their minds tick the appropriate answer support or be against the stated items the questionnaire was clearly divided into yesno rarelyregularly state of mind and tick the appropriate option the questionnaire was structured into four parts with section a dealing with the demographic information of the respondents section b focused on questions dealing with nature of conflict in the southwestern part of nigeria section c focused on questions based on means of resolving conflict in the southwestern part of nigeria and section d concentrated on questions dealing with appraisal of the strategies employed in the process of conflict resolution in the southwestern part of nigeria 1 questionnaire section b nature of conflict in the southwestern nigeria 7 have you ever witnessed any conflict 8 what is the nature of the crisis you witnessed 9 what class of the society is commonly involved in the conflict resolution 10 which gender do you think is usually involved in conflict the gender distribution of the respondents shows that 539 percent are male while the remaining 461 percent are female age distribution of the participants shows that most of them are adult and 439 percent are youth also the distribution of respondents based on state of resident shows that 167 percent are selected table 3 shows that 917 percent of respondents asserted that they have witnessed crisis in south western nigeria while 83 percent objected to seeing crisis in south western nigeria also most of the participants hold the view that conflict rarely occur in south west nigeria while 384 percent of respondents believe that conflict is a regular occurrence 633 percent of the respondents affirmed that conflicts in the study area are political in nature 211 percent identified socioeconomic factors as causes of conflicts while the remaining 156 percent believed that conflicts in southwestern part of nigeria are caused by religion differences in addition the table shows that 833 percent of the respondents believed that the youth are more involved in conflict than the adults similarly most of the participants are of the opinion that males are involved in conflict while only 223 percent believed that the females are involved in conflict in southwestern part of nigeria 4 reveals that 557 percent of the respondents are of the view that religion is a major weapon in conflict resolution 67 percent are indifferent and 378 percent disagreed also 489 percent of the respondents are in strong support of the use of culture as a tool for conflict resolution n the other hand about 261 percent are not genuinely convinced while the remaining 25 percent believed that culture has no place in conflict resolution in south western part of nigeria similarly figure 1 shows that 722 percent of the respondents vouched for the use of language as a tool for conflict resolution whether in doubt or as a matter of inconsistence 156 percent of the respondents are neutral while 122 percent are against the use of language as a tool for conflict resolution figure 2 shows that 322 percent of the respondents are in support of sociomedia as a strong tool in conflict resolution also 316 percent of the respondents stated that public canvassing will play a vital role in entrenching conflict resolution and 262 percent of the participants are of the view that conflict resolution can be channeled through education conversely a collective festival as a means of resolving conflict is supported by 10 percent of the respondents furthermore table 5 shows that 4953 percent of the respondents agreed that the present political situation in the country can bring the expected peace and tranquility in the nearest future while the remaining 3616 percent of the participants are against the view that the present political situation can bring the expected peace in the nearest future however 1431 percent of the respondents are indifferent based on the findings of the research article recommendations are indicated by the researchers the effective use of language is important since it is a major source of interaction in a volatile economic and political situation subtle language and respect for others in communication plays a major role in calming anger down religion has three arms in nigeria but each of this arm has a major role to play when it comes to generating peace every religion organizer research methodology research questions for the purpose of this study the research questions that direct the focus of the research article are stated thus 1 what are the causes of conflict in southwest nigeria 2 which class of society is involved in conflict 3 what are the means of resolving conflict 4 how effective are the means of resolving conflict objectives of the study the specific objectives of the study are as follows i examines the cause or nature of conflict in the study area ii identify people who are mostly involved in conflict iii investigate different means of resolving conflict in southwestern region of nigeria iv examine the effectiveness of religion culture and language as means of conflict resolution the research article makes use of survey research design analysis survey research design refers to a particular type of research design where the primary method of data collection is by survey this method is considered fit for the research article because it provides a quick and efficient way of how can conflict resolution be entrenched in a multiethnic society 16 how has the world religions forestalled conflict in the society 17 the political view of many nigerians is selfseeking yesno 18 can the political situation of nigeria bring the expected peace in the nearest feature 19 can the use of language be a way of putting an end to conflict year and duration of survey the year and duration of survey covers the period september february 2023 some of the obstacles faced include fuel scarcity insecurity and fear of unknown time and period of the research also posed some limitations the police community heads and heads of ministries were contacted before carrying out the research work result and discussion the data collected were analysed based on the number of respondents covered by the research article

nigeria and the world at large has experienced series of conflicts which have led to killing of innocent citizens and wanton destruction of valuable properties despite all efforts made at proffering solutions to conflicts and violence nigeria is yet to achieve the intended resolution this paper focuses on investigating the use of language religion and culture in generating a peaceful coexistence among the people of southwestern nigeria in this research article it was uncovered that the intended peak of conflict resolution in nigeria is yet unattained the research article was based on social exclusion theory and adopted a survey research design a structured questionnaire was used to collect data from a total of 180 respondents data were analyzed with the use of descriptive statistics it is expected that the research article will help nigerians to resolve their internal conflict through the appropriate use of language culture and religion

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introduction more than 15 million adults are incarcerated in us prisons in 2008 the incarceration rate was 1 of every 196 residents surpassing any other industrialized nation most persons entering correctional facilities have histories of risky health behaviors and substance abuse tobacco smoking is a major prison health challenge rates of tobacco smoking among prison populations range from 70 to 80 up to four times the national average incarcerated persons also have higher rates of chronic illnesses that are exacerbated by smoking such as hypertension access to primary medical care and prevention services persons leaving prison face numerous reentry challenges including reestablishing relationships finding employment and housing and dealing with addictions and mental health issues concerns regarding disease prevention and health maintenance such as smoking cessation may be less likely to receive attention from these individuals smoking has been observed to be a normative part of the culture in prison and tobacco use was tolerated by correctional authorities over time however the overwhelming evidence of the adverse public health effects of tobacco on both smokers and those exposed to environmental smoke coupled with the risk of litigation by prisoners involuntarily exposed to tobacco smoke has prompted correctional authorities to implement tobacco smoking bans to minimize both health and legal risks according to a recent survey of 49 state correctional departments and the federal bureau of prisons 60 of prison systems report having total smoking bans as the majority of us correctional institutions implement smoking bans it is important to consider whether this mandated health behavior change can be maintained after release the majority of smoking relapses occur within 3 months of cessation after several years of successful behavior change the probability of maintenance increases prison sentences are usually at least 1 year in length those released after a smoking ban will potentially have a minimum of more than 3 months and likely 1 or more years of smoking cessation prior to return to the community where they may smoke postrelease they will be long past the period of peak withdrawal symptoms as well as past the period of greatest relapse risk there are few research reports on the effects of smoking bans in prisons in 2005 cropsey and kristeller noted that smokers who continued to smoke postban were more nicotine dependent and reported more withdrawal symptoms even when accounting for dependence and baseline withdrawal scores distressed smokers had the highest levels of withdrawal additionally an analysis of intent to smoke upon release from jail found a correlation between future intent to smoke and current desire to smoke but no relationship to length of incarceration or nicotine dependence although no studies to date have reported rates of return to smoking postrelease from prison a group of chronically ill smokers released from jail were found to have a relapse rate of 863 1month postrelease by lincoln et al prior research has identified a number of predictors of smoking relapse in the general population predictors previously identified include intention to quit negative affect alcohol consumption presence of other smokers in the immediate environment fewer coping skills decreased social support presence of medical conditions prior smoking behavior and demographic factors however during mandated or involuntary behavior change the typical antecedents of a chosen health behavior change may not have occurred factors predictive of relapse in other smokers may not apply to a prison population we therefore examined whether prerelease and postrelease measures of these factors would apply to this unique situation the wisconsin department of corrections implemented a ban on tobacco smoking in state prisons effective 1 september 2006 given the lack of research into maintenance of involuntary health behavior change and the potential public health impact of assisting prisoners in maintaining smoking abstinence postrelease the wisconsin doc smoking ban policy presented a unique opportunity to investigate possible determinants of smoking behavior after release from prison methods participants and recruitment participants included 49 male prisoners from a minimum security wisconsin state prison participants were within 1 month of their release and willing to participate in two confidential interviews ≤1month prerelease and 1month postrelease the prerelease interview was performed facetoface in prison and the postrelease community assessment was performed by telephone survey participants were incarcerated adult men who selfreported daily tobacco smoking prior to this incarceration or prior to the prison smoking ban exclusion criteria included offsite work release employment inability to communicate in english severe cognitive impairment or dementia that precluded informed consent or physical placement in segregation prior to release making it impossible to meet with study staff in a confidential setting the study was approved by the human subjects committee of the university of wisconsin school of medicine and public health a federal certificate of confidentiality was obtained prior to enrolling participants all participants provided written informed consent and received a small stipend for their participation procedure prison social services staff sent flyers advertising the study to men who were within 1 month of release from prison those who indicated interest were scheduled to meet facetoface with the study interviewer in a secure and confidential room within the social services center at the prison at this meeting the study was explained and if the person was eligible and wished to participate informed consent was obtained the first 51 respondents consented and were interviewed two were excluded from the analysis one admitted during the interview that he had actually not been a regular smoker and the other because he limited his tobacco use to chewing tobacco and did not regularly smoke cigarettes next a qualitative interview was conducted and a quantitative survey completed postrelease contact information was obtained all participants were offered a referral to a tobacco quitline and provided a tollfree telephone number to contact study staff in order to provide updated contact information or to obtain the tobacco quitline number after release a telephone survey was also scheduled during this meeting to occur about 1month postrelease approximately 1month postrelease the study interviewer attempted to contact the participant by telephone at the appointed time and day during this call a quantitative survey was completed and a referral to a tobacco quitline was again offered measures we assessed demographics health behaviors emotional state and behavioral skills prerelease demographics included age ethnic background education relationship status number of children and incarceration length participants were asked whether they had taken prescription medications for a health problem while in prison and whether they had received services for a substance use or emotional problem and substance use history and lifetime smoking history were obtained participants were asked about intent to smoke postrelease and rated importance and confidence around intent to remain smoke free after release based on community predictors of smoking relapse the following survey instruments were administered to participants both prerelease and postrelease by a trained research nurse positive and negative affect scale social attachment subscale of the social provisions scale patient health questionnaire 8 problem solving scale fagerström test of nicotine dependence alcohol use disorders identification test and substance use by drug abuse screening test unless otherwise specified below time periods elicited were for the month prior to this incarceration or in the time since release the panas is an assessment of mood or current emotional state it consists of two 10item scales the participant is asked to respond on a 5point scale to feelings words indicating how much he has felt this way the spssas is used to assess perceived adequacy and satisfaction with emotional support participants rate perceived support on 4point scales with anchors from strongly disagree to strongly agree after reverse scoring two items scores are summed such that higher scores reflect greater levels of support this fouritem measure of emotional support has been found to have adequate internal consistency the phq8 is an eightitem measure of depression similar to the phq9 in terms of diagnosing depressive disorders but with scores 10 indicative of severe depression phq8 consists of eight questions covering symptoms for diagnosing depression participants are asked to tell how many days in the past 2 weeks they have been bothered by each symptom from not at all to nearly every day scores can range from 0 to 24 the pss contains five questions related to use of problemsolving strategies in daily life it is based on psss a subscale of the social problemsolving inventory responses are on a 5point scale from 1 to 5 ftnd contains six questions scored for between 0 and 10 points to indicate level of addiction to nicotine scores of 03 indicate low addiction 46 medium and 710 high for this scale prerelease we asked respondents to apply the time period of in the month prior to this incarceration auditc is a threeitem alcohol consumption measure each item is scored from 0 to 4 points with total scores ranging from 0 to 12 prerelease we asked respondents to apply the time period of in the month prior to this incarceration dast10 has a yesno format of answers to 10 questions related to use of drugs excluding alcohol prerelease we asked respondents to apply the time period of in the month prior to this incarceration postrelease information included whether the participant had served time in prison or jail since his original release current living situation including the type of residence he currently occupied number of other adults and children sharing this residence and whether there were smokers sharing this living space employment status was assessed if the participant was employed he was asked the percentage of coworkers who smoked and whether smoking was permitted onsite other sources of income including disability service utilization use of prescription medications and perceived health status were recorded quit attempts and smoking history since release were obtained along with intent to quit in the next 60 days or 6 months importance and confidence ratings were elicited for quitting smoking or staying quit participants were asked whether they supported the prison smoking ban and what they thought would be helpful to people who wished to stay quit on release finally they were asked whether a telephonedelivered smoking intervention to help maintain abstinence on release would be helpful to them andor to others data analysis bivariate analyses were performed to compare preand postrelease variables using chisquare tests for binarycategorical variables and t tests to compare means data were analyzed using sasstat version 80 odds ratios and 95 confidence intervals were used to study the unadjusted association among demographic emotional and behavioral factors and postrelease smoking behavior stepwise multivariate logistic regression analysis was conducted to determine independent factors associated with postrelease smoking behavior results prerelease fortynine men were included in the final analysis they ranged in age from 19 to 60 years they had 819 years of education length of sentence was 9 months to 19 years the raceethnicity of the sample was diverse and representative of the prisons inmate population the number of children per participant ranged from 0 to 9 the most commonly reported relationship status was single current health status service utilization during this incarceration and substance use history in the month prior to this incarceration were obtained twentyeight participants had received services for alcohol drug or emotional problems during this incarceration twenty were taking a prescription medication for a health problem participants initiated smoking between ages 8 and 32 years and had smoked 240 years most had previously attempted to quit smoking at least one to five times but significant variability in previous quit attempts was observed the length of smoking quit for each participant reporting a quit ranged from 0 to 252 months fourteen accepted the tollfree number for the wisconsin tobacco quitline ftnd mean score for smoking behavior in the month prior to this incarceration was 431 ten participants reported smoking since the ban asked whether they intended to smoke upon release 11 answered yes 33 answered no and 5 were unsure thirtythree considered their health status to be improved since the smoking ban dast10 scores for drug use in the month prior to this incarceration ranged from 0 to 10 and auditc from 0 to 12 current emotional state was assessed using spssas social support scale panas consisting of a positive affect scale and a negative affect scale phq8 depression scale and pss postrelease fortyfour participants completed 1month postrelease surveys by telephone of the five who did not complete surveys two were lost to followup and three were reincarcerated within the first month surveys were completed 1470 days after release two who completed surveys had spent 1 or more days in jail since their original release most were living in someone elses home or apartment others were in temporary living placements their own homes or apartments and one participant was in an inpatient drug treatment facility more than half were not working but were looking for employment five were not working and not seeking work eight were working parttime and nine were working full time few received other income outside work such as social security disability insurance or child support twentyeight participants considered their health status improved since release 10 rated it unchanged and 6 reported it to be worse sixteen had received services for alcohol drug or emotional health problems in the community twelve were taking a prescription medication for a health problem one reported substance use excluding alcohol during this postrelease time period the mean alcohol use score was less than 2 of 12 on the auditc with 21 reporting alcohol use since release twentyseven participants reported abstinence from cigarettes 1month postrelease of those smoking ftnd mean score was 34 on average each participant was living with two smoking adults 53 reported they were not allowed to smoke indoors fortytwo percent of employed participants were allowed to smoke at work either indoors or outdoors 55 of coworkers smoked seventeen postrelease participants supported the prison smoking ban forty participants thought a program to help people remain quit on release from prison would be helpful and 37 thought it would be helpful to them personally asked whether they would seriously consider quitting smoking or staying quit within the next 60 days 34 said yes when the same question was asked with a 6month time frame 38 said yes eight participants accepted a quitline referral postrelease comparisons participants who completed postrelease emotional state measures had mean scores of 1257 on spssas 3805 on panas positive affect 2073 on panas negative affect 439 on phq8 and 2014 on pss paired t tests to compare preand postrelease mean scores revealed significant decreases in panas negative affect and phq8 depression scores postrelease ftnd scores were lower for a comparison of the 17 postrelease smokers similarly at 1month postrelease the number of respondents reporting alcohol and other substance use was small predictors univariate logistic analysis identified associations among demographic factors behavioral variables standardized survey measures and postrelease smoking raceethnicity was the only significant demographic variable white race correlated with smoking relapse a trend was seen toward use of alcohol correlating with smoking on release but this was not significant participants who reported better prerelease health since the prison smoking ban were less likely to report smoking postrelease finally prerelease intention to smoke was strongly correlated with postrelease smoking none of the prerelease emotional state measures behavioral skills measures nor prerelease ftnd correlated with postrelease smoking discussion this is the first study to assess smoking relapse in men who experienced a statewide prison smoking ban in this study postrelease intentions to smoke were highly predictive of reported postrelease behavior for the 33 participants who either desired to remain smoke free after release or who were uncertain 82 reported abstinence the first month outside a smokefree prison environment participants were comparable to the population of men reentering the community after release from wisconsin state prisons most were nonwhite less than 40 years old and had been incarcerated less than 3 years they reported an average of 124 years of education this may be attributed to wisconsins strong promotion of high school equivalence degree programs for incarcerated individuals most were single and reported a mean of 22 children relatively low rates of substance use were reported in our sample postrelease however much of the relapse literature focuses on jail populations where lengths of stay are significantly shorter and there is less treatment during incarceration compared with prison treatment was received by 43 of our participants during incarceration pelissier et al found that differing levels of supervision as well as whether a person completed substance use treatment during incarceration significantly affected time to relapse on release in their study 29 had evidence of substance use 6months postrelease on average smoking was initiated at age 15 similar to that reported elsewhere and participants had been smoking almost 15 years before the prison smoking ban most had attempted at lease one quit and almost 80 reported wanting to quit or stay quit within the next 60 days after release almost 65 believed their health had improved since the smoking ban the high level of reported nonsmoking in this study is especially significant considering the barriers to continued smoking abstinence postrelease participants reported an unstable financial and housing environment on reentry most were unemployed and more than 80 were either living in temporary housing or in someone elses home or apartment most lived or worked with other smokers more than 10 were either reincarcerated or spent at least 1 day in jail within the first month financial and emotional stressors as well as a return to an environment where old smoking cues are once again encountered have been shown to be strong predictors of late relapse in other populations in a recent study of relapse to smoking postrelease lincoln et al found much lower rates of nonsmoking at 1 month however lincoln et al studied chronically ill smokers with high rates of hepatitis c who were released from jail where average incarceration lasted 2 months our study followed a general prison cohort where the average length of incarceration exceeded 2 years these differences highlight the need for further study in this study smoking intent prerelease was a powerful predictor of postrelease smoking in a study of smoking intent in a jail population voglewede and noel also found that future intent to smoke predicted current need to smoke depression did not predict smoking on release consistent with findings that depression history predicted smoking 1 month but not 6 months postquit in addition ftnd scores in the months preceding incarceration did not predict smoking on release this may be attributable to the length of incarceration and time lapse since symptoms of physical nicotine dependence it may also be due to faulty recall of smoking behavior in the community the number of respondents reporting postrelease alcohol and other substance use was too small to allow valid analysis a belief in improved health status after the prison smoking ban was significantly correlated with nonsmoking status on release since incarceration is a time when people frequently express interest in making positive health behavior changes this perception of improved health is logical and an important potential point of intervention in future programming for this population although this study capitalized on a unique public health event it does have several possible other limitations there was a high level of reported nonsmoking at 1 month this may be due to selection bias as the sample was men responding to a flyer soliciting participation in a study of the prison smoking ban this may have been more appealing to those intent on not resuming smoking postrelease a quit may have been classified differently while some believed abstinence that was chosen was a quit others considered abstinence related to incarceration to be included the short time period before followup small sample size and social desirability may account for the observed outcome additionally biochemical confirmation of selfreported abstinence was not undertaken however there were few perceived incentives for participants to lie about their smoking behavior and 20 admitted to smoking in prison after the smoking ban prisons have the potential to make important contributions to public health by providing prevention services to this hardtoreach highrisk population the period before release presents an important opportunity to reach and motivate these individuals to maintain smoking abstinence on return to the community although there is evidence that transitional interventions can reduce substance use or sexual risk behaviors among men leaving correctional settings the effect of prison reentry interventions on mens smoking behavior has not been the subject of published reports participants in this study reported acceptance for the idea of a smoking relapse prevention program around the time of release the lack of other available programming to maintain andor enhance health for those being released makes such a service offering particularly important the observed relationship between improved health status and nonsmoking postrelease may provide a useful motivational element for such programs if the decreases in negative affect upon release observed in the present study are robust they could serve as additional motivators particularly for persons who use smoking to manage emotions research suggests that determinants of early and late smoking relapse may differ and we have not yet identified treatments specifically to address late relapse risk observing a population of formerly incarcerated persons for a longer followup interval would provide an ideal opportunity to identify correlates of late relapse and test interventions to assist in maintaining abstinence after release the high rates of retention and acceptance for relapseprevention programs found in this study show that this strategy can be feasible declaration of interests

prerelease smoking intention predicted postrelease behavior belief in improved health after the prison smoking ban correlated with nonsmoking on release targeted relapse prevention interventions are needed for people reentering the community 24 among incarcerated vs 18 in community diabetes 70 vs 48 and asthma 85 vs 78 national commission on correctional health care 2006

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low neighborhood ses is associated with childrens developmental risk since the advent of socioecological theory developmental psychologists have increasingly recognized that children are influenced by intersecting circles of individual and environmental prosocial behavior adversity academics 3 factors including features of the neighborhood in which they are raised there is significant variability in neighborhood ses and this variability shapes the lived experiences of the neighborhoods child residents specifically children raised in low ses neighborhoods often face many challengesincluding social physical and psychological stress exposure to crime lower quality childcare and schools and limited access to other educational services and resources in turn these neighborhoodlevel risks are associated with increased behavioral and emotional difficulties and lower academic performance and attainment both concurrently and over time for example exposure to community violence is often more frequent in low ses neighborhoods and can interfere with childrens cognitive functioning and academic performance similarly exposure to air water and noise pollution underresourced schools and fewer educational enrichment opportunities are more common in low ses neighborhoods and detract from childrens ability to demonstrate their full academic potential importantly the effects of neighborhood ses are not uniform across children some children who grow up in disadvantaged neighborhoods appear to be more atrisk than others and there is significant heterogeneity in childrens adaptation and outcomes consequently developmental science has sought to understand how where and for whom neighborhood characteristics matter the most in particular identifying factors that represent resilience or can protect children against academic risk in contexts of adversity has emerged as a top research priority such research prosocial behavior adversity academics 4 can enable policymakers to reduce achievement gaps along socioeconomic lines when children are young thereby diminishing inequalities that could otherwise persist across the lifespan and even across generations socioemotional competencies as protective factors in contexts of adversity to protect against the risks associated with early adversity researchers have highlighted the importance of positive socialemotional skills which enable children to recognize and regulate their emotions and behavior set and achieve positive goals and form and maintain positive reciprocal relationships for example randomized trials broadly designed to promote socioemotional skills across domains decreased disruptive behavior and stress more among children from lower family ses compared to those from higher family ses this work suggests that socioemotional skillsbroadly and encompassing multiple domainsare particularly protective among disadvantaged youth research on the protective role of socioemotional skills has been limited in two key ways first research has primarily measured adversity at the family levelusing measures of family income and maternal educationwhich obscures the importance of neighborhoodlevel adversity to extend this work it is important to understand whether socioemotional skills protect against academic risks associated with low neighborhood sesie the larger socioecological contextbecause as they age children spend increasing time outside the home and family engaging with peers and resources in their neighborhood prosocial behavior adversity academics 5 a second limitation of prior research is that it has primarily focused on broad measures of socioemotional skills which encompass multiple domains of childrens ability to regulate emotions and behaviors communicate pursue goals and build relationships with others while this approach provides a rich picture of childrens overall functioning it obscures the possibility of pinpointing which specific behaviors are most relevant identifying specific child behaviors that protect against neighborhoodlevel risk may inform the design of more targeted behavioral interventions to promote childrens positive adaptation and reduce inequalities for example a classroombased intervention that focused specifically on encouraging elementary students to help each other reduced disruptive behaviors and increased positive peer relationships moreover this approach may highlight avenues for promoting positive protective behaviors outside ofor in addition toformal interventions for example if we know which specific child behaviors protect against neighborhoodlevel risk communities can begin to scaffold opportunities for children to practice those behaviors in daily life prosocial behavior may mitigate effects of neighborhood adversity one specific subset of socioemotional skills that has garnered a great deal of interest across childhood is prosocial behavior prosocial behavior is positively correlated with a range of other positive socioemotional skills but represents more specifically the propensity to provide instrumental assistance and emotional support to others childrens capacity to engage prosocially with peers is believed to foster positive behavioral and academic growth for example elementary and middle school prosocial behavior adversity academics 6 children who displayed high levels of prosocial behaviorsuch as sharing and cooperatingachieved higher academic grades when measured at the same time point later in the same year and 5 to 7 years later similarly one study in australia suggested that kindergartners who displayed high levels of prosocial behavior demonstrated higher performance on literacy and numeracy tests in kindergarten and in third grade it is important to replicate and extend this finding to other settings to understand how prosocial behavior relates to academic achievement when children are young and entering formal education for the first time thus establishing patterns of behavior that shape their educational trajectory in addition to directly relating to positive child outcomes prosocial behaviors may mitigate the negative effects of environmental adversity it has been hypothesized that when children help others they foster positive relationships and emotions that can buffer them from the negative effects of contextual stressors and resource limitations such as those encountered in low ses neighborhoods for example children ages 3to7 from poorer neighborhoods and schools who also demonstrated more prosocial behaviorsas reported by parentsdeveloped fewer emotional and behavioral problems compared to their less prosocial peers however we do not yet know whether prosocial behavior similarly mitigates neighborhoodlevel academic risks it is particularly important to investigate whether prosocial behavior is a protective factor during early childhood when children have increasing opportunities to both engage with peers and demonstrate academic competence independently in the school setting prosocial behavior adversity academics 7 current study the present study had two primary goals first we aimed to replicate and extend previous work by investigating whether prosocial behavior predicts academic achievement at multiple time points early childhood consistent with existing evidence from middle childhood we hypothesized that prosocial behavior would be positively associated with academic achievement across early childhood second we investigated whether prosocial behavior serves as a protective factor against academic risks associated with neighborhood adversity we hypothesized that prosocial behavior would protect against academic risks among young children from low ses neighborhoods such that neighborhood ses would be positively related to academic achievement only among children who demonstrate relatively fewer prosocial behaviors in secondary exploratory analysis we tested whether these associations differed by individual differences in childrens gender and ethnicity we did not have a hypothesis for the direction of the gender and ethnicity moderations past research is equivocal some evidence suggests that gender and ethnicity moderate associations between prosocial behavior and child experiences while other evidence suggests that prosocial behavior operates similarly across groups of children to test these hypotheses and conduct exploratory analyses we drew on a large and diverse sample of children living in bradford uk we employed a governmental index of neighborhood ses a standardized teacherled assessment of childrens prosocial behaviors and standardized teacherobservations and direct assessments of three academic outcomes measured across three different time points from ages 4 to 7 this robust multimethod approach minimized potential method bias further our longitudinal design enabled us to examine prosocial behavior adversity academics 8 outcomes across early childhood to increase robustness of our findings we conducted additional sensitivity analyses controlling for measures of general peer relationship quality and emotional and behavioral skills in this way we aim to shed light on whether prosocial behavior can mitigate the early academic risks of growing up in low ses neighborhoods methods sample our analytic sample was drawn from born in bradford a longitudinal multiethnic birth cohort study conducted in bradford a city in northern england the city of bradford has high levels of socioeconomic deprivation and ethnic diversity compared to other cities in england specifically bradford has the 5 th lowest income and 6 th lowest employment rate in england bradford also has the largest proportion of families of pakistani ethnic origin in england the bib cohort is broadly characteristic of the citys population the bib study was designed to assess child and adult health women were recruited in community clinics during pregnancy the full study recruited 12453 women and 3353 of their partners across 13776 pregnancies and 13858 children from 2007 to 2010 when children were ages 4 to 5 years mothers provided their home address and this was linked to government indices of neighborhood adversity at the same time point a subset of children participated in the starting school project which was nested within the larger bib study and designed to collect additional educational data for a subset of the bib children the starting school project enrolled 4to 5yearold children in schools where there were ≥ 10 children from the bib cohort in their class prosocial behavior adversity academics 9 that academic year schools that met this criterion collaborated all bib children in these schools were eligible to participate and parents were sent an optout waiver of consent more detailed information on the starting school project is available elsewhere as a part of the starting school project teachers completed a standardized assessment of their observation of childrens prosocial behaviors for children in their classrooms school administrative educational records yielded three academic outcomes the first was a structured teacherobservational assessment of childrens early learning goals at age 4 to 5 years the second two were standardized direct assessments of phonics skills at age 5 to 6 and academic performance at age 6 to 7 the starting school educational data was collected in classrooms and so has a structure of children nested within classrooms the full bib cohort was roughly 50 south asian and 50 white or other ethnicities our analytic sample was restricted to children for whom both of our independent variables were available and was 50 female 35 white 51 south asian and 9 other ethnicities compared to the full bib cohort participants in our analytic sample on average had lower levels of early learning goals 587 p 001 and family ses 2968 p 001 but did not differ across other study variables consistent with the bradford area neighborhoods in our sample were relatively segregated ranging from 66 south asian and 26 white in the poorest neighborhoods to 11 south asian and 89 white in the second to wealthiest neighborhood see supplementary prosocial behavior adversity academics 10 materials table s1 for more detailed information on diversity within and across neighborhoods in our sample classroom diversity in our sample varied widely ranging from 0 south asian participants to 100 south asian participants measures neighborhood ses mothers provided their addresses via questionnaire when children were 4 to 5 years old to index neighborhood ses these addresses were linked to a neighborhoodlevel socioeconomic index of multiple deprivation this is an official government measure of neighborhood affluence in england based on income employment health and disability education barriers to housing and services crime and living environment we used the rankings within bradford in order to capture the full variation among bradford neighborhoods specifically there were 310 small neighborhoods in bradford each with a population of 1500 these 310 neighborhoods were then rankordered by their deprivation scoreaccording to the government calculationsand summarized into deciles in other words the 31 neighborhoods with the lowest deprivation rankings were categorized into the 1 st decile which represents the 10 of neighborhoods in bradford with the highest ses compared to other locations in the city the next 31 neighborhoods in these rankings were categorized into the 2 nd decile and so on for the governmental index ten indicates relatively more deprived neighborhoods however we reverse coded this so that higher levels of our measure neighborhood ses reflect greater wealth and less adversity and lower levels indicate greater poverty and more adversity prosocial behavior adversity academics 11 prosocial behavior to index childrens prosocial behavior we used the strengths and difficulties questionnaire a brief behavioral screening questionnaire that assesses psychological attributes including prosocial behavior peer relationships emotional symptoms conduct problems and hyperactivity the childs class teacher completed this measure when the child was age 4 to 5 years we focused on the prosocial subscale of the sdq which includes five items this child is considerate of other peoples feelings this child is helpful if someone is hurt this child is kind to younger children this child often volunteers to help others and this child shares readily with other children the teacher responded to each item as 0 not true 1 somewhat true or 2 certainly true the prosocial composite was the sum of these five items ranging from 0 10 cronbachs a 85 icc by teacher 13 academic outcomes we captured childrens outcomes with three measures which we conceptualized as developmentally appropriate measures of academic functioning at three different time points this approach enabled us to examine how associations changed across early childhood to index early learning goals we used childrens scores on the early years foundation stage profile a teacherled observational assessment that includes six broad areas of learning and assesses progress relative to the average child at the end of their first year of schooling at age 4 to 5 teacher icc 10 to index childrens phonics skills we used a teacherled assessment of childrens phonics abilities phonics is the ability to correlate sounds with letters or groups of letters in an alphabetic writing system and has been shown to be an important component of childrens later reading ability this measure assesses childrens phonics abilities relative to the average child at the end of their second year of schooling at age 5 to 6 specifically teachers showed each child a paper with lists of 40 different imaginary words that represented imaginary creatures children were asked to sound out or read the words that they saw on the page they were allowed as long as necessary to sound out each word once children had responded teachers marked each item as correct or incorrect phonics scores were the sum of all items ranging from 0 40 teacher icc 04 to index childrens academic performance we used childrens scores on the key stage 1 a standardized schoolbased direct assessmentexam that includes math reading and science subscales measured at age 6 to 7 early achievement at age seven has been shown to have enduring effects on individuals downstream educational attainment socioeconomic status and wellbeing for all three academic outcomes we standardized each subscale and calculated a mean with higher scores indicating relatively higher performance teacher icc 01 covariates we controlled for child gender ethnicity and a composite measure of family ses as assessed by maternal reports during pregnancy of maternal education cohabitation status employment governmental benefits and perceived financial difficulty as described further in armstrongcarter et al all measures were coded at the individual participant level statistical analysis missing data was low with 017 of children missing data for early learning goals 380 for phonics skills and 397 for academic performance there was no missing data for other study variables we standardized all continuous variables we used multiple regression models to examine whether childrens prosocial behavior and neighborhood ses were directly and interactively associated with academic achievement outcomes after controlling for child gender ethnicity and family ses given that each of the 180 teachers reported on an average of 66 students and the educational data was collected in classrooms and therefor was nested we included teacher fixedeffects to account for this clustering of students nested within teachers model 1 examined how neighborhood ses and prosocial behavior were directly and uniquely associated with academic achievement outcomes model 2 additionally examined how an interaction between neighborhood ses and prosocial behavior was associated with academic achievement outcomes specifically we created an interaction term by multiplying standardized values of neighborhood ses and prosocial behavior together significant interactions were further probed using the simple slopes technique by testing the associations between neighborhood ses and academic achievement outcomes for children with high and low levels of prosocial behavior analyses were conducted in stata version 131 secondary models described below tested for robustness and probed exploratory hypotheses using additional variables ethical approvals data sharing the research project used only existing deidentified data and the sponsoring institutions irb board determined that this project did not meet the definition of human subject research the blinded ethics committee provided ethical approval for the born in bradford study with parents providing written consent for themselves and on behalf of their children prosocial behavior adversity academics 14 before data collection researchers retrieved the sensitive educational records through a managedaccess process approved by the bib executive board results table 1 displays descriptive statistics for key study variables for the full sample and separately by gender and ethnicity table 2 displays bivariate correlations among all study variables on average children from higher ses neighborhoods showed higher levels of early learning goals phonics skills and academic performance similarly children who demonstrated more prosocial behavior had higher levels of early learning goals phonics skills and academic performance children from higher ses neighborhoods were more likely to be white compared to south asian and boys compared to girls prosocial behavior was more common among girls which is consistent with prior work prosocial behavior was not associated with ethnicity or neighborhood ses please insert tables 1 2 approximately here table 3 displays please insert table 3 approximately here model 2 demonstrated that the interaction between neighborhood ses and prosocial behavior was marginally associated with early learning goals and significantly associated with phonics skills and academic performance figures 12 and 3 display a consistent pattern of interactions neighborhood ses was positively associated with academic achievement for children with lower levels of prosocial behavior in contrast neighborhood ses was not associated with academic achievement for children with higher levels of prosocial behavior please insert figures 1 2 3 approximately here sensitivity exploratory analyses in secondary models we tested the robustness of our findings full results are displayed in supplementary materials and summarized briefly here first we controlled for childrens peer relationships emotional challenges and behavioral conduct challenges as assessed by the corresponding subscales of the sdq the interaction between neighborhood ses and prosocial behavior was marginal for early learning goals but remained a significant predictor of phonics skills and academic performance to probe consistency of our findings across child demographics we also tested whether the observed significant interactive effects varied by childrens gender and ethnicity to do this we first tested whether threeway interactions between neighborhood ses prosocial behavior and each demographic variable were associated with each academic achievement outcome these prosocial behavior adversity academics 16 threeway interactions were not significant suggesting that our observed pattern of results was consistent across gender and ethnicity discussion children born into neighborhood adversity are at risk for lower academic achievement during early schooling and across the lifespan conversely neighborhood advantage causally and positively impacts longterm educational outcomes identifying factors that protect children against academic risk has long been a top priority because such research can enable policymakers to reduce achievement gaps along socioeconomic lines when children are young in response we sought to understand if young childrens prosocial behavior serves as a protective factor against academic risk in contexts of neighborhood disadvantage in a large diverse longitudinal sample of children followed from before birth until age seven we investigated whether associations between neighborhood ses and academic achievement varied by the level of childrens prosocial behaviors our research approach employed a governmental index of neighborhood adversity standardized teacher assessments of prosocial behaviors and early learning goals and direct assessment of phonics skills and academic performance we found a consistent pattern of results across all measured outcomes that were relatively robust across alternative specifications considered in sensitivity analyses low neighborhood ses was associated with concurrent and subsequent academic risk only among children who displayed low levels of prosocial behavior but not among children who displayed high levels of prosocial behavior prosocial behavior adversity academics 17 these results suggest that prosocial behavior may be a protective factor for the academic achievement of children faced with limited contextual resources and educational opportunities prosocial behavior positively predicts academic performance across early childhood our first set of models demonstrated that neighborhood ses was positively associated with teacher observations and direct assessments of academic performance across early childhood consistent with prior work moreover childrens prosocial behavior was positively associated with childrens early learning goals phonics skills and academic test performance over and above neighborhood and family ses prosocial behavior has already been positively linked to academic achievement during middle childhood replicating one prior study among australian kindergartners we extend this research to early childhood when children are entering formal education for the first time however these direct associations were qualified by significant interactions our main set of findings prosocial behavior buffers academic risk in neighborhood adversity our second model revealed that neighborhood ses predicted greater academic achievement only among children who displayed low levels of prosocial behavior specifically children who helped their peers relatively less displayed lower levels of academic achievement if they came from poorer neighborhoods but higher levels of academic achievement if they came from relatively wealthier neighborhoods in contrast children who tended to help their peers more did not differ in levels of academic achievement across the spectrum of neighborhood ses these results suggest that among diverse children living in prosocial behavior adversity academics 18 neighborhoods with low ses prosocial behavior may be a key protective factor or promote resilience for achieving early academic success several possible mechanisms may underlie this pattern of results one possibility is that when helping others children gain opportunities for cognitive stimulation via practicing perspectivetaking communicating selfregulation or other forms of ontask engagement which in turn protect against the adverse effects of contextual risk on academic achievement as such prosocial behaviors may facilitate access to opportunities for learning beyond the resources available in their immediate neighborhood environment a second possible explanation is that when young children help others they foster positive relationships and emotions that can buffer them from contextual stress specifically children who often help their peers may have other supports in the home or at schoolnot captured by neighborhood sesthat in turn promote social and emotional wellbeing and enable them to effectively cope with neighborhood stressors these supports likely come from teachers or parents rather than peers because sensitivity analysis controlling for general peerrelationship quality did not change our observed pattern of results for example responsive family relationships opportunities for social and cognitive stimulation and positive interactions with siblings all promote prosocial behavior similarly children who help others more may be more engaged in the classroom setting andor experience positive relationships with teachers who in turn help them to achieve academic success and resilience despite neighborhood disadvantage in addition children who are perceived as more helpful are liked more by their teachers and may receive greater attention and investments in their education compared to their peers who tend to help less prosocial behavior adversity academics 19 for example prior research has shown that 10yearold children from low ses neighborhoods scored lower on standardized academic tests compared to children from high ses neighborhoods but only if they did not experience supportive relationships with peers and teachers we found that prosocial behavior was protective across demographic groupsfor boys and girls and for white and south asian youth although we did not have a strong hypothesis for this exploratory analysisas prior research on demographic differences in childrens prosocial behavior has been mixed these results could be considered surprising historically and currently south asians are a discriminated ethnic minority in the uk this is also reflected in our finding that south asian families were more likely to live in lower ses neighborhoods compared to white families thus one might expect that prosocial behavior would be an even more potent protective factor for an ethnically discriminated group compared to an ethnically nondiscriminated group for example one of the proposed potential mechanisms is the advantage of a positive studentteacher relationshipwhich may be more common among children who are perceived as more prosocialand could be more protective for children who face discrimination although prosocial behavior appears to be similarly protective across gender and ethnicity in our study future research should continue to investigate how protective factors in neighborhood adversity vary across groups of children implications our results should not be interpreted as a pull yourself up by the bootstraps view of resilience to achieve academic success in the face of adversity it should not be only the childs responsibility to simply change their behaviors in contrast schools and neighborhoods should structure childrens opportunities for helping others and developing prosocial behavior adversity academics 20 prosocial competencies and habits as such policy makers educators and family caregivers are crucial for nurturing resilience in children teachers and other adults should model teach and foster the development of students helping behaviors in formal and informal learning environments consistent with this adaptive systems perspective of resilience and a body of research demonstrating the effectiveness of socioemotional learning programs our results highlight prosocial behaviors as one specific factor that may promote childrens positive academic functioning and resilience in contexts of environmental risk classroombased social and emotional learning programs have been shown to improve childrens academic achievement in low ses contexts such programs for example those run by the collaborative for academic social and emotional learning a nonprofit also reduce behavior problems and promote positive socialemotional outcomes using and socioemotional framework our results extend this work by suggesting that opportunities specifically for children to help each otherperhaps in community settings beyond structured socioemotional learning curriculummay be beneficial in particular children in lowincome communities may benefit from more opportunities to practice contributing to the lives of other people around them for example by helping peers or teachers in the classroom participating in group projects or sociallyminded activities or helping family or adults with daily tasks moreover since prosocial behavior buffered the effects of social and economic disadvantage measured across neighborhoods interventions targeting children on the neighborhood level that encourage childrens helping prosocial behavior adversity academics 21 behaviors may be beneficial finally in line with the socioemotional literature increasing childrens opportunities to help others may help to promote academic adjustment as young as age 4 limitations future directions we acknowledge limitations and highlight future directions for study we were unable to measure childrens relationships with parents and teachers specific experiences when helping peers and other variables that may have partially buffered risk and confounded observed associations we attempted to address this by controlling for child gender ethnicity and family ses as well as general measures of behavioral and emotional functioning and peer relationship quality in sensitivity analyses but we were unable to fully capture childrens experiences and relationships across settings as such the precise mechanisms remain unclear from our study in addition although we used three different developmentally appropriate academic measures across early childhood which were highly correlated and supported by a latent factor analysis it is possible that these measures partially reflect distinct academic domains future research should further explore whether prosocial behavior and neighborhood ses relate differently to different domains of academic functioning future research should also investigate the interplay between prosocial behavior neighborhood ses and young childrens specific cognitive skills that promote academic success although sensitivity analyses were aimed to reduce confounds the findings are observational in nature and do not indicate causal pathways future research could address this by evaluating targeted interventions designed to increase childrens helping behaviors future research could also randomly assign children to help their peers and examine the causal prosocial behavior adversity academics 22 impact on academic performance and attainment finally sociocultural elements that are unique to bradford may limit the generalizability of the findings to other settingsin particular the high levels of poverty overall across the city compared to other cities in the uk our study was also based on a subsample of participants from the full bib study although our analytical sample was similar to the full bib cohort across most study variables it may differ by other unobserved variables the current study examined childrens propensity to help their peers as a specific aspect of behavior that might promote academic resilience in contexts of neighborhood adversity a handful of prior studies have shown that prosocial behavior is positively associated with academic achievement during middle childhood and can be protective against early psychopathology but these have not shed light on the how prosocial behavior and neighborhood contexts interactively relate to academic achievement during early childhood we extend prior work by demonstrating that prosocial behavior promotes academic resilience across ages 4 to 7 among children living in disadvantaged neighborhoods in bradford uk a city with high levels of adversity our results suggest that children growing up in neighborhood disadvantage do not exhibit lower levels of academic performance if they tend to help their peers and others relatively more often this work highlights the complex interplay between local microcosms and individual differences in young childrens social behaviors for foundational educational progress

children raised in neighborhoods with low socioeconomic status ses are at risk for low academic achievement identifying factors that help children from disadvantaged neighborhoods thrive is critical for reducing inequalities we investigated whether childrens prosocial behavior buffers concurrent and subsequent academic risk in disadvantaged neighborhoods in bradford uk diverse children n 1175 were followed until age seven with measurements taken at four times we used governmental indices of neighborhoodlevel ses teacher observations of prosocial behaviors and direct assessments of academic achievement neighborhood ses was positively associated with academic achievement among children with low levels of prosocial behavior but not among children with high levels of prosocial behavior prosocial behavior may mitigate academic risk across early childhoodchildren raised in neighborhoods with low socioeconomic status ses face heightened risk for experiencing environmental adversity and exhibiting developmental difficulties and low academic achievement leventhal brooksgunn 2000minh muhajarine janus brownell guhn 2017 identifying factors during early childhood that protect against academic risk in contexts of adversity is crucial for informing interventions to reduce educational disparities between children caspi et al 2017masten barnes 2018reardon 2019 childrens prosocial behaviorie the propensity to act kindly or generously towards peers and other peoplehas been directly associated with positive emotional social and academic adjustment

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in 2017 we became aware of a call for papers for the 2018 issue of the journal epidemiologic reviews which would focus on the topic of prisoner health as researchers studying public health with a specific emphasis on improving the health of incarcerated populations who disproportionately experience health burdens we thought the theme sounded offkey for the past few years in keeping with the requests of persons who have been incarcerated in the united states many correctional think tanks and advocates have tried to incorporate personfirst language the nonprofit osborne association recently established a humanizing language project and developed a useful guide for referring to persons in custody following this guidance we aim to refrain from using the word prisoner as well as the terms offender inmate detainee convict felon parolee probationer releasee exprisoner exoffender etcany terms that define a person by a place or standing within the criminal justice system a recent letter in the journal of the american medical association by lorie s goshin pointed out how such terms run contrary to the rules of the american medical association manual of style by promoting overgeneralizations about people who have been touched by the correctional system this year organizers of a leading conference on correctional health research the academic and health policy conference on correctional healthcare for the first time insisted in the call for abstracts that authors not use stigmatizing language the call included a glossary of suggested terms we are joining effective social moments that are aligning to remove stigma from impoverished communities affected by the dominant culture that could control their existence with labels that might disempower them politically and economically labels and language matter language has the power to condemn or redeem and words reflect our values and beliefs as clinicians scholars and members of the community labels have less power when collectively we stop using them personfirst language is the foundation for clinical practice that fosters shared decisionmaking human dignity and hope it has gained traction in the fields of psychology and social work and has been deemed important in moving substance use disorder and treatment research toward a more recoveryoriented model historical background the origins of personfirst language come from disability advocacy in the 1970s and 1980s it was then that people with disabilities first started to call for an eradication of labels that defined an individual by their impairment or difference disability advocates began to call for linguistic representation that recognized that people are more than their disabilities thus terms like people with disabilities person with vision impairment individual who uses a wheelchair and person with intellectual disability arose this push emerged in the wake of other civil rightsrelated efforts to ensure the communities of concern determined the preferred language used to discuss them people with disabilities wanted others including care providers to demonstrate a recognition that people with disabilities are complex individuals with multiple important identity features although there are some disabilityrelated subgroups that prefer identityfirst language such as some in the deaf community and the autism community who may find their differentness as central to their identity formation on the whole personfirst language remains an important feature of disability advocacy as goshins commentary demonstrates the transformation toward personfirst language has been slower in medicine apparently epidemiology has just now taken notice the terms persons living with hiv and persons who inject drugs have recently become standard in the medical literature so that the acronymns plwh and pwid rarely need explanation efforts to characterize and improve the health of people in correctional systems must keep pace as these communities attest language has moral weight labels can serve to other people and signify a lower social position based on a conflation of a person with a socially devalued trait thus it is critical to recognize and respect the humanity in individuals who have experienced incarceration by choosing to use and promote the language this community prefers applying personfrist language to correctional health the health of persons who pass through a jail in a year or are confined to a prison influences the health of the community as a whole in recent years approximately 10 million individuals in the united states spent at least part of the year in a jail or prison on a given day in 2015 a total of 67 million persons were under the supervision of the criminal justice system onethird were in a locked facility and twothirds were on parole or probation in the community even if only 3 of us adults are under supervision today the proportion of affected individuals who pass through a confined environment each year is enough to sway some epidemics for example 30 of persons with hepatitis c have spent part of a year incarcerated access to treatment while incarcerated which is currently rare could transform our nations ability to eliminate an eminently curable disease although the united states leads the world in its incarceration rates other countries also have rising levels of confinement most often experience with the criminal justice system is not a salubrious one health rarely improves the standardized mortality ratio for persons ever incarcerated compared with the general population is less than 1 however the exact toll that incarceration imposes on the health of those passing through is unknown the chronic underfunding of correctional health research contributes to our ignorance arcane regulations found in 45 cfr 46 subpart c stymie attempts to conduct welldesigned studies the regulation allows demonstration projects but to conduct a randomized clinical trial using a placebo control the secretary of the department of health and human services must personally approve the protocol and that can take place only after convening a panel of experts with so many hinderances to investigating how public health interventions can improve the health status of persons who are incarcerated we should not add insult to injury by using dehumanizing language we acknowledge that language alone is insufficient to shift the pervasive stigma that continues to grip individuals who have spent time incarcerated these populations encounter shortand longterm barriers to employment housing financial aid and civic participation and evidence has shown that it is the dichotomous experience of ever being incarcerated that matters more than its dosage although efforts to adjust the language we use in describing the populations we serve are important these initiatives must complement more structural actions including enhancing access to healthcare in correctional settings supporting reentry into the community and ultimately reforming the prisonindustrial complex as a whole moving forward nonetheless language is a fundamental place to begin to erode many decades of stigma epidemiologic studies inform the clinical guidance that providers use to best serve their patient populations and establish the extent and distribution of health problems for public health practitioners to take action future research may include measurement of health outcomes when language is systematically changed policymakers increasingly turn to research evidence to guide budget and policy decisions it is clear that epidemiology represents the headstream from which many activities to address population health flow thus it stands to reason that we should hold ourselves to the highest standard when discussing the health of some of the most marginalized members in our society ostensibly research on correctional health stems from a fundamental belief that people are capable of positive change after involvement with the criminal justice system the words that fill our manuscripts and that are ultimately consumed by students researchers and providers should align with this belief conclusion inclusive language is designed to improve the social emotional and physical wellbeing of families and communities areas of future research may include measuring health outcomes when language is systematically changed the barriers that thwart successful reentry may be lessened when further marginalization is removed and humanity is restored i dont like labels like felon offender exprisoner or former prisoner i am a person who served time in prison many years ago and that experience doesnt identify all of who i am first author

after objections surfaced following a call for papers on prisoner health the editors of epidemiologic reviews decided to rename this years volume incarceration and health in this commentary we trace the origins of personfirst language and explain why using appropriate terms in correctional health including correctional health epidemiology matters we discuss the potential consequences of personfirst language for justiceinvolved individuals and how inclusive language might affect the social emotional and physical wellbeing of individuals families and communities future directions may include measuring health outcomes when language is systematically changed the barriers that thwart successful reentry may wane when dehumanizing language disappears

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background the government health system in vietnam coverage of government primary health care facilities has greatly improved in the past two decades in vietnam by the end of 2008 99 of all communes in the country had a communal health station including the northern mountainous communes inhabited by ethnic minorities 1 communal health stations provide primary health care including free immunization for children treatment for minor diseases and common drugs assistance during deliveries and take part in health promotion activities in the communes including mother and child health education and hygiene and sanitation education this study was conducted in the northern mountainous regions of vietnam where 32 of chss having doctors and 86 having midwives or assistant doctors specialized in paediatric and obstetric care 2 chss are small health stations situated in each commune which refer seriously ill patients to larger intercommunal clinics and district hospitals which provide facilities for surgeries and inpatient treatment as well as more diagnostic services most villages in the northern regions of vietnam also have active village health worker 2 who form a crucial part of the phc system they are laymen with shortcourse training in health and human diseases typically three months of training plus occasional upgrade courses they work parttime and have five official tasks perform health education disease prevention including hygiene promotion mother and child health care including advocacy of family planning first aid and disease treatment and to participate in health programs with authorities and chss 3 private health providers are also a crucial part of the wider health system in vietnam including a large numbers of traditional medical and herbal experts spiritualists and private biomedical practitioners 4 it has also become normal practice among vietnamese to purchase and selfmedicate with overthecounter drugs many sold without prescriptions from the large number of private drugstores and pharmacies 5 6 7 the health situation of ethnic minority children improving child health indicators is a major priority for the vietnamese government who have initiated several child health programs and policies under the national target programs on health since the early 1990ties prevention of communicable diseases improving coverage of the expanded child immunization program and improving child nutrition status are some of the main child health objectives these programs all aim at providing basic child health services and promotion to all parts of the country to ensure affordability and increase coverage of services the national health care fund for the poor was established in 2002 to provide insurance for ethnic minorities and poor communities making all treatment and drugs at chss and district hospitals free of charge for those insured 8 however child health inequalities still exist between rural and urban and between majority and minority population groups diarrhoeal diseases are the number two leading cause of morbidity and is endemic in the northern mountainous regions of the country inhabited mainly by emgs 9 as are parasitic infections of children 10 it was recently estimated that 12 of children in a mountainous rural district of vietnam had experienced diarrhoea within two weeks 11 children living in the northern and central highlands also experience higher risks of malnutrition compared with children living in urban and rural lowland 1112 a recent analysis of official statistics also highlights that far more ethnic minorities and children from the northern regions live in poverty have poor shelter and limited coverage of water sanitation and immunization compared with urban regions and kinh children 13 caregivers use of health care services and drugs for child illness management in principle all caregivers in vietnam have access to a wellestablished and free phc system for children and several studies have shown that selfmedication of child illnesses is also common in urban as well as rural vietnam 14 and that antibiotics are commonly prescribed and overprescribed to children 14 15 16 one study in a kinh populated rural district found that only 54 of caregivers used antibiotics and 36 used analgesic and antipyretics to treat the childs diarrhoea while only 97 gave the child ors 15 compared with the majority of vietnamese parents quantitative studies have found that ethnic minority caregivers are even less likely to give ors and seek treatment at chss when children have diarrhoea 1718 one of these studies also found that ethnic minority caregivers perceived diarrhoea episodes as less severe compared with kinh caregivers 18 indirect costs of treatment user fees and long distances to health facilities have also been mentioned as important factors that hinder the use of health facilities among poor and the emgs living in highland areas 1920 however the perspectives of vietnamese ethnic minority caregivers on child illness management and treatment preferences and perceptions are not well described in the literature this study explores treatment seeking strategies among ethnic minority caregivers of children with diarrhoea in northern vietnam in order to suggest improved health services for emgs and other vulnerable groups in vietnam methods study area population and health services six months of fieldwork was conducted in two adjacent rural communes in the northern province of lao cai in vietnam in 2008 investigating the general living and working conditions perceptions and practices of health hygiene and sanitation among ethnic minorities 21 for the current study and building on previous findings two additional months of fieldwork was conducted in 2009 focusing on caregivers management and perceptions of child diarrhoea the total population of the two communes was 10000 with 85 being ethnic minorities fieldwork was conducted among the four most populated minority groups in the area giáy tày xa phó and red dao about 40 of households were below the government poverty line of 2006 2010 for rural areas with a higher concentration of poor households among the xa phó and the red dao in the highland 22 all ethnic minorities depend on subsistence rice farming animal husbandry and forestry with all adults doing hard physical fieldwork daily all four ethnic groups have traditionally lived in multigenerational households and are all patrilineal with men being the heads of households and owners of all property and patrilocal with daughters moving to their grooms families when married further details on the study area and the minority groups have been reported earlier 21 two chss one also hosting the preventive medicine office in charge of conducting preventive activities in both communes were located in the lowland part of each commune both chss were run by assistant doctors and had nurses pharmacists and nurse midwives employed both chss had a selection of common drugs and remedies available including ors antibiotics other antidiarrhoeals and allopathic medicines village health workers had been appointed by the chss for almost all of the 39 villages in the communes government district and private hospitals and drug stores were located in the district town 35 kilometres away from the clinics no private biomedical practitioners clinics or drug stores were found in the two communes but several spiritualists were identified as important health providers in highland villages performing fortune telling and warding rituals to strengthen health the lowland villages were located closest and within five kilometres to the chss the xa phó villages were located within eight kilometres while highland villages were scattered and located on steep dirt roads up in the mountains 1015 kilometres away from the chs no public transportation exists and people walk bike or drive motorbikes to the chss and district towns data collection the main source of data was 43 semistructured indepth interviews with caregivers of preschool children who had experienced a case of diarrhoea in the past month in addition two weeks of observations of patientstaff interactions were performed at the two chss and three focus group discussions were conducted with men data from participant observations in four different study communities conducted in 2008 was included as general background information of the living conditions in highland and lowland settings information about diarrhoea cases in 10 lowland and two highland villages of the four ethnic groups were collected by asking caregivers if their child had experienced an incidence of loose or watery stools at least three times per 24 hours during the past month using the diarrhoea definition of who 24 several sampling methods were used to ensure that cases included mild and severe cases and cases treated at home and by various health providers these included two weeks of observations at the two chss a project community diarrhoea survey covering both communes by references from vhws and housetohouse visits by the first author and assistants in villages interviews included questions on perceived causes of diarrhoea decision making about treatment treatment choices and use of health services the main informant was the adult caregiver who had attended to the child during sickness but during seven of the interviews more than one caregiver was present and answering questions for their children attempts were made to avoid having grandparents in the same interviews as mothers to allow mothers to talk openly about family decision making to gain insight into influences on treatment seeking and choices of fathers and grandfathers three fgds were conducted among men from two lowland villages and a highland village characteristics of participants are shown in table 1 interviews and fgds were conducted in vietnamese by two vietnamese assistants with the first author being present during half of the interviews and all of the fgds to ask elaborating and clarifying questions young local women assisted with translation during interviews in the highland and xa phó villages if the interviewees did not speak vietnamese caregivers with sick children encountered at the chss and in households were not interviewed but asked if they were willing to be interviewed at a later time once the child had recovered two caregivers with sick children met at the chs declined to be contacted again one caregiver with a sick child undergoing treatment was met in a xa phó village and interviewed at a later stage all interviews were audio recorded with informed verbal consent and promised full anonymity and confidentiality recordings were transcribed crosschecked and translated ad verbatim into english by the two assistants data was coded for thematic content analysis 25 by the first author using preset and emerging empiric and theoretical categories by the nvivo 8 software program 26 the study was approved by the national institute of hygiene and epidemiology in hanoi the department of health in lao cai province and peoples committees in the two study communes results two ethnographic descriptions of two diarrhoea cases drawing on observations and interview data from various sources illustrate the identified similarities and differences in perceptions of disease and health choices in a highland and lowland setting these cases serve as a point of departure for the analysis and discussion of the underlying logic for treatment seeking in ethnic minority families the two cases show that the nonprofessional popular medical sector constituted by health care taking place within the spheres of family and community 27 plays a crucial role in the treatment of sick children among ethnic minorities of northern vietnam it is within this popular sector that all treatment is initiated and where families negotiate whether to contact the professional sector such as government health facilities or the folk sector with other health specialists such as spiritualists or herbal experts 27 secondly the cases depict several of the social economical and structural obstacles identified for using the free government health services these obstacles are investigated below table 2 a highland case of child diarrhoea management discovering the disease one evening when a 23year old mother returns from field work in the hills the children who have been attending her 12months old baby say that the child has a hard belly and hasnt defecated during the day during the night the child defecates liquid and greenish stools thrice cries and develops a bellyache and slight fever the mother describes the child as very sleepy weak and not wanting to eat anything except for taking breast milk treatment in the home the diarrhoea goes on for three days during this period the parentsinlaw allow the mother to remain home to attend to the child and cook for the family when asked about the cause of the diarrhoea the mother is uncertain maybe because of the weather but i dont know i thought it was maybe because the child ate something unsuitable drank dirty water or played dirtily she explains unsuitable foods as something which couldnt be digested by the child including sweet milk or toxic forest fruits for the first two days the mother carries the child around all the while breastfeeding and urging the child to drink boiled water and eat some rice in the hope that the disease will cease on the third day the parentsinlaw decide to call the village thầy mo he explains how to cure diarrhoea first we have to do bói and if there is a ghost we can see it then we can do the mo he talks in tongues and counts his fingers and says that the disease does not take a comprehensive ritual or large offerings to chase away the disturbing ghost he chants and burns incense to contact the ghost while offering small gifts of rice meat and homebrewed wine but the child keeps defecating and crying during the evening and night the mother is now unsure of what she should do since she is inexperienced as a mother she has not attended village meetings where health advocacy takes place and there is no womens group in her village and she doesnt understand what is communicated on the radio and tv in vietnamese she places her trust in her motherinlaw who decides to prepare a bitter drink of boiled guava buds for the child during the next five days the motherinlaw attends to the child and feeds it with the drink thrice daily while the mother is away working in the fields the child gradually stops defecating liquid stools and regains some strength using drugs and government health services the mother did not go to the chs for medication but preferred drugs from the pharmacy in town which she perceived were of a higher quality after another six days at home the diarrhoea resumes and the mother now perceives it as a serious disease she wants to go to the chs but i dont know how to ride a motorbike and my husband was not at home the local custom prohibits her to sit on a motorbike with another man and the chs is too far away for her to walk to and she feels unable to communicate with any of the health workers at the chs in vietnamese the parentsinlaw decide to send her brotherinlaw with the sick child to the chs he returns with some sachets of powder a fever reducing drug and ors and written instructions on correct dosages of the medicaments in the medical notebook of the child he was told to ask the vhw for further explanation if needed the mother is illiterate and says that she never meets the vhw who lives on the other side of the hill further he never comes around to advice on child health she says so she decides to give both powders the same way two three times a day in a teaspoon of boiled water or tea until the child stops defecating liquid stools she is very afraid that the diarrhoea would not stop before the medicines run out she says but after three days of medication the child recovers and the mother is relieved that she would not have to ask her familyinlaws to take the child back to the clinic or to the district hospital which would have been very time consuming and costly for the family economic and logistical constraints to accessing health services some clear differences in treatment seeking and health care choices were found between the poorer ethnic groups living and working in the highland compared with richer groups living in the lowland setting as described in case 1 greater difficulties in assessing treatment at health facilities were observed for highland caregivers living furthest away from chss and hospitals compared with the richer and more centrally located communities in the lowland even though health insurance would cover the direct costs of treatment and admissions highland caregivers in particular worried a lot about the substantial indirect costs such as transport buying food arranging homesitting and paying for extra drugs and services at the chs or hospitals distance and time was also a constraint for highland caregivers from poor families without means of transportation who would have to spend half or a full day if walking to the chs caregivers acknowledged that this was too time consuming if a child was seriously sick in focus group discussion and interviews caregivers all said that they would borrow or spend their money to pay for transport to get to the chs in time despite having very low incomes the cost of petrol or renting a motorbike driver for a roundtrip from a highland village and the chs was 2025000 vietnamese dong equalling several days of work for a highland farmer in comparison lowland caregivers lived a maximum of five kilometres away from the chs and all had bicycles or motorbikes accessible within their households gender roles as a constraint for accessing health services observations in households and interviews with caregivers confirmed that all four groups of ethnic minorities live according to patriarchal gender roles with the oldest men taking all major decisions and the youngest women being the main domestic labour force this was most strongly expressed in highland families where young mothers were also the main agricultural labour force of the families and who expressed low decision taking powers about their childrens health which complicated seeking the government health facilities in the highland six out of 19 caregivers of children during sickness were grandmothers and mothers and grandmothers indicated that elders were the primary persons in the household in charge of deciding preparing and discovering the disease one evening a 25year old mother from a tày lowland village discovers that her 17month old child is slightly feverish and coughing without any objections from her family she stays at home the next day to attend the child in the morning the child starts defecating very watery and yellowgreenish stools the mother describes the child as weak tired crying thirsty having stomach pains and only wanting breast milk treatment in the home the mother immediately initiates a range of treatments at home to ward off the fever caused by the cold winds hitting the child she performs the traditional đánh gió with a silver coin an egg and some ginger mixed in a piece of cloth she strokes the head and body of the child at the same time she gives the child a dose of a fever reducing drug a leftover from the previous time the child was sick maybe the diarrhoea was caused by incompatible foods she says she therefore restricts the childs diet from such harmful foods avoid sour and fishy things such as eggs and we didnt have any vegetable soup in 34 days i didnt dare to let him eat it she urges the child to drink water and eat rice mixed with water salt and minced meat she also restricts her own diet from green vegetables being afraid of passing any harmful substances on to the child in the breast milk on the second day the diarrhoea stops and the mother is happy to have handled this light diarrhoea at home apparently this treatment was compatible to the disease of the child she says when asked how she knew what to do she says that she always asks her motherinlaw and other elder women in the village they know everything they have been through it all she has also noticed some campaigns during epidemics and some advice sanitation when watching tv at the neighbours at the regular womens union meetings she also learned about child care and personal hygiene finally she prepares a herbal drink for the child the old people in the village told her to do so the old women said that they brought up many children in the past they all collected the herbal medicines for drinking she finds the herbal medicines more compatible for a body of a child since they are not harmful as drugs can be she says she also finds it more practical and effective compared to drugs the clinic medicine is drunk just twice per day about the herbal medicine he can drink it anytime hes thirsty i just let him drink whenever he asks for drinking water i boil it and leave it in the pot furthermore she can drink it herself and pass the healthy substances to the child in the breast milk unlike any drugs given directly to the child after four days of this combination of treatments the child recovers and the mother is proud to have successfully handled this disease of her first child using drugs and government health services but after another four days the diarrhoea begins again this time the mother immediately goes to the chs on her bike without involving her husband or parentsinlaw she now describes the diarrhoea as serious and therefore not treatable at home when asked why she did not firstly consult the vhw she says she doesnt have medicine to provide the people and she doesnt care about the childs diarrhoea at the chs she does not tell the assisting doctor about the treatment she carried out at home or what might have caused the disease she returns home with four kinds of drugs which she knows as antibiotics fever reducing drugs digestion enzymes and ors without consulting anybody she decides to only give the fever reducing drugs and the enzymes she finds the antibiotics incompatible with a sick childs stomach it is too sweet and too hard for the child which can cause even more diarrhoea she does not know what the ors is for and did not dare ask the chs staff they are often cross with me they think i come too often to ask for medicines she says administering the treatment for a sick child mothers were not allowed to travel unaccompanied or with male nonfamily members to health facilities and needed permission from elders to stay at home from field work to care for the sick child a group of highland men explained when the child gets fever falls ill belly pain or something similar the grandparents have to take care of the child and prepare the medicines the men continued everything must be discussed with the grandparents after discussing if all agree we let the child go highland women also had very few opportunities of accessing information in the community on health care options and preventive measures compared with women in the lowland tvs and radios were only accessible in few households and not broadcasted in local languages making it difficult for most women to understand the provided information since they had short or no education and therefore did not speak much kinh village meetings were mostly attended by male heads of households and womens groups were not established in the highland communities furthermore vhws were not consulted much in comparison many lowland family units were smaller and less influenced by the older generations a group of xa phó fathers said the men here all live separately they do not depend on the grandparents if our child is sick the husband and wife are independent most lowland mothers also had basic education and spoke fluently kinh they all stressed that they took decisions on their own about staying home from work to tend the child going to the chss or buying drugs in town most lowland women also attended womens union meetings in their communities regularly watched tv on daily basis and could understand the radio and loudspeaker announcements broadcasted in kinh language reluctance towards government health services despite the fact that all caregivers from highland as well as lowland communities highly appreciated access to government health services and drugs free of charge many caregivers sought these services with some apprehension none of the interviewed caregivers sought the advice or were visited regularly by the vhws working in their villages caregivers said they normally only had contact with the vhws when attending child vaccinations or child nutrition surveillance on a monthly or bimonthly basis which were also perceived to be the main tasks of a vhw he just weighs the small children once per month i only saw him doing that as expressed in both cases caregivers also said that vhws did not have important health services to offer sick children such as drugs first aid ors or good medical knowledge all caregivers had therefore experienced receiving a standard advice of going to the chs from the vhw this made them go directly to the chs without consulting the vhw first health station staff on the other hand were perceived to be qualified to diagnose diseases and prescribe drugs but as exemplified in case 2 the majority of caregivers had bad experiences when consulting the chs their illiteracy and backward lifestyles were often commented on negatively by different types of health staff thirteen caregivers told stories of being scolded ignored or blamed for seeking treatment too late or too often a caregiver from the highland explained most of the people here are scolded by the doctors doctors often blame people for not taking good care of their children they should try to understand the situation here it is really hard in a place like this a young lowland mother added i just want the doctors to be more enthusiastic with patients only when people fall sick they come to the clinic so the doctors have to behave softly with them so people can be satisfied language barriers were also mentioned by caregivers during observations and in all interviews with highland women they felt they could not communicate accurately in kinh language with staff at the chs health staff also expressed frustration about not being able to communicate with patients they therefore used very simple language or in rare cases used other waiting patients as translators or asked patients to have someone in their own community read and explain the prescriptions to them to avoid being misunderstood or perceived as backwards caregivers uniformly said that they never shared ideas about causes of diseases asked clarifying questions about the prescribed drugs or told any health staff including vhws about the homemade treatments they had used before coming to the chs this was verified during observations at the chs here no caregivers were observed to share any information on the child disease or ask about prescriptions diagnose or the guidelines given by health staff staffs were observed to only ask few direct questions on disease symptoms and personal details explanatory model for treatment seeking praying in four directions and perceived severity of disease as illustrated in the two cases caregivers sought and chose treatment according to a pragmatic logic of medical pluralism applying and combining a range of treatments from different medical systems to increase chances of effect and recovery this strategy was described with the vietnamese proverb praying in four directions we call it praying in four directions when we get sick we do whatever we have to a highland mother added it is safer when doing all because sometimes doing mo will recover sometimes going to ask for drugs at the health clinic will as described in the two cases caregivers commonly shifted between folk popular and professional biomedical treatment systems as a disease developed and choices were often based on the perceived severity of the disease homeadministered remedies including herbal mixtures concoctions and massage were perceived sufficient for light or minor episodes lasting two four days with irregular defecation of liquid stool belly pains and general uneasiness this type of diarrhoea was also described as a normal disease common during childhood easy to treat and not severely affecting the child the old people said that the children have diarrhoea when they grow up its not a special thing if a child gets diarrhoea a lowland mother added i saw the diarrhoea as normal he had diarrhoea for threefour days and then recovered he didnt lie down and he went out to play all day as usual among all caregivers diarrhoea was perceived heavy or serious when lasting more than 24 days reemerged shortly after recovery or included high fevers sudden onset of very frequent defecation and the child becoming very lethargic or losing weight in these cases all caregivers mentioned consulting the chs and taking western medicines as a necessary treatment referral to a hospital was also generally agreed as a necessary action if treatment with western drugs did not stop the diarrhoea this was also acknowledged among older caregivers from highland communities with longer distances to the chs when he kept being very sick we couldnt let him stay at home we went down to the health clinic to ask for drugs he was sick at home for twothree days and it was getting too serious the longer we stay at home the more serious it gets nevertheless a total of six children had been sick with diarrhoea for several weeks and were seriously weakened before being taken to the chs and admitted up to 12 days at the intercommunal clinic or the district hospitals receiving frequent intravenous sodium glucose solution and drugs explanatory model for treatment seeking compatibility as a guiding principle respondents frequently used the expression of a treatment or method being compatible or suitable for a child with diarrhoea compatibility turned out to be a central and complex concept functioning at various levels and having implications on all aspects of diarrhoea management including the perceived cause the chosen treatment and evaluations of its outcome compatibility and causal factors reflections about the possible causes of a diarrhoeal episode were important for the choice of treatment in all four groups of emgs a local cosmology of keeping the body of mother and child wellbalanced and unexposed to certain unsuitable elements in the environments or incompatible foods and drugs dominated the explanations of diarrhoea unsuitable environmental factors for children included exposure to sudden changes in weather eg from hot to cold or rainy weather or being exposed to something dirty eg dirty playing environment or eating dirty foods unsuitable items for childrens stomachs causing diarrhoea mainly included too hot sour or sweet items including sweet drugs foods with fishy taste or smell sour vegetables or fruits fatty foods and hot breast milk as described in case 2 the suitable treatment for exposure to these factors was to rebalance the body by restricting the behaviour or diet of the child or the breastfeeding mother in all four emgs a diet for a sick child often included rehydration measures such as giving rice porridge with salt and sugar green teas or herbal concoctions all breastfeeding mothers also said they had continued breastfeeding during diarrhoea unless they were forced to go to work compatibility and treatment testing the process of testing and establishing the compatibility of a treatment was crucial for disease management in general caregivers perceived a treatment to be compatible if they saw the diarrhoea lessening or stopping within a short time as in case 1 this was expressed clearly by highland caregivers who always sought spiritual treatment before or parallel with chs based treatment this was perceived a compatible treatment for children affected by angry ghosts a spell or a discontent ancestor since such factors had to be eliminated first in order to make the child susceptible to biomedical treatment the chs checks if the child is having a disease but at home the thầy mo keeps doing bói and mo to make the child recover or not when finishing bói and water transmissions and injections we can see if the child can recover compatibility and choice of medication all types of medication were also evaluated according to whether it was perceived compatible with the specific person or the specific disease a lowland father explained the choice of herbal medicines if the child is compatible to that herbal plant heshe will recover soon if that medicine was not compatible then we go to the health clinic a lowland mother similarly explained the effect of western medicines depending on which medicine is compatible to him he will recover after drinking it 12 times a group of highland fathers explained how they also had to consider the compatibility of a disease with a drug if the disease is suitable to the foreign medicine you take a little bit to recover as already mentioned shifts from herbal medicines to western drugs were related to perceptions of severity of disease as the quote indicates and as described in case 2 these perceptions were linked to general perceptions of western drugs being very powerful and therefore potentially harmful and incompatible with the body compared with natural medicines antibiotics were perceived as particularly powerful six caregivers described them as too hard too strong and too sweet for a sick child unfortunately as exemplified in case 2 and confirmed in interviews and by observations it was common to receive 24 different kinds of prescribed drugs for diarrhoea at the chs with antibiotics and fever reducing powders the most frequently mentioned in order to limit the intake and harm from western drugs many caregivers said they gave smaller daily doses of the drugs than prescribed or they decided to give only some of the drugs and shifted from one drug to another if recovery did not take place quickly these perceptions also had implications for the use of ors only one xa phó mother knew how ors differed from drugs others perceived it as any other drug did not understand the principle of rehydration and did not believe that the child could tolerate the large quantities of powder mixed with water or the unpleasant taste of it a highland mother explained they said mix it with a bowl of water but the child couldnt drink it all i had to mix with a little bit of water for him to drink it then it was sweet and the child liked to drink if the water is too acrid the child doesnt like to drink some caregivers also expressed suspicion and doubts about the quality and effectiveness of the free western drugs handed out at the chs in the health clinic they are afraid that we do not know how to drink it they give us the diluted medicine therefore despite having very low incomes or living in remote areas some caregivers occasionally bought drugs at private pharmacies in town instead expecting higher quality drugs when we buy we pay the money and they will give us a good drug so we can get well soon hence the expectations to the effectiveness of western medicines and the easy access to drugs provided by commercial providers seemed to sometimes override concerns of cost distance and harmfulness of drugs summing up findings suggest that logistical and social barriers exist for accessing the chss in addition two guiding principles constitute a local explanatory model for managing childhood diarrhoea among ethnic minority caregivers in this area simultaneous resort to multiple treatments or praying in all four directions is the leading strategy relying on the two core concepts of severity and compatibility reflections of compatibility were drawing on local cosmologies of balancing the body as well as testing and determining effectiveness of various therapies and drugs discussion this study describes how logistic constraints gender roles local treatment seeking strategies and reluctance towards government health workers together constitute a suboptimal use of free government health services among ethnic minority caregivers in two rural communes in northern rural vietnam these constraints are discussed in the following to suggest ways of improving the quality and use of government health services economic and logistical constraints when choosing health provider low usage of government health providers among emgs compared to kinh have previously been ascribed to failures in insurance coverage 19 and logistical constraints to access health services from the highlands 1928 but as pointed out by london 8 health service fee exemptions only cover one component of health service costs while indirect costs may present bigger challenges for the poor this was also expressed by highland caregivers in this study who worried a lot about the substantial related costs of admittance which potentially delayed seeking treatment for seriously sick children interestingly despite having insurance with access to free treatment for their children at government chss higher costs and longer distances this and one other study 19 have identified a willingness among ethnic minority caregivers to buy drugs from private drug stores the common practice among the rural population of vietnam of seeking private health services and buying overthe counter drugs for selfmedication 57 apparently extend to poor emgs the study also showed that vhws who are the closest health providers were not considered qualified by caregivers who instead bypassed vhws and travelled long distances to access private or public health facilities problems of distance to health services might therefore be lessened by upgrading services at community level either by increasing skills and competences of vhws in remote communities to perform effective health promotion and basic treatment or by increasing the frequency of outreach visits by chs staff to remote communities balancing between a local explanatory model of disease management and government health services the study also identified a local explanatory model of disease management among ethnic minority caregivers clearly differing from a biomedical treatment system simultaneous resort local medical cosmologies of obtaining bodily balances concepts of compatibility of treatment and humoral qualities of medicines as identified in this study are all commonly found in the asian context of medicine and well described in minority as well as majority populations in asia and vietnam 7 29 30 31 however our study also found that health staff ascribed such health seeking patterns as ethnic and backwards and that government health services are not always the first and most wellliked choice of health service for ethnic minority caregivers health is a key objective of state policies and governance in vietnam and health sciences in modern vietnam have become symbolically associated with socialist modernity rationality and progress 832 further ethnic minorities have commonly been described as marginal and developmental backwards and therefore targeted by the socialist state to assimilate to mainstream developmental standards 3334 while also being encouraged by the state to preserve cultural traditions not posing any threats to progress of the socialist state 3335 superstitious beliefs and practices such as shamanistic rituals and animal sacrifice have been deemed as backward health practices and a constraint for progress and modernity 3235 hence our study provide further evidence that ethnic minorities seem to balance between practicing to them meaningful health rituals while also interacting with a modern government health system this might explain why ethnic minority caregivers do not reveal local explanatory models of disease to health staff and opt for drugs from the private sector where they are not met with demands to change health behaviours improving health services and health staff competencies for ethnic minorities this study agrees with previous findings on health service use in vietnam that low trust and dissatisfaction with medical staff 17 and discouraging communication with health personnel affects disadvantaged womens and ethnic minorities treatment seeking behaviours and use of the public health sector 2836 this is underlined in a recent world bank report stressing that female ethnic minority caregivers in vietnam are particular vulnerable and in special need of appropriate health services 34 the public health system of vietnam has been described as particularly providercentred not anticipating patients to speak up their needs or questioning health providers 3738 this is possibly worsened for illiterate emgs who also live in areas with poor health service coverage and where it is difficult to attract and retain qualified health staff 2 hence this study argues for a need for the vietnamese health system to focus on service levels in remote areas of the country and to change the approach to marginal population groups in vietnam to increase their trust in and use of government health services crosscultural competence models 3940 have been developed to address communication challenges in the health sector they stress that health staff working in ethnically diverse populations must understand patients actions and perceptions of disease as expressions of their social realities including constraining socioeconomic factors and local explanatory models of disease for health staff in daily contact with emgs in vietnam this clearly implies acknowledging the flexible praying in four directions approach to choosing treatment and local cosmologies of disease management as well as avoiding the persisting stereotyping of emgs as culturally backwards to address these needs vietnamese medical universities have recently strengthened community health training of medical students 41 while other staff groups remain to be considered this study primarily focused on understanding the perspective of ethnic minority caregivers on use of child health services further studies into the constraints of delivering effective government health care in mountainous areas of the country would add important information to understanding the full complexity of providing effective health care for all children in vietnam our findings also corroborate other studies highlighting the potential problem of selfmedication and overprescription of drugs to children in vietnam training of health staff should therefore focus on improved prescription practices and guidance to patients on how to administer drugs and ors they should encourage open discussions with patients on when to expect effects from drugs and when to shift treatment and health care system smallscale interventions have managed to improve drug prescription and purchasing practices in urban sites in vietnam 42 43 44 it is strongly recommended that such interventions be scaled up to include rural and mountainous areas where ethnic minorities are in need of good guidance opportunities for improved health promotion and trust in government health systems empowering and encouraging vietnamese caregivers with good care practices can enhance and sustain better childcare and health care practices in rural communities 45 46 47 the current study highlights that most caregivers from all four emgs recognize symptoms and evaluate the severity of diarrhoea within few days of onset and respond caringly and rapidly by applying various treatments however caregivers felt that hardly any encouragements or preventive advice were given to support these care giving efforts during contact with vhws or chs staffs we highly recommend that all staff at government health facilities use every opportunity to praise and encourage such good care giving behaviours this can form a fruitful starting point for further integrating preventive messages and child health promotion into the contact with caregivers this may strengthen caregivers experience of being in contact with a caring and trustworthy health system in the present study we also saw strong indications of patriarchal gender roles creating difficulties for young highland mothers in particular to follow health messages and seek chss depending on male and older family members permissions these findings are in agreement with other studies in the rural population of vietnam 3048 and other ethnic minorities in asia 29 which show that older community members and grandmothers in particular play core roles in child disease management and care however current child health promotion programs in vietnam and health promoters mainly target and educate mothers as sole caregivers it is therefore strongly recommended that health promotion in vietnam include other family members as key people in childrens care groups and their resources in child care these people can be reached through different grassroots organisations or community stakeholders in daily contact with men and elders eg village heads diviners and chs staff finally we acknowledge the beneficial practices of rehydrating children with diarrhoea using continued breastfeeding and homemade oral rehydration solutions of green teas water or rice gruels with added salt and meats these practices should be known to all health providers including spiritualists pharmacists and vhws as beneficial and included as advice during contact with caregivers this might be more effective than prescribing ors to less severe cases since it is perceived compatible with children while ors is perceived a noncompatible western drug and also administered incorrectly by many caregivers study strengths and limitations this study has provided new information on the qualitative aspects of why and how ethnic minority caregivers in vietnam use and choose health services for child diarrhoea however despite triangulation of methods and a thorough sampling strategy the study faces some limitations firstly as also pointed out by toan et al 19 the geographical inequity in access and use of government and private health services as well as language barriers and poor economical conditions are anticipated to be stronger for emgs living in less developed areas of the country eg in high mountains with longer distances to health facilities and urban environments secondly difficulties of gaining access to the insider perspective as outsiders to a research community can present serious limitations to qualitative research 49 since some caregivers expressed being marginalised and disrespected by kinh people due to their ethnicity the researchers and assistants backgrounds might have caused reluctance from respondents to disclose actions which could be perceived as wrong traditional or backward this problem was anticipated by the first author having good prior knowledge of the living conditions and having socialized with many community members and their children during a previous six month long fieldwork in the same study area being outsiders to the area was also mentioned as a benefit by some respondents who felt safe to disclose bad experiences with health staffs and family members since the researcher and assistants were not affiliated with any local authorities or organisations however it did constitute a special challenge to gain the trust of young highland mothers living in patriarchal families and making them speak up about sensitive issues of gender and decision making research assistants therefore aimed at interviewing mothers without the presence of elders and men and encouraged trusted friends and sisters to take part thirdly some information is likely to be lost or transformed during translations with the first author not speaking kinh the research assistants not speaking ethnic minority languages and the need for double translation in xa phó and dao communities where some women did not speak kinh the quality of translation was validated as research assistants crosschecked and discussed recordings and each others transcriptions of all interviews and fgds with the first author conclusions this study investigated treatment seeking strategies for child diarrhoea among four groups of ethnic minority caregivers in northern vietnam the study identified several socioeconomic and logistical constraints for highland caregivers in particular to seek treatment while also identifying a local explanatory model which guided disease management among caregivers in all four ethnic groups suggestions for future child health promotion include increased quality of government health services including improved communication skills and drug prescription practices of government health staff village health workers who are important primary health providers but not sought by caregivers should also be upgraded broader health promotion programs should address the strong patriarchal gender norms limiting highland mothers to seek treatments encouraging existing good child care practices and including elder family members as important caregivers also present important opportunities for effective future child health promotion additional material additional file 1 caregiver interview guide the interview guide which was used during the collection of the main data source 43 semistructured indepth interviews with caregivers of preschool children who had experienced a case of diarrhoea in the past month authors contributions tr was responsible for and carried out the data collection analysed the data material and drafted the manuscript fk and hs participated in designing the study and fk hs and ad provided comments on the analysis and revised the manuscript together with tr all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background in vietnam primary government health services are now accessible for the whole population including ethnic minority groups emgs living in rural and mountainous areas however little is known about emgs own perspectives on illness treatment and use of health services this study investigates treatment seeking strategies for child diarrhoea among ethnic minority caregivers in northern vietnam in order to suggest improvements to health services for emgs and other vulnerable groups methods the study obtained qualitative data from eight months of field work among four emgs in lowland and highland villages in the northern lao cai province triangulation of methods included indepth interviews with 43 caregivers of preschool children six years and below who had a case of diarrhoea during the past month three focus group discussions fgds with men and two weeks of observations at two communal health stations chgs data was contentanalyzed by ordering data into empirically and theoretically inspired themes and subcategories assisted by the software nvivo8 results this study identified several obstacles for emg caregivers seeking health services including gender roles long travelling distances for highland villagers concerns about the indirect costs of treatment and a reluctance to use government health facilities due to feelings of being treated disrespectfully by health staff however ethnic minority caregivers all recognized the danger signs of child diarrhoea and actively sought simultaneous treatment in different health care systems and homebased care treatments were selected by matching the perceived cause and severity of the disease with the compatibility of different treatments to the child conclusions in order to improve emgs use of government health services it is necessary to improve the communication skills of health staff and to acknowledge both emgs explanatory disease models and the significant socioeconomic constraints they experience broader health promotion programs should address the significant gender roles preventing highland mothers from seeking health services and include family elders and fathers in future health promotion programs encouraging existing child health care practices including continued breastfeeding during illness and the use of homemade rehydration solutions also present important opportunities for future child health promotion

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introduction multicultural education at this time is critical in education especially in indonesia which is diverse in life for the future of the indonesian nation especially in terms of developing indonesian intellectual human resources not only intellectuals in the field of science but humans who are intelligent in ethics have the character of being democratic moral and so on so they are capable of mastering various sciences they can solve multiple problems that occur in the field multicultural education is a relatively new phenomenon in the world of education education gives an essential meaning in the development and progress of a nation to provide enlightenment and develop the quality of human resources education plays a vital role in shaping public life but it is also believed to be significant in shaping politics and culture the development of multicultural education is in line with the journey of democracy that occurs in one country the principle of multicultural education is to desire equal rights for all people including the right to access education education for all this is the same as the development of the democratization process triggered by the recognition of human rights without distinguishing between skin colour religion and gender for every citizen thus with multicultural education one can accept other people together to build one unit regardless of differences in religion culture language ethnicity gender or ethnicity so thus as an effort to realize the principles of justice democracy and humanism it is very important that multicultural education in indonesia needs to be developed given the current conditions there are many factors that we must look at including first the field of religion in indonesia religion in indonesia is not tiny this is a fact on the ground that there should be mutual tolerance in this religious harmony in indonesia second multiethnic and various languages that each ethnic group owns in different regions in indonesia these various ethnicities can become a national conflict if they are not properly and adequately accommodated so this is where the fundamental role of multicultural education is taught as a determinant to prevent interethnic conflict third about gender social status and gender this multicultural education can help address the gender gap and social background of a person fourth the difference in terms of the ability for someone who has it both viewed physically and nonphysically this multicultural education should be carried out by the goals of education in general which incidentally is not only a transformation of knowledge but also seen from the process of internalizing values in addition everyone can acquire knowledge without discrimination from one group to another or vice versa this particular group should help each other to achieve this through multicultural education indonesia is one of the largest multicultural countries in the world this fact can be seen from the sociocultural and geographical conditions that are so diverse and broad indonesia has 13000 islands an estimated population of 250 million people around 300 tribes and approximately 200 regional languages there are also various religions namely islam christianity catholicism hinduism buddhism and confucianism as well as many other beliefs research method this type of research is qualitative research with a library research approach consisting of two types of data namely primary and secondary data preliminary data were obtained using documentation techniques namely data collected from documents in books journals magazines articles and other scientific works related to the discussed title namely multicultural education this writing analysis technique is content analysis namely data processing in a separate way related to discussing several ideas or thoughts on multicultural education which are then described discussed and criticized then it is categorized with similar data and its contents are analyzed critically to obtain a concrete and adequate formulation so that in the end it is used as a step for concluding findings and discussion the concept of multicultural education in indonesia the grounding of multicultural discourse in formal education today is getting stretched the rise of multiculturalism is accompanied by the spread of preliminary issues the many incidents of clashes and horizontal conflicts in society various parties voiced this idea louder and implemented it earlier in the education curriculum multicultural education consists of two words namely education and multicultural education means a conscious and planned effort given to students so that they can develop their potential they become individuals who are helpful to their religion nation and country multicultural means cultural diversity multicultural education means developing all human potential that respects plurality and heterogeneity due to cultural ethnic ethnic and religious diversity understanding this has vast implications in education because education is a continuous or lifelong process the root word multicultural means many cultures etymologically multiculturalism comes from the words multi culture and if multicultural ism is added in depth this word implies acknowledgment of the dignity of a person who lives in a group with their own unique culture furthermore azyumardi azra explained that the term multicultural can be used both at the descriptive and normative levels which describes the issues and problems of multicultural education meanwhile from a psychological point of view hariansyah explained that multicultural education views humans as having several dimensions that must be accommodated and developed as a whole that human humanity is basically an acknowledgment of the plurality heterogeneity and diversity of humans themselves that diversity can be in the form of ideology religion paradigm mindset needs desires and intellectual level according to burnet in ali maksum multicultural education is education for people of color meanwhile james banks interprets multicultural education as an idea that explains that all students regardless of which group they belong to such as those related to gender ethnicity race culture social class religion without exception should experience educational equality in schools ainur rofiq dawam interprets multicultural education as the process of developing all human potential that respects plurality and heterogeneity as a consequence of cultural ethnic ethnic and religious diversity through multicultural education it is hoped that there will be the highest respect and respect for human dignity and status wherever they come from and whatever their culture so that there is true peace security without anxiety and fear prosperity without manipulation and happiness without social engineering in essence multicultural education is an educational model that provides equal learning opportunities for all students whatever the religion the colour of his skin and wherever he comes from all of that should help to learn so that the ideals and goals of national education can be achieved besides that anshori it is explained that simply it defines multiculturalism as cultural diversity furthermore he explained some terms are often used in rotation given the condition of society namely three words are widely used including the first this term appears a lot when discussing religion language race and different cultures different the second term is diversity and the third is multicultural these three expressions do not represent the same thing even though all of these refer to nonsingularity so on this basis the concept of plurality presupposes that there are things that are more than one the diversity here shows that when there is more than one two or three are different heterogeneous and even cannot be equated if you look at the previous concept multiculturalism is relatively new besides that many experts explain the meaning of multicultural education if we see that basically multicultural education is insignificant and there are still many educational experts who question this explanation however multicultural educations meaning still needs to be clarified the purpose of education has many interpretations by experts so that one can explain the meaning of education especially regarding the importance of multicultural education in simple terms actually multicultural education can be interpreted as education relating to various diversity be it cultural or otherwise as explained by james banks as explained by choirul mahfud that giving an understanding of multicultural education is a foundation of education that directs people of color that is multicultural education examines differences as a necessity then how can we respond to these differences in the field with full tolerance and an egalitarian spirit on another occasion the definition of multicultural education was also explained this was explained by m ainul yaqin that multicultural education is an educational technique that is formulated in all subjects by explaining cultural differences to students such as differences in religion ethnicity language ethnicity gender race social class as well as ability and age so that students in the learning process can be easy and effective in this case ainul explained that multicultural education can also be directed to train and build the character of students so that they are able to act pluralistic democratic and humane in their living environment so we can interpret multicultural education as a style of education that applies the concept of equality and respects and respects plurality and heterogeneity in the environment respecting diversity multicultural education has characteristics namely 1 its aim is to form cultural people and create a cultured society 2 the material teaches noble human values national values and ethnic group values 3 the method is democratic which respects aspects of differences and cultural diversity of nations and ethnic groups 4 evaluation is determined on the assessment of the behavior of students which includes perceptions appreciation and actions towards other cultures multicultural education in the view of islamic education discourses about multiculturalism in the education sector especially in education in schools have recently become more intense there are many ideas and ideas that multiculturalism is very suitable to avoid the spread of bad issues so that there are many incidents or conflicts in society that arise as a result of not accepting differences in religion race ethnicity and others based on the phenomena that occur in the midst of society various ideas and ideas are voiced that it is necessary to implement multicultural education and include it in the overall education curriculum both from the elementary level to tertiary institutions besides that multicultural education has begun to be given ideas and integrated into the curriculum of religious education for some this opinion is very important as explained in the multicultural education book concept and application that the current islamic religious education is considered no longer suitable in creating harmony in social life so that many people have horizontal conflicts in historical reality the people of indonesia especially the javanese have had a track record that is not too bad in social and cultural management this is because javanese people very easily accept two or more value systems even though they are different such as the existence of buddhists and hindus who stand side by side and javanese kings who are referred to as buddhist shiva as a form of representation of the dialogue between two hindubuddhist civilizations in addition to the views above there are other opinions which state that multicultural awareness is a mentalpsychological readiness to accept differences as sunnatullah with this mental readiness awareness will arise in a person of the importance of living together in a diversity of cultures and religious differences with a spirit of equality and mutual trust equality respect for differences mutual understanding and uniqueness towards creating peace conclusion of the various problems regarding differences of opinion and differences in understanding within the community of course it will have a considerable impact on survival especially the entry of ideas that do not agree with the local community if this happens then one that must be developed within the community is multicultural education one of the human potentials whose mindset can be changed and appreciates its plurality and heterogeneity as a living unit that is harmonious peaceful not blaspheming each other not blaming each other both between ethnic groups and sectsthe conclusion and recommendation of the author are given in this section and are consistent in using the term conclusion the conclusion of the research should serve the urgent purposes of the study within this section this can be followed by suggesting the relevant future studies multicultural education is an initial foundation that emphasizes accepting what is in the face of the times especially in todays sophisticated and fastpaced culture both individually and as a group but also so in the view of islam multicultural islamic education which directs mutual respect and embrace mutual assistance from all forms of diversity regardless of ethnicity race ethnicity religion and others thus what is expected in the islamic religion especially in social life will grow wisdom from all forms of existing diversity a life full of tolerance dialogue and deliberation mutual help hospitality brotherhood and others

this article discusses multicultural education from the perspective of islamic education in indonesia multicultural education is a foundation for accepting the times especially in todays modern era which is allsophisticated and the culture is entering so quickly either individually or in groups multicultural education is insignificant and many education experts still need to question the explanation multicultural education leads to cultural diversity in actualizing social and cultural changes in the community multiculturalism in indonesia has two potential opposing sides on the one hand multiculturalism is a wealth of cultural treasures to be proud of on the one hand multiculturalism has the potential for conflict due to the lack of awareness of living together in a state of love and humanity multicultural islamic education becomes the normative basis for realizing how the educational process in islam should be managed perfectly so that the indonesian people are aware that multicultural education is essential

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medical marijuana use andor decriminalization laws 4 thus marijuana legalization is expected to increase the health effects of marijuana are widely debated 5 6 7 8 9 10 11 chronic use in adults is associated with cognitive impairment chronic bronchitis respiratory irritation and addiction as well as earlier onset of psychotic disorders in individuals who are prone to psychosis 67 in young marijuana users certain marijuana use trajectories can affect academic preparedness 1213 as well as health outcomes in later life 14 15 16 moreover some personality characteristics may make certain users more prone to negative health outcomes after periods of extended use 17 18 19 20 adult marijuana users have been shown to have a significantly higher prevalence of tobacco use than nonusers 21 22 23 24 25 dual and concurrent use may increase the risks of nicotine dependence 26 and marijuana dependence 2426 a particularly highrisk group for marijuana use is young adults with an estimated 68 million or 196 of this age group reporting current marijuana use 27 research examining marijuana use in college students has documented differing trajectories of marijuana use including infrequent or occasional users those who decrease their use during college and those who increase their use throughout the college years 2829 young adults selfreported reasons for marijuana use are varied 3031 including experimentation relaxation boredom conformity as a coping mechanism and for the high the latter 2 reasons being associated with marijuana use later in life and related poor health outcomes 3031 many young adults perceive few harmful health effects associated with marijuana 3233 a belief that both influences 33 and is influenced by 34 increasing social acceptability despite what is known about reasons for marijuana use in young adults less is known about who quits using and why prior research 35 documenting distinct trajectories of marijuana use found that low selfcontrol more externalizing behavior greater sensationseeking and more internalizing behavior were associated with being quitters or decreasers versus nonusers or occasional users in addition low selfcontrol more externalizing behavior and greater sensationseeking were associated with being a chronic user as opposed to being a quitter or decreaser those more likely to quit using also include those who only use marijuana when socializing 3637 while marijuana users also using tobacco are less likely to quit using marijuana 2538 another major influence is social roles one study examining marijuana use trajectories during young adulthood found that those who got married and had children were more likely to quit or decrease marijuana use relative to chronic users 39 other research has indicated that women who become pregnant or wish to start a family are more likely to cease the use of marijuana 3740 documented reasons that adults quit using marijuana include avoidance of the undesirable image it projects and limited social acceptability 41 42 43 in addition to these reasons older adults also tend to be more motivated by health concerns 4144 unfortunately few measures have been developed to assess reasons for quitting marijuana the marijuana quit questionnaire is a previously developed 176item questionnaire that has documented that selfimage selfcontrol health concerns interpersonal relationship concerns legal concerns social acceptability concerns and selfefficacy are important dimensions for cessation 44 however this tool is cumbersome and was developed for the broader range of adult marijuana users given the differing culture currently surrounding marijuana use in different generations targeted exploration regarding who in the young adult population is likely to quit using marijuana and why young adult marijuana users may choose to quit marijuana is needed these data are critical as individuals reasons for using and wanting to stop using marijuana should inform interventions the current study draws from the existing literature regarding motives for marijuana cessation 44 as well as social cognitive theory 4546 which has been broadly applied to substance use literature in particular we considered outcome expectancies of marijuana use and cessation given that this is a central component of social cognitive theory 4546 we used a sequential exploratory mixedmethods design to examine differences among never current and former marijuana users in terms of sociodemographic other substance use and mental health as well as their reasons for initiating marijuana use continued use andor cessation and develop a scale assessing reasons for marijuana use cessation among young adult marijuana users methods the parent study project decoy is a 2year 6wave longitudinal cohort study that involves 3418 raciallyethnically diverse students from 7 colleges and universities in georgia where medicinal marijuana use was legalized in 2015 schools are located in both rural and urban settings and include 2 public universitiescolleges 2 private universities 2 communitytechnical colleges and one historically black university data collection began in fall 2014 and consisted of selfreport assessments via an online survey every 4 months for 2 years detailed information on sampling and recruitment are described elsewhere 47 and briefly summarized here the registrars office from each campus provided email addresses for englishspeaking students ages 1825 we randomly selected 3000 email addresses from each of the 3 largest campuses and emailed a census of students at the 4 campuses with fewer than 3000 students response rates at the campuses ranged from 120 to 594 the overall response rate of 229 albeit low was obtained over a short time frame and met the sampling quota targets 47 our intent was to enroll participants who were engaged in email and were potentially more likely to be retained in the subsequent waves of the study the sociodemographic characteristics of the baseline sample were largely reflective of the student bodies of the campuses included in this study however the sample was disproportionately female 47 current analyses draw from 2 data sources described below study 1 qualitative interviews participantsin may 2015 we recruited via email users of various tobacco products identified at wave 2 of project decoy to participate in semistructured interviews we purposively recruited current and lifetime marijuana users within this sampling frame of the 99 participants recruited 80 consented and 60 participated in this portion of the study three refused questions regarding their marijuana use and were excluded from the current analyses a total of 46 of the 57 reported having experience using marijuana specifically 26 were current marijuana cousers and an additional 20 were former marijuana users qualitative semistructured interviewstelephonebased interviews that lasted about 30 minutes were facilitated by 3 female master of public health graduate students trained in qualitative data collection participants provided verbal consent at the start and were compensated with a 40 amazon gift card the interviews were audiorecorded for subsequent coding current analyses focused on marijuana use topics specifically responses to questions explicitly asking participants to report their reasons for initiating or not initiating marijuana use continuing to use marijuana and quitting or potentially quitting using marijuana in the future data analysisto address our first aim in part qualitative data were analyzed using maxqda 12 two members of the authorship team independently reviewed all transcripts which they then used to generate preliminary codes using deductive and inductive coding methods primary and secondary codes were established then each transcript was fully and independently analyzed by 2 additional mph graduate students and coded using the preliminary codebook all new codes that arose during coding were added to the codebook and applied to all ads codes were compared and consensus for coding was reached final codes were used to identify themes and relevant and representative quotes were chosen descriptive statistics were conducted to characterize the interview sample using spss 230 study 2 examining difference in use status and scale development participantsscale development involved data from the wave 3 survey which was conducted in august 2015 the sample included 1759 never 500 current and 607 former marijuana users measuresdata collected at wave 3 included a range of psychosocial and substance use variables below we outline our primary measure of focus the newly developed reasons for marijuana use cessation scale and the correlates of interest to assess marijuana use participants were first asked to report the number of days they used marijuana in the past 4 months we also measured participants reasons for marijuana use cessation after reviewing the literature 25 36 37 38 40 41 42 43 44 and the present qualitative findings a panel of experts that included the current author and other colleagues developed a list of 15 potential reasons for marijuana cessation participants reporting lifetime but not past 4month use of marijuana were instructed you indicated that you have used marijuana at least once in your lifetime but have not used marijuana in the past 4 months below are some reasons for why you might have quit using marijuana please indicate how true each of these reasons are for you using the scale below for social factors we asked if a parent currently used marijuana 32 and about the number of participants 5 closest friends who are marijuana users 32 these items were operationalized as dichotomous variables we also asked about perceptions of marijuana specifically addictiveness harmfulness of use and social acceptability on a likert scale of 1 not at all to 7 extremely 32 for other substance use participants were asked to report the number of days they used each of the following products in the past 4 months cigarettes lccs smokeless tobacco ecigarettes hookah and alcohol 48 those who reported any use in the past 4 months were then asked to report the number of days they used the respective product in the past 30 days given the difference in distributions of use alcohol use was used as a continuous variable while tobacco use was dichotomized as current users versus nonusers we assessed depressive symptoms using the patient health questionnaire 9item 49 we developed a continuous variable resulting from a sum of the items cronbachs alpha for the current study was 086 data analysisto address our first study aim quantitatively in part first we examined differences in sociodemographics other substance use and psychosocial factors among never current and former marijuana users using analysis of variance and chisquare tests then we used multinomial logistic regression examining significant correlates of being a never current or former marijuana user using former marijuana users as the referent category to address our second aim we conducted an exploratory factor analysis of the reasons for marijuana cessation items using promax rotation we used eigenvalues of greater than one as the criterion for number of factors then we examined the content and internal consistency of the factors finally we conducted bivariate analyses examining subscale scores in relation to these correlates of interest to examine convergent and discriminant validity analyses were conducted with spss 230 and alpha was set at 05 results study 1 qualitative interviews participant characteristicstable 1 presents data regarding participant characteristics for the qualitative interviews table 2 summarizes major qualitative themes and subthemes as well as representative sample quotes for each theme factors influencing marijuana use initiationregarding factors impacting marijuana use initiation participants expressed various reasons for trying marijuana or initiating use several decided to try marijuana out of boredom or curiosity while others were persuaded by social influences particularly friends or siblings relatedly alcohol use and availability of marijuana through ones social network also influenced initiation a few reported trying marijuana while in a period of rebellion against their parents others reported trying it for the first time as part of gaining a sense of independence from their parents after leaving home and starting college reasons for marijuana useone major theme regarding reasons for marijuana use was the use of marijuana to achieve a desired psychological effect stress relief and relaxation were most commonly reported followed by assisting with focus or concentration many also reported using marijuana to socialize with others usually with friends and to facilitate relaxation and bonding perceptions of marijuanaregarding the physical health effects of marijuana most participants believed that there were no negative effects or scientific evidence indicating negative health risks additionally many believed that marijuana was a natural substance therefore lacking negative health consequences several indicated that they believed there might be positive health effects of using marijuana citing marijuanas medicinal or therapeutic properties a few also reported that overdosing on marijuana is not a danger thus indicating its safety only a few participants noted negative concerns about marijuana specific to inhaling marijuana smoke in terms of the psychological effects several indicated concern about the effects that marijuana use has on brain functioning and personality however several also indicated a lack of concern about the effects of marijuana use on behavior relative to other types of drugs regarding addictiveness a few believed that marijuana was highly addictive but most discounted marijuanas addictive properties some suggested that marijuana could be mentally addictive or habitual but they did not perceive it to be physically addictive reasonspotential reasons for cessation of marijuana useparticipants were asked why they chose to quit using marijuana or if they had not quit why they might plan to quit in the future the most commonly noted reasons for cessation of marijuana use included userelated health concerns and social pressures to quit particularly from parents the illegality of marijuana was discussed as a significant reason for cessation by several participants maturation and life transitions also were reported as reasons to quit using marijuana by many people many people discussed transitioning to new social groups graduating from college focusing on their careers or building families as reasons to quit several participants indicated no intent to quit using marijuana study 2 examining difference in use status and scale development correlates of never current and former marijuana usethe sample was an average age of 2053 356 male 636 white 225 black and 76 hispanic it included 118 cigarette users 96 lcc users 34 smokeless tobacco users 102 ecigarette users and 117 hookah users average number of days of alcohol use was 383 in bivariate analyses differences in marijuana use status were found among the never current and former users in age race type of school attended and use of each tobacco product and level of alcohol use in the multinomial logistic regression examining differences in never current and former users correlates of being a former versus never marijuana user included being older currently using cigarettes lccs ecigarettes or hookah and higher levels of alcohol use correlates of being a former versus current marijuana user included being older not currently using cigarettes or lccs and lower levels of alcohol use factor analysis reasons for cessationthe sample of former marijuana users was an average age of 2105 334 male 644 white 242 black and 76 hispanic factor analysis identified 2 factors instrumentality indicating the undesirable effects of marijuana use and social legal reasons indicating concerns about image social influences and legal ramifications of marijuana use two items were deleted as these items did not fit with the previously described factors or assess specific reasons for cessation the 2 factors largely mirrored the reasons most prominent in the qualitative interviews and accounted for 612 of the variance cronbachs alphas for each subscale were 93 and 75 respectively the correlation between the 2 subscales was 67 convergent and discriminant validitytable 5 provides data regarding convergent and discriminant validity scores on the instrumentality subscale were positively associated with perceived addictiveness and harmfulness of marijuana and negatively associated with social acceptability of marijuana use and use of cigarettes lccs and hookah scores on the sociallegal subscale were positively associated with perceived addictiveness and harmfulness of marijuana and negatively associated with friend use of marijuana social acceptability of marijuana use and use of lccs smokeless tobacco ecigarettes and hookah discussion the current study is one of the few studies that used a qualitative approach to examine reasons for marijuana initiation use and cessation and is among the first aimed at quantitatively assessing a range of reasons for cessation specifically among young adults our qualitative findings informed our scale development efforts and the new measure largely reflects the literature that informed our conceptual framework 50 51 52 53 54 55 56 57 58 59 60 as well as the constructs and associations involved in the social cognitive theory 4546 the resulting scale may be useful for understanding how and why young adults quit using marijuana assessing and understanding these reasons is critical in addressing this emerging public health issue particularly among young adults in terms of identifying correlates of being a former marijuana user we found that former users were older than both never and current users which may reflect a trajectory wherein an increased number of young adults will have used or experimented with marijuana over the course of their young adulthood but many will either only experiment or transition out of use 282927 in addition former users were more likely than never users to use cigarettes lccs ecigarettes or hookah and to more frequently use alcohol on the other hand former users were less likely than current users to be currently using cigarettes or lccs and used alcohol less frequently these findings suggest that current marijuana users demonstrate the highest substance use risk which is intuitive given that use of different substances commonly clusters particularly in young adults 565861 our qualitative findings indicated a range of reasons for initiating marijuana use but most who continued using did so to achieve the psychological effects and due to social influence or in social settings reasons to quit using marijuana included the legal implications social pressures to quit and life transitions which were reasons reflected in both the qualitative and quantitative findings many of these phenomena have been documented previously not just among marijuana users 62 but also tobacco users 6364 indicating that many of these factors may operate similarly across these substances quitting marijuana due to legal implications may be reflective of our studys geographic location recreational marijuana use is currently still illegal in the state of georgia this reason may need further comparative study with young adults in other states with differing policy contexts legal implications also were reflected both in the qualitative results and in the factor analysis of the developed scale paired with social reasons as one factor within this factor the lack of marijuana use within participants friend groups and marijuana use not coming up in social situations correspond with the literature indicating that users who only do so in social situations are more likely to quit using before those who use it for the effect 3637 relatedly the other factor indicated in our developed scale regarded instrumentality participants who quit using marijuana for these reasons may have felt that the negative effects of use outweighed the achieved high or other desired effects these reasons could be utilized in cessation interventions or education campaigns as reasons to quit the current study has implications for research and practice further research is needed to improve understanding of the reasons for initiation use and cessation in young adults to design theorybased interventions that prevent or mitigate the risks associated with marijuana use in particular it is important to note the different use patterns over time in relation to different reasons for using and quitting marijuana to inform interventions 18 65 66 67 68 overall the high prevalence of marijuana use in young adults 2 calls for increased attention to potential reasons for cessation to develop successful interventions and public health campaigns to reduce the harms of marijuana use in young people limitations despite this studys contributions to the literature several important limitations must be noted first findings from the samples involved in these analyses are not intended to be generalizable but rather to inform future generalizable studies 69 future studies will need to assess reasons for cessation in a broad scope of populations of various demographics second our scale items may not reflect all potential reasons for marijuana cessation however the items developed and included here were drawn from the literature related to reasons for marijuana cessation and from our qualitative findings these analyses are also limited by the selfreport nature of the assessments for the qualitative phase of the study the results are indicative of the opinions of participants who were willing and able to discuss these topics with the researchers finally the crosssectional design does not allow us to draw causal attributions or determine intraindividual trajectories of marijuana use over time implications for health behavior or policy our findings can be used to inform future research aimed at further expanding on or replicating the validity of this tool for assessing reasons for marijuana cessation furthermore these mixedmethods findings might inform theoretical frameworks regarding sociocontextual factors associated with cessation among young adult marijuana users given the changing cultural and political climate surrounding marijuana use practitioners and policymakers should use these findings and other thorough comprehensive research about marijuana use to inform health education campaigns and interventions about the dangers of marijuana use participant flowchart social context relaxing with friends youre not quite going out youre not drinking…just you and a few friends you chill out take it easy at the end of the day white male current marijuana user bonding you can be sitting around wherever youre at and your friend will be like hey come smoke a bowl with us and you get high and you all feel the same and have some crazy conversations very in depth and really good conversations while usingwhite male current marijuana user perceptions of marijuana author manuscript author manuscript payne et al

objective in this study we examined 1 differences among never current and former young adult marijuana users and 2 reasons for use and cessationwe conducted interviews with 57 young adults including 46 marijuana users enrolled in a longitudinal study of 3418 young adults and a survey in this cohort n 2866 participants reporting former but not current use on the survey n 607 completed the reasons for marijuana cessation section results interview data indicated reasons for initiating or not initiating use continued use and quitting the reasons for marijuana cessation scale included 2 factors 1 instrumentality and 2 sociallegal reasons conclusions these findings might inform theoretical frameworks upon which marijuana cessation occurs and direct future intervention studies

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the instructional role continues to be emphasized in professional librarians work in academic libraries 2 even socalled digital natives do not enter postsecondary educational contexts with sophisticated information searching or information evaluation skills 3 academic librarians therefore have significant responsibility to help students to become informationliterate this teaching role is complex and challenging and it has shifted over time from a strict focus on teaching students how to find materials in the library to broader goals which include teaching transferable skills such as critical thinking and information evaluation this study reports a recent survey of us professional librarians with instructional responsibilities that was conducted to explore respondents views practices and concerns the survey provided useful feedback on current pedagogical methods client groups of focus assessment and evaluation marketing instructional objectives incorporating the new framework for information literacy for higher education into instruction the role of technology in instruction the importance of relationships with faculty and administrators and a range of common challenges faced by this community 4 this is the first comprehensive national survey of this type in the united states although similar surveys have been conducted in other countries 5 march 2018 the definition of information literacy used in this study comes from the association of college and research libraries information literacy is the set of integrated abilities encompassing the reflective discovery of information the understanding of how information is produced and valued and the use of information in creating new knowledge and participating ethically in communities of learning 6 we were also interested in the extent to which the framework for information literacy for higher education is being used by instructional librarians the framework operationalizes the acrl definition of information literacy by focusing on seven threshold concepts and related knowledge practices and dispositions the threshold concepts that constitute the framework are • authority is constructed and contextual the survey data are useful to identify best practices to identify opportunities for improvement to current practice to compare practices across different contexts and to inform preprofessional preparation of librarians who will become providers of instruction previous evidence suggests room for improvement in the preparation of librarians for this role 8 in addition the survey results are directly comparable to several previous surveys conducted in canada which allow for future comparative analysis 9 research questions the following questions motivated this study 1 what are the instructional practices of librarians with responsibility for information literacy instruction in academic libraries in the united states 2 what are the challenges faced by these librarians in their instructional roles 3 what are some of the opportunities for improvement in information literacy instruction practice methods data were collected via an online national survey the survey asked respondents for demographic data to identify the context in which they worked these data points included the kind of library they worked in the size of their undergraduate population and their job title the main body of the survey focused on instruction practices issues surrounding information literacy and assessment of instruction concerning instruction practices the survey asked whether respondents focus their instruction on any particular discipline whether their library offers any formal or informal instruction whether they articulate written objectives for their instruction which staff take responsibility for instruction what proportion of staff time is spent on instruction what proportion of the student population receives information literacy instruction the content and methods of instruction the client groups of focus the effect of changes in information technology on instructional methods and content and current and ideal instructional objectives issues of information literacy were explored in questions that asked what constitutes information literacy who should take responsibility for developing information literacy skills in students and to what extent is instruction informed by the acrl framework 10 the survey also asked questions about the quality of instruction and how it is assessed this part of the survey collected respondents opinions on whether instruction is meeting objectives and asked about methods of assessing student learning methods of evaluating instruction financial and nonfinancial support for instructional work marketing of instruction and challenges to instruction the survey is provided in appendix b the survey instrument was designed in english using selectsurvey and was intended to take no more than 20 minutes to complete general feedback on the survey design and item responses was solicited from two professional librarians with instructional responsibilities at two geographically disparate universities their feedback was useful to ensure that the survey reflected current terminology and practice participants were recruited from the ilil listserv an american library association listserv that focuses on information literacy instruction at the time of the survey the listserv had approximately 6000 subscribers these subscribers are typically professional librarians and paraprofessional library workers who have an interest in information literacy the introduction to the survey specified that professional academic librarians who had responsibilities for information literacy instruction were the target sample therefore any librarians or paraprofessionals on the listserv who were employed in other types of libraries were not invited to respond consent to participate in the survey was implied by completion of the survey prior to participant recruitment and data collection ethics approval for the study was obtained at the universities where the authors are employed in spring 2016 the survey invitation was posted to the ilil listserv the survey remained open for six weeks with reminders sent out after two weeks after four weeks and one week prior to closing selectsurvey provided basic quantitative analyses of data and responses to openended items were analyzed using a qualitative content analysis method 11 results respondents the total number of respondents was 622 although the number of respondents per survey question varied since the size of the population is unknown this is not a probability sample the largest proportion of respondents work in universities while 39 percent work in colleges or technical institutes the largest fortynine percent of respondents who provided their job title had information literacy instruction or a similar concept as part of their job title examples of other job titles submitted include assistant librarian social sciences librarian head of public services and associate professor only 92 participants indicated that their library focuses on a particular discipline or subject area the largest proportion focus on a wide range of disciplines or a mixture of disciplines while 16 percent focus on healthrelated disciplines and 11 percent focus on humanitiessocial sciences or liberal arts thus the data indicate that most respondents worked in libraries with general academic collections when asked who had primary responsibility for instruction the majority of respondents put referencepublic service librarians at the top of the list with 63 percent of all responses fulltime instructional librarians were also seen as responsible for instruction receiving 55 percent of all responses and other librarians were also considered to carry responsibility for instruction by 101 respondents staff other than fulltime instructional librarians were seen as carrying primary responsibility for instruction by 43 respondents instructional practices in terms of time spent on instruction by staff other than fulltime instructional staff the survey differentiated between time spent at the start of academic terms versus the rest of the year respondents estimated that staff spend significant time on instruction at the start of the academic term of the total respondents 137 said staff spend up to 25 percent of their time on instruction 123 said staff spend 26 to 50 percent of their time on instruction 66 said staff spend 51 to 75 percent of their time on instruction and 10 said staff spend more than 75 percent of their time on instruction in contrast respondents estimated that during the remainder of the academic year nonfulltime instructional staff continue to spend time on instruction among respondents 199 said staff spend up to 25 percent of their time on instruction 107 said staff spend 26 to 50 percent of their time on instruction and 30 estimated staff spend 51 to 75 percent of their time on instruction none of the respondents estimated that staff spend more than 75 percent of their time on instruction during the remainder of the academic year these data are displayed in table 2 below most respondents reported that teaching information literacy is a shared responsibility with teaching faculty and with the students themselves table 3 respondents views on academic librarians level of responsibility for various aspects of information literacy recognizing when information is needed frequency percent not responsible 15 6 partially responsible 114 45 fully responsible 25 10 understanding how information is generated organized stored and transmitted frequency percent not responsible 2 1 partially responsible 99 39 fully responsible 98 9 understanding some ethical legal economic and sociopolitical information issues frequency percent not responsible 2 1 partially responsible 131 53 fully responsible 39 16 understanding that there exists a wide variety of information sources beyond the obvious frequency firstyear students are the focus of 85 percent of respondents and 81 percent of respondents focus on undergraduates in particular disciplines only 24 percent of respondents offer instruction to teaching faculty the largest proportion of respondents estimated that they reach 50 to 75 percent of their undergraduates with their instruction 28 percent reach fewer than 25 percent of their undergraduates and 23 percent reach 76 to 100 percent of their undergraduates the vast majority offer formal instructional opportunities in their libraries participants who work in libraries that do not offer formal instruction provided reasons such as partly size of library staff but mainly a n … unconscious belief that information literacy will just happen as part of the regular course work and the culture at this institution hasnt been favorable for including librarians and information literacy skills as part of the curriculum but we are in the process of negotiating new partnerships and opportunities to develop a program nearly all respondents offer informal instruction but only 52 percent have a written statement of objectives for their instruction the most widely reported foci for instruction are databases search strategies library use in general and the online catalog the data on instruction foci are provided in table 4 below respondents primarily use handson instruction in a computer lab and oneonone instruction lecturesdemonstrations in subject classrooms and webbased subject guides as their instructional methods the data on methods of instruction are provided in table 5 below respondents noted that technology has affected instructional delivery and content in the past few years 61 percent believe that it has affected instructional delivery quite a bit or a great deal fewer believe that it has affected content 49 percent report that instructional content has been affected quite a bit or a great deal fortyfive percent of respondents believe that use of it has improved students interest or participation in instructional opportunities for 45 percent n allows students to independently organize their learning experience in a manner that suits their personal style it provides a more active experience for students and creates a more studentfocused environment another commented i think students are aware of how much information technology is impacting their professionsdiscipline and so are motivated to engage with it now as students as they see it as a key competency and a competitive skill however another respondent warned i would say that it has increased somewhat interest and participation but i dont think that it is a silver bullet that can cover up a poorly designed or prepared instruction or a class with little space for active learning i also dont think that technology has the wow factor it once did and it is more or less an expectation of students most respondents also reported that using it has improved instruction one commenter noted p edagogically i employ constructivist theories to my practice because of this i believe that linking academic skills that i am teaching to nonacademic skills or experiences with which students are familiar can help make headway to true learning the way i can do that is through use of the i nternet and digital technologies which students employ in their real lives another noted t o quote the framework scholarshipresearch becomes more of a conversation than a lecture one wrote i think the various technologies allow us to reach students with varied learning styles and varied levels of accessibility another stated i think that creatively designing instruction sessions that leverage the technologyallow students to learn and discover total respondents 343 march 2018 things on their own and share that knowledge with others has improved the learning experience for students and librarians respondents reported that their primary instructional objective is to teach students how to critically evaluate the quality and usefulness of information followed by teaching general research strategies when asked to rank their instructional objectives participants gave the highest ranking to teach students how to critically evaluate the quality and usefulness of information the second highest ranking was teach students general research strategies the rank order of instructional objectives was mirrored in participants preferred instructional objectives some respondents indicated they had additional instructional objectives but did not rank these as important a complete list of items and rankings is presented in table 6 below responses to other survey items reveal that slightly fewer than half believe that they are meeting their current instructional objectives 29 percent do not believe they are meeting these objectives and 23 percent do not know student learning is assessed primarily through faculty feedback formative assessment during inclass sessions and student selfassessment evaluation of the librarys instructional program is equally informal 59 percent do so through informal faculty feedback 53 percent do so through respondents also noted that their instruction is only partly informed by the new framework for information literacy for higher education 12 the largest proportion of respondents report that the framework has had no influence or only a minor influence on their practice while 31 percent indicated that it has had a significant influence most respondents feel fully or partly supported by their library administrations for their instructional work but only 6 percent have budgeted funds for instruction challenges a wide range of challenges to instruction were reported but a few significant themes emerged some of the challenges identified in the openended responses are connected with lack of time and lack of adequate staffing • time 1 to get into the classes 2 to prep the classes 3 scheduling all the instruction sessions frequently they happen in a small period of time making a couple of weeks really crazy we focus on instruction for fullsized classes in the english department and for all students on a 11 student basis other challenges relate to lack of student motivation • students who dont realize they dont have researching skills • my library focuses only on freshmen and sophomores we may see some of the total respondents 273 march 2018 same students a few times in any given semester and its clear that they become bored with library instruction sessions and think each session contains the same content even thoughfrom our perspectivewe tailor each instruction session to the course subject and research assignment i want to make our instruction sessions more engaging with a greater focus on the information literacy framework concepts through activities and gamification techniques i want students to leave with a greater understanding of how information works and develop transferrable skills that they can use beyond the classroom • student motivationattentionengagement and same for nonlibrarian faculty several other respondents echoed the inconsistency of buyin from nonlibrarian faculty • faculty investmentwe have a mandated set of classes that need to provide library instruction and faculty buyin varies greatly do in library instruction sessions has much valuehis focus is on 3d printers and virtual reality games respondents were given an opportunity to make final openended comments and some are particularly revealing while some indicated significant problems others were more optimistic here are some examples • there is hope and change is happening i have a few faculty on my side and a plan for incorporating information fluency more intentionally into the curriculum interest is growing and faculty are realizing that we can work together to improve learning outcomes • i became an academic librarian to teach with the addition of the framework for information literacy i have fully evolved my library instruction with tremendous success teaching learning services within my libraries have raised our instructional brand in a significant way • i am lucky to be in an environment where faculty truly see me as a partner both inside and outside the classroom • currently in the process of developing a new information literacy plan and program where research skills are the beginning and reflective of the acrl standards after research skills the research process is the focusfaculty and librarians collaborate on curriculum and assignments in order to incorporate the acrl framework in disciplines • we are improving in the teaching and assessment of student learning outcomes but have a long way to go the il standards were great as training wheels to get us moving in the right direction towards authentic assessment but the il framework will truly set us free reimagining what we can do with the reference desk will also be a piece of the puzzle as will partnering more closely with the writing center discussion opportunities for improvement these data demonstrate significant commitment to information literacy instruction as well as a host of substantial challenges to success the data also suggest multiple opportunities for improvement in instructional practice in particular fewer than half of respondents articulate written objectives for the instruction the practice of recording instructional objectives is a key step in assessing instructional outcomes and evaluating instructional effectiveness thus consistent with that finding the survey also revealed that assessment and evaluation remain largely informal in the absence of systematic assessment of learning outcomes associated with information literacy instruction the return on investment in instructional work is uncertain and administrators may have difficulty supporting instructional work in addition marketing of instructional opportunities remains relatively informal suggesting an area that might be strengthened the picture of instructional practices of librarians responsible for information literacy instruction in the united states that emerges from the data is one in which undergraduate students are the main target population and this audience is reached mainly through formal but also informal instructional opportunities in libraries however only about half of libraries have formal objectives for instruction which may hamper their ability to fully assess programs or to have the data at hand to demonstrate the impact the library has in ensuring that students reach competency in information literacy the focus of much instruction is the use of databases search strategies general library use and use of the online catalog while these topics reflect needed skills they also represent the mainstay of instructional efforts while some respondents report including topics such as social media open access publishing images and fair use and citation metrics most instruction is skillsbased and though increasingly integrating information technology has yet to incorporate the threshold concepts outlined in the framework for information literacy for higher education 13 this may in large part be due to the newness of the framework thus changes in practice may not have had time to be fully implemented it is exciting to see that the vast majority of respondents see connections between the concepts presented in the framework and their responsibility to raise the level of information literacy among students in assessing student learning and evaluating the effectiveness of instruction librarians are using a variety of strategies but the main data sources for these evaluations march 2018 lean heavily on student selfassessments and faculty feedback to gauge student learning and selfevaluation and informal feedback from faculty and students when assessing the quality of the instruction program among respondents in this study assessing the quality of instruction and programs are topics that academic librarians continue to struggle with the challenges faced by these librarians are many the main issues are time and insufficient support respondents talk about being spread thin in terms of their ability to cover the number of classes necessary to meet the needs of the student body even though they are stretched thin librarians are frustrated by the view that information literacy can be achieved over the course of a onehour demonstration and want to see more support and a greater visibility as instructors who have a high level of needed expertise recognition and support are needed from administrators and nonlibrarians and academic librarians continue to work to educate these stakeholders in the importance of information literacy and the usefulness of instructional partnerships with librarians several respondents had stories of success to share comparison with canadian data the survey findings are largely echoed in data from canadian surveys of information literacy instruction in academic libraries over an extended period of time 14 while the canadian surveys were distributed differently the instrument used was identical so data are roughly analogous in addition it must be noted that the last canadian survey was conducted five years ago and some changes in practice may have occurred since that time there are few significant differences in results between the us and the latest canadian data but one difference is a much larger proportion of librarians in the us sample whose primary job responsibility is information literacy instruction according to the last canadian survey primary responsibility for information literacy instruction is shared across multiple reference librarians this difference could be due to the passage of time the survey results regarding informal assessment and evaluation are similar in the canadian data however written statements of teaching objectives were even less common in canadian academic libraries thus some of the biggest opportunities to improve instruction are evident in both countries finally respondents in the us and canadian data sets reflect identical issues and concerns including variable buyin from students and course instructors as well as from library administrations implications for preprofessional preparation through this survey the practice community has provided data with significant potential to inform the preparation of librarians for instructional work first understanding the basic who what and where of instruction can assist preprofessionals to understand the scope of daily practice areas where opportunities for improvement to practice exist can also inform course content decisions made by educators in preprofessional programs understanding the ongoing challenges faced by instructional librarians which appear to be rather enduring can also open opportunities for discussion and strategic thinking among preprofessional librarians about ways to ameliorate barriers to achieving the full potential of information literacy instruction 15 future research as has been done with the survey data gathered in canada this survey or a version of it could be conducted periodically over time to provide longitudinal data analyzing trends can help to demonstrate progress as well as identify ongoing and persistent challenges that may merit particular focus for amelioration more indepth exploration of instructional work through focus groups and interviews for example could also enrich these survey data there are good examples of such studies that could be used as models 16 conclusion information literacy instruction is a fundamental professional practice in academic libraries and academic librarians are primary providers of information literacy instruction generally improvements to that practice are possible only when current practices across the field are understood before this survey there were no published descriptive data on those instructional practices for the united states as a whole a gap that this study sought to fill as information literacy is widely understood to provide a critical foundation for success in daily life the workplace and in civic engagement it is important to promote best practices for information literacy instruction the data gathered in this study have the potential to be foundational for identifying and promoting those best practices appendix a invitation to participate in the survey survey of information literacy instruction in us academic libraries are you an academic librarian with instructional responsibilities you are invited to participate in an online survey aimed at us academic librarians the purpose of the survey is to identify information literacy instruction practices in us academic libraries the research is being done by dr heidi julien from the university at buffalo and dr don latham and dr melissa gross from florida state university the survey should take no more than 20 minutes to complete and is accessible using this link link here the survey is voluntary you have the right to not participate in this study and you have the right not to respond to any particular question items on the survey if the survey is completed and submitted your consent to participate will be assumed once your survey responses are submitted you will not be able to withdraw from the study the survey does not collect identifying information so survey respondents are anonymous the survey data will be handled in compliance with standard ethical principles the study has been approved by the university at buffalo institutional review board and the florida state university institutional review board the data will be used to write research papers and make conference presentations as far as is known there are no particular benefits to you to participate in this study nor is there any potential harm the only inconvenience to you is your time if you participate your survey responses will be stored in a safe place until the study is completed and the results are disseminated then they will be deleted if you have any questions about this study now or in the future please contact dr heidi julien department of library and information studies state university of new york at buffalo 7166451474 you can also contact the research participant advocate at 7168884845 or appendix b survey of information literacy instruction practices in us academic libraries welcome are you an academic librarian with instructional responsibilities you are invited to participate in an online survey aimed at us academic librarians with instructional responsibilities the purpose of the survey is to identify information literacy instruction practices in us academic libraries

an online survey sent to the community of professional librarians in the united states who provide information literacy instruction in academic libraries provided insights into their practices and the challenges they face data include current pedagogical methods client groups of focus assessment and evaluation marketing instructional objectives incorporating the new framework for information literacy for higher education into instruction the role of technology in instruction the importance of relationships with faculty and administrators and a range of common challenges faced by instructional librarians 1 the survey results can help to identify best practices to improve current practice to compare practices across different contexts and to inform preprofessional preparation of librarians who will become providers of instruction

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introduction in this paper i aim to demonstrate how emotional reflexivity can help researchers aspire to the guiding principle of objectivity and negotiate the pitfalls of the reflexive turn based on my research experiences in an interdisciplinary multimethod longitudinal study of lowenergy social housing in aberdeen scotland the first step in this paper will be to provide a literature review around the themes of objectivity emotions field position and the reflexive turn before outlining the study undertaken it will then be argued that the authors firsthand exposure to the emotional stories told by some participants during the three rounds of indepth interviews enhanced his understanding of the household occupants following this it will be demonstrated how emotional reflexivity allowed the author to understand the developing empathy he felt with these participants and how he began to share their frustrations and disappointment with the response of some council workers and the effect this had on his interpretation of research findings further reflection on the impact the emotional exchanges had on him also allowed him to locate himself within the research field and to understand the influence this had on his representation of the research field this then allowed him to temper his focus on the negative experiences of some of the household occupants and produce a more comprehensive report on a fuller range of occupants perspectives this it will be argued allowed the author to enhance the degree of objectivity achieved in this project and provided a useful means of negotiating the reflexive turn throughout it will also be demonstrated that emotions and emotional reflexivity are multilayered and have implications for research participants research teams and for the knowledge that emerges from the research emotions have always been central to sociological analyses and occupied an absent presence in classical sociology however historically social scientists widely assumed that by focusing on the production of knowledge as the sole aim of sociological enquiry researchers could minimise bias however becker and gouldner created debate when they argued that the valuefree sociology advocated by weber is an unobtainable goal and the use of the concept of bias in evaluating research has been problematized for assuming a positivist ontology according to cunliffe social scientists have contested the conventional notion of social reality knowledge and the validity of social inquiry to provide an absolute objective view of the world christians further points out that there has now been an emergence of a new model of research ethics in which human action and conceptions of good are interactive resulting in a field of qualitative research which advances social justice and is grounded in hope thus the kind of objectivity required for a valuefree approach is both unlikely and even if it could be achieved overrated social researchers are socialized beings and whilst objectivity is a useful benchmark for guiding research it is never something that we can fully achieve for our values attitudes and beliefs will impact upon the research we carry out and our findings therefore i agree with becker when he points out that sociological analysis is always from a particular perspective or as many feminists such as hartsock say from an epistemological standpoint finch points out that this is particular pertinent in studies of women and researchers need to be wary as to how female participants perspectives are represented whilst this feminist perspective is not central to the argument presented in this paper it has to be acknowledged that the researcher comes from a particular perspective before during and after the research has taken place and that the resultant data emerges from the contextual relationship between the researcher and the researched therefore the researcher needs to ensure that the standpoint adopted provides an inclusive account and does not misrepresent the views of research participants ward warns that researchers need to be aware of how our identities impact on our ability to elicit data that is valid truthful and useful… in line with the reflexive turn researchers must therefore reflect on their experiences and reveal the influence field position has on their representations the reflexive turn and the guiding principle of objectivity reflexivity however poses a problem for researchers we have to reflect upon our position within the research field and our methodology but at the same time we also have to avoid perpetually deconstructing our arguments narcissistic navelgazing by placing our position ahead of the research participants and in pointing to the shortcomings of our methodologies undermining the validity of our research instead we must reflect upon our research fields and findings in such a way that it adds legitimacy to our authorial voices the effect of the researcher in the field can be positive and reflexivity does not require us to give up the guiding principle of objectivity hammersley and gomm 1997 para 412 to quote bourdieu at length to adopt the point of view of reflexivity is not to renounce the objectivity but on the contrary to give it its full generality by questioning the privilege of the knowing subject arbitrarily freed as purely noetic from the work of objectivation it is to work to account for the empirical subject in the very terms of the objectivity constructed by the scientific subjectin particular by situating him or her at a determinate place in social space and thereby to acquire awareness and mastery of all the constraints that may impinge on the scientific subject through the ties that bind him to the empirical objects those interests pulsions presuppositions with which he must break in order fully to constitute himself as such the guiding principle of objectivity in this study therefore relates to adopting a field position that allows the researcher to account for the widest array of participants voices at the same time and in line with the demands of the reflexive turn it also relates to locating the researcher within the field and revealing how this has influenced the interpretation of the research data and the representation of it however tackling the reflexive turn is no simple matter in this paper i will demonstrate how emotional reflexivity can provide a useful means of negotiating the pitfalls of the reflexive turn and should therefore be seen as a resource rather than a methodological problem emotional reflexivity has been used in a variety of ways here emotional reflexivity refers to both reflecting on emotions and the effects emotions have on reflecting which will also be influenced by the temporal and spatial distance from the research field burkitt argues that emotion should be understood …as a motivating factor to reflexivity colouring and infusing reflexivity itself we can also put emotions back into the 16 17 18 19 110 context of social interactions and relationships in which they arise emotion is not just something that we reflect on in a disengaged way it is central to the way people in social relations relate to one another it is woven in the fabric of the interactions we are engaged in and it is therefore also central to the way we relate to ourselves as well as to others emotional reflexivity and the reflexive turn the founding figures of sociology durkheim marx and weber paid little explicit attention to emotions this is perhaps because emotions were assumed to pose a threat to the objectivity claims of the rational scientist this kind of attitude still persists in the wider professional field today to some extent at times alienating qualitative researchers from their quantitative colleagues that is quantitative methods are typically seen as more objective than qualitative kleinman and copp say as members of the larger discipline fieldworkers share a culture dominated by the ideology of professionalism or more specifically the ideology of science according to that ideology emotions are suspect they contaminate research by impeding objectivity hence they should be removed this can create a dilemma for the social researcher debating whether or not to report on emotional dimensions of their work and has led to some researchers leaving the emotional aspects of their research unreported however kleinman and cantómilá points out that emotions became a more legitimate focus of study for sociologists in the 1970s and 80s drawing on the dramaturgical approach of goffman hochschild blazed the trail for the growth of the sociology of emotions in her study of airhostesses in delta airlines and the sociology of emotions is now a wellestablished field of study which cannot be fully reviewed here key concepts pertinent to this paper will be explained cantómilá argues that emotions should be understood as feelings individual have and sometimes share and as invisible threads that bind us together in endless webs of interrelations and that they are socially constructed through discourse as well as through repeated practices that cultivate certain emotions over others and certain ways of experiencing them over an array of options that is our emotions are guided by what hochschild called feeling rules which refer to standards relating to what is due and owing in the currency of emotions in different social setting and encounters flam and kleres explain that feeling rules tell members of any given society when to feel which emotion and also with what intensity and duration hochschild also makes an important distinction when she further points that we employ emotional labour when following feeling rules during paid employment and emotional work when we follow feeling rules outside of it both have costs for the individual but hochschild argues that emotional labour can take a greater toll on the psychological welfare of the individual who may be coerced into displaying emotions that do not correspond with their internal feelings for barbalet emotion simply indicates what might be called an experience of involvement… that a person cares about something registers in their physical and dispositional being it is the experience that is the emotion… seebach and nùnezmosteo further argue that sharing these experiences creates links between those who feel the emotion and those for or because of whom they feel it these concepts amongst others have provided useful frameworks for researchers to reflect upon their emotional experiences whilst conducting social research as part of the reflexive turn and there is now a wealth of literature surrounding this issue bellas states that despite the emphasis on emotional detachment and neutrality researchers can become deeply involved in their subjects lives particularly when there is sustained contact between researchers and subjects therefore whilst emotions may not be absent from other types of research it is the researcher using ethnographic techniques who may be more emotionally involved with the research field because they spend more time interacting with research participants in an attempt to capture their world view qualitative researchers however may feel reluctant to report these feelings because they feel vulnerable to criticisms of the broader professional field indeed burkitt argues that emotions have been perceived as a barrier to clear reflexive thought and holmes points out that theories of reflexivity have tended to ignore emotions however romocea argues that emotions do not compromise the scientific standard of research but rather adds a new dimension to doing research feminist methodology has now made the role of the researchers emotions explicit in the research process and those who have tackled the dual dangers of the reflexive 111 112 113 21 turn and talking about emotions have demonstrated that feelings have significance when conducting research for example seal discusses the implications her feelings of ambivalence towards women accused of murder had in her archival research of representations of them however it is ethnographic researchers who have explored the impact of emotions on research in the greatest depth they have discovered that emotions such as sadness and euphoria can enhance ethnographic knowledge hubbard et al argue emotionallysensed knowledge is an indispensable part of the research process it has also been argued that revelatory moments when conducting ethnography can be stimulated by deeply emotional experiences thus it has been recognized that knowing and feeling cannot be separated and emotions therefore have epistemological significance which should not be ignored indeed flam and kleres argue that scholarly discourse can be understood as a specific interpretation of reality with implicit or explicit emotion and i agree with kleinman when she argues that ignoring emotions in research could be considered a form of neglect many researchers have now demonstrated the benefits of reflecting on the emotional aspects of research in trying to capture the worlds of the participants ethnographic researchers must develop an empathy with their subjects if they wish to produce credible ethnographic knowledge and it has been recognised that developing empathy involves emotional labour on the part of the researcher gray says the nature of the relationship between the researcher and the object of study has important affective dimensions with implications for research practice blackman explicitly explores this issue in hidden ethnography when he crosses emotional borders and discusses the significance of emotional relationships between the researcher and the researched in his qualitative studies of young peoples lives goodrum and keys and dicksonswift et al further discuss the emotional labour carried out by qualitative researchers when researching sensitive topics arguing that such research is an embodied experience and can be damaging for both the researcher and participants blackman further points out sensitive research can intrude on areas that are private stressful and sacred researchers therefore need to employ strategies to promote selfcare and the care of the participants furthermore the emotional impact of the research relationship does not end when the researcher leaves the field hammersley and atkinson contend that researchers rarely leave the field unaffected by the research experience and must therefore continue to reflect upon the impact the complex identities and relationships within the research field have on our representations of it to the wider community that is we may require a spatial and temporal distance from the research field in order to be effectively reflexive hubbard et al say the emotions of the respondent and also those of the researcher are likely to influence and inform our understandings of the topic under investigation delamont further argues that qualitative researchers need to be more reflexive in their account of leaving the research field as exiting the research field can have an impact on our understanding of the research field and will impact upon our representations of it therefore emotional experiences in the research field can lead to the researcher developing a particular perspective this is an issue that has been explored by lumsden in you are what you research where she evaluates how her position within the research field impacted her research of boy racer culture in aberdeen scotland she describes how she unintentionally took sides with the boy racers in her research and reflects on how this affected her representation of the subculture that is she felt a responsibility to give voice to the underdog viewpoint in public debates indeed critical ethnographers often adopt an overtly critical and political approach towards the research field as they aim to expose inequalities in an effort to affect social change however i agree with lumsden when she concludes as part of the reflexive turn researchers should be open to an examination of their values on the research process their representations of the researched and the dissemination of research findings the study this paper is based on a longitudinal multimethod interdisciplinary study of lowenergy social housing in aberdeen scotland which took place between january 2012 and june 2013 the houses based in three different sites used a variety of sustainable technologies including air source heat pumps solar hot water panels photovoltaics mechanical ventilation heat recovery triple glazing grey water recycling and rainwater harvesting the research was commissioned by aberdeen city council in response to the mixed experiences of occupants that is whilst some occupants seemed happy in their new homes acc faced serious complaints about breakdowns in technology and high electric bills this research was funded to try the study involved a survey the collection of technical data workshops three rounds of indepth qualitative interviews and a research diary it involved researchers from different disciplines including the social sciences science and engineering this paper is primarily based on the qualitative indepth interviews that the author carried out and the research diary he kept because whilst emotions may not be absent from other methodological approaches it is those researchers who spend more time with participants who may become more emotionally involved with the research field the sample comprised fourteen households of different types and is illustrative rather than representative participants across all adult age groups and both genders were represented in the sample which included families with and without children and individuals living alone depending on the wishes of the research participants some interviews were conducted with two adult residents of the household and in others with just one participants were identified in part as selfselectors through volunteering at the initial public workshops as well as through snowball sampling via word of mouth recommendations by acc however not all households participated in all the follow up interviews with one dropping out at the second round and a further four at the final round this was due to the difficulties in organising a convenient time for the interview to take place and to participant fatigue the next step will be to describe the emotional stories told during the household interviews and the impact this had on the researcher and his consequent representations of the research field the names of participants have been removed to protect their identities in line with ethical standards of good practice emotional exchanges field position and representation after experiencing a number of complaints from householders in the new lowenergy housing regarding technical problems and high electric bills acc funded research to investigate the householder experience from the outset it seemed that some residents viewed the situation as a battle between acc and the household occupants when i became involved with the study the principal investigators reported that emotions were running high amongst many of the household occupants across the three sites whilst many of occupants professed that they loved their new homes at the initial workshops others displayed anxiety and anger surrounding the technical problems and allegedly high energy costs the survey findings reflected these issues and pointed to differing feelings towards the new homes some reported that they were very happy generally speaking i am extremely satisfied with this flat however others highlighted frustrations around technical problems and costs for example when asked the open question if they thought the technology was worthwhile one respondent replied if i had the chance i would move out of this house due to all the problems and high rent that goes with it no one at the council seems to care that we go six days sometimes without a shower or hot water if a solution is not found shortly i will be demanding a move out of here however it was not until the household interviews took place that the full level of emotion became apparent to me household interviews and emotionallysensed knowledge the level of emotion circulating amongst the interviewee took me by surprise as it was not something that i had fully anticipated as indicated by my research diary entry after one of the first interviews this interview seemed to go very well this occupant had a lot of problems particularly initially i could feel that she was becoming rather upset when talking about her problems and it struck me that this is not something i had banked on this made me feel a little awkward and i thought it may be worth discussing with the research team in advance of the next round of interviews in other studies the willingness of participants to vent emotions openly in interviews has been put down to the intimacy of the research setting and to the trusting relationship developed between the researcher and the participants however in this study it may be that participants volunteered for the research as they wanted an opportunity to vent their anger from the moment i contacted occupants to organise interviews some were keen to express their feelings about their new homes when calling an occupant to organise an interview he stated that i would be sorry to ask them about their home he felt that it was a disgrace how they had been treated by the council on arriving at the homes of participants some started to complain when they answered the door the occupants in this household said that they hoped that i was ready for their complaints from the minute of entering the house both occupants complained that this house was not what they had been promised they felt that they had been misled and were paying for the privilege of putting up with problems like not having heating or a flushing toilet these interactions were important and demonstrated that interviews begin at the point you make contact with participants and highlights the importance of recording these exchanges in a research diary that is the diary can allow the researcher to capture the emotional impact of the interview encounter that may not be immediately evident when reading the interview transcript alone this points to the primary importance of the experiential component of emotion when conducting interviews some of the questions received an emotional response for example one couple saw no advantage to moving to their new home interviewer so are there advantages to having moved here interviewee 1 no i would rather deal with the stairs than the trouble that weve had i mean even outside the cost of the electricity bills the cost of being left with no shower for ten days em… its just its a good idea but theyve done it wrong interviewee 2 if it had worked if wed come in i know theres going to be teething problems but if everything had worked as its supposed to it would be ideal like if we didnt have to wait ten days for a shower because thats our only method of washing apart from a tiny sink dyou know what i mean weve had to then go down to family and friends or whatever to get showers you know its just ridiculous that somebody can leave us ten days without any proper washing facilities after this interview concluded the couple informed me that other occupants on this site had already put in for a council transfer due to high energy costs and technical problems they then went on to say that they were trapped in their new home because there was so little social housing available with the disabled access they required this conveyed to me how desperate they must feel in their current housing situation and i could sense feelings of empathy for these residents growing stronger and i felt motivated to help them as much as i could that is the sharing of emotions created a link between the interviewer and the interviewees some participants became visibly upset during the interview whilst interviewing an elderly woman she said that she could feel herself becoming upset as she recounted the technical problems she had with her toilet her heating and hot water when she moved in she explained that the lack of heating and hot water caused her arthritic pain to worsen and how embarrassed she felt having to ask to use her neighbours toilet when hers was not working i could see her trying to control her emotions holding back tears and wringing her hands and it became clear that participants had to employ emotional work during the interview process it also pointed to the possible influence that emotional experiences can have on participants accounts of their experiences and indicates that participants also engage in emotional reflexivity during the research process thus emotions influence memories whilst at the same time remembering influences our current emotional states the above interview had a particularly strong impact on me i could feel myself becoming emotional as i imagined how my mother would feel in such a situation not wanting the emotional exchange to escalate as i could sense that the participant wanted to control her emotions for fear of embarrassment and i wanted to maintain a professional demeanour i listened to her story quietly before moving on on reflection it struck me that there is an emotional cost for both participants and researchers when conducting research in which participants reflect on emotionally charged negative experience participants engage in emotion work whereby they try to control their negative emotions whilst researchers engage in emotional labour by controlling their emotional responses in not responding to the research participant in the way i would a friend also instilled feelings of guilt on my part this fuelled an increasing responsibility to represent these participants perspectives to the research team and acc it also occurred to me that negative emotions may have a more powerful impact on researchers when listening to participants accounts of their experiences than positive ones 315 the second round of interviews revealed the continuing emotional impact the technical problems and high costs had on the occupants in the new homes one occupant claimed that the financial stress caused by high rents and energy bills took its toll on her marriage interviewer so what kind of impact have all these problems had on your life then interviewee my marriage breakdown interviewer ok interviewee because its either pay your rent or worry about your energy prices that youre having to pay with all the faults and everything thats gone on in the house it leads to arguments and worries and my marriage broke down when discussing this issue i could see that the interviewee was trying to control her emotions by avoiding eye contact and maintaining a steady voice in this instance it seemed that she was using emotion work to follow feeling rules she felt framed the encounter this made me feel a little awkward as i wanted to show sympathy without escalating her emotional state another occupant became upset as she explained that moving to her new home had completely changed her lifestyle and that of her children in a detrimental way interviewer how has moving here impacted upon your lifestyle interviewee em i just think over in my old house i did not have much worries you know i could put on my electric i did not ever think oh i cannot put on the kettle or i cannot put on the tv but here im constantly worried and i just feel it was the worst decision in my life to take a house like this do you know what i mean during this part of the interview the interviewee became upset and i had to switch the recorder off to allow her to take a breather she went on to explain that due to the high rents and energy bills she could not afford to live in her new home on the benefits she received and her teenage daughter had therefore to give up a promising career in football to get a paid job so that they could afford the bills again i could recognise the reciprocation between the emotion work and costs to the participant and the emotional labour of the researcher following standardised protocols to deal with upset research participants that is i had to follow guidelines drawn up by the research team in line with professional ethics and in doing so my response felt unsatisfactory as i would have liked to have shown my sympathies more overtly it occurred to me that my lack of emotional response to participants stories could also appear unsympathetic to the research participants this may have contributed to research fatigue and participants withdrawing from the study or appearing less enthusiastic to participate in followup interviews this is demonstrated in notes taken in my research diary during the last round of interviews when i arrived for interview the participants were not at home i waited and the female householder drew up in the car she said that she forgot about me coming today and she was busy but to come in anyway whilst i chatted to her she carried on putting shopping away and repeated that she and her family were fed up with the whole thing and she could not be bothered talking about it anymore i therefore decided to forgo the interview and informed her that her views would be put forward to the council in the final report this stood in contrast to the earlier enthusiasm this household displayed when they initially volunteered to take part in the research it may also go some way to explain why a number of participants reported feeling fed up and appeared less motivated to participate in the second and third interviews with some participants dropping out this points to an important consideration when conduction longitudinal research of negative experiences in that the ongoing cost of emotional reflexivity and emotional work of participants coupled with the muted emotional response of the professional researcher may discourage participants completing the research project this suggest that whilst sharing emotional experiences can link people together a failure to display emotions can result in a disconnection between them it also highlights the importance of providing care for both research participants and researchers when dealing with emotional subject matter these qualitative interviews allowed me to empathise with the emotional impact moving into these homes had on occupants i could easily identify with the technical and financial problems and imagine the kind of impact that they would have on elderly relatives and singleparent families within my own family i also shared some of their frustrations and disappointments i believe therefore that i developed a fuller understanding of these research participants this demonstrates how emotionallysensed knowledge can enhance ethnographic understanding i will now go onto demonstrate how reflecting on these emotional aspects of the research also allowed me to understand how my feelings of empathy with these occupants developed and how this then effected my representation of the research field 316 317 emotions field position and representation from the beginning of the report writing stage it seemed clear that i was more motivated to present a fuller account of the occupants negative experiences for example on reading the first report for acc i noted that the technical problems and high costs faced by occupants had not been fully documented the project leaders explained that this was because the council already had a record and knowledge of the complaints however i argued that some occupants felt that their complaints had not been fully heeded i therefore argued that we had a responsibility to represent the occupants views and give voice to a less powerful group as repayment for their time and cooperation in the research process the team agreed to some extent and added more ethnographic detail surrounding technical problems and high costs to the report with a fuller summary of problems added as an appendix similarly in the second report i felt that the impact the technical problems and high costs had on the lives of the occupants needed to be documented with examples from the second round of interviews whilst some ethnographic detail was then added to the report i still felt that more emotive examples could have been used however i felt that i could not further my case against the wishes of the senior researchers this is illustrated in a note in my research diary after reading the draft of the second report for acc i felt disappointed that more details of the residents negative experiences had not been included i emailed the principal investigators who replied that we needed to focus on ways to improve the experience i still felt guilty that i had not been able to represent these householders in the way i would have liked but had to be satisfied that i had tried to get their voice heard and had succeeded to some extent it also struck me that the project leaders seemed focused on evidence of learning and adaptation at the expense of problems for example i was somewhat surprised to read discussions of local experts and champions when i felt that the evidence continued to point to continuing technical problems and a lack of knowledge and understanding of the technologies on discussing this with one of my colleagues he explained that he wanted to produce a report that the council and householders would find useful rather than reminding them of problems he also pointed out that his disciplinary baggage as an educational researcher probably shaped his reading of the data this highlights the importance of researchers biographies and one of the advantages of reflexivity as a collective process indeed further reflection on my part highlighted that i needed to be careful not to be so influenced by the negative experiences that it excluded the perspectives of residents who reported a more positive experience this further implies that negative emotions may be more influential than positive and may require more close scrutiny in our reflections thus emotional reflexivity allowed me to reveal how my field position influenced my interpretation of the data that is the emotional stories told during the interview resulted in my developing a greater empathy with those research participants who had had a negative experience than others in the research team i am not therefore suggesting my colleagues did not sympathise with the occupants but i am arguing that my first hand exposure to their stories led to a fuller understanding of the emotional impact moving to their new home had and provided me with a fuller understanding of their situation in this case listening to the emotional stories of the occupants deepened my understanding of this particular group within the research field and enhanced my ethnographic knowledge my colleagues who tendered for the research project and who had spent more time with the council representatives may have had a greater understanding of what was required by the funders and a fuller understanding of their viewpoint we therefore occupied different positions within the research field which impacted upon how we wished to present our research findings whilst it is not an issue that will be fully explored here this points to the importance of power politics and the construction of knowledge in funded research and a potential role for emotional reflexivity in exploring these dynamics what i hope to demonstrate here is how emotional reflexivity enhanced the degree of objectivity attained in this project emotional reflexivity and the guiding principle of objectivity on reflection it became clear that many of my additions to the report were about the negative experience of some participants when looking back through the data again there was clear evidence that some occupants were happy in their new home for example one occupant commented i would recommend these technological systems to be installed in all social housing it would save people on low incomes an awful lot of money and make a big impact in reducing carbon emissions similarly there were those respondents who reported liking their new homes interviewee yes the house is great much more room than my last place and the people are nice the neighbours n that ken the wifey from the coonsil as well shes been really good getting things fixed and showin us how to work the heatin furthermore whilst some occupants had very expensive energy bills which were difficult to account for others perceived their bills to be greater than they actually were for example four occupants who claimed that their energy bills were much higher than their previous home proved to be mistaken when costs were explored in greater detail in the second round of interviews these perceptions i feel were affected by the high levels of anxiety across the sites one occupant said that she was worried about her forthcoming bill even though she had yet to receive one many occupants also spoke about residents getting to get together to discuss bills as they came in interviewer do you discuss your bills with your neighbours interviewee yes its just like as soon as the post hits the mat were all out into the park to discuss how much weve been ripped off this time it seemed to me that the negative emotions surrounding energy bills and technical problems amplified perceptions of cost amongst occupants similarly when asked about the information and guidance given and what they had learned about the technologies many of the occupants offered negative replies interviewer when you first moved in what information were you given about the technologies here interviewee none interviewer nothing interviewee none interviewer did anybody from the council tell you about the technologies interviewee nope they just told me not to touch the upstairs cupboard where all the stuff for the solar panels is another typical response from occupants claimed that the only thing they had learned about the technology was that it does not work however when probed further it became apparent that occupants had been given some information and guidance in the form of manuals and demonstrations and many had learned a lot about the technology in their homes for example there was some evidence of occupants fixing problems with their neighbours heating and hot water it occurred to me that the stress and anxiety caused by the technical problems and the failure to achieve quick repairs had overshadowed the learning experience the emotional experiences coloured the residents accounts and highlights the importance of considering the effect negative experiences can have on research participants and their accounts i can now also recognise that in sharing these anxieties with occupants during the interviews my perceptions could have also been influenced this in turn could have then led me to emphasise these negative experiences at the expense of the positive by focusing on these problems i could therefore hinder the objectives of others in the research team they therefore to remind me that one of the aims of the research project was to try to get past the focus on technical problems and high costs and instead to identify ways to improve information and guidance maximize the learning experience and to encourage cost efficient practices it is also important however to keep in mind that these reminders of the council and research team objectives changed my position within the research field and in turn my interpretation and dissemination of the research data it must also be recognised that one advantage of group research projects is that colleagues can stimulate reflexivity and encourage a more balanced analysis conclusion historically whilst the links between emotions and knowledge have been long established emotions have not been an explicit focus for sociological researchers nor in their discussions of methodology because they were perceived to pose a threat to the objectivity claims of the social researcher however whilst objectivity should remain as a guiding principle in social research it has rightly been recognised as overrated and unobtainable and emotions have been an increasingly important research area since the 1970s and 1980s feminists demonstrated the importance of reflecting on emotions and the research process as part of the wider reflexive turn in the social sciences and there is now a plethora of literature surrounding emotions and research qualitative researchers are particularly concerned with emotions and research but there are dangers to both reflecting on emotions and the reflexive turn more broadly emotions can still be seen as unscientific by the 42 43 wider professional community and reflexivity can undermine the validity of the research however those researchers who have tackled the dual dangers of discussing emotions and the reflexive turn have demonstrated the importance of emotionallysensed knowledge in developing an ethnographic understanding of the research field and the advantages of reflecting on emotions drawing on my research experience in an interdisciplinary multimethod longitudinal study of lowenergy social housing in aberdeen commissioned by aberdeen city council this paper demonstrates that emotional reflexivity can help locate the researcher within the field and reveal the relationship between field position and data interpretation and representation whilst enhancing the degree of objectivity achieved in the research in doing so emotional reflexivity can help the researcher negotiate the dual dangers of discussing emotions in social research and the reflexive turn i have argued that due to my firsthand exposure to the stories of participants during the qualitative interviews the emotionallysensed knowledge enhanced my understanding of their situation in comparison to others in the research team during these interviews i developed an empathy with those occupants who reported perpetual technical problems and allegedly high energy costs and shared some of their frustrations and disappointments this in turn led to my desire to give voice to this less powerful group in the reports produced for acc however reflecting on the effect negative experiences had on the accounts of the research participants and the consequent effect the emotional stories of participants had on me as well as on my reflections and on my contribution to reports for the council demonstrated that i had unintentionally become more focused on the perspectives of some occupants the recognition of the influence my field position had on my interpretation and representation of the data allowed me to moderate my representations and help the team produce a more comprehensive account of the full range of resident experiences this demonstrates that emotional reflexivity can help the researcher aspire to the benchmark of objectivity as a guiding principle for social researchers it also demonstrates how qualitative and quantitative researchers from different disciplines can work together collectively to reflect more effectively and to produce a more inclusive account of the research field in conclusion emotional reflexivity can therefore provide a means for researchers to negotiate the pitfalls of discussing emotions and the reflexive turn and demonstrates how emotions can evolve during the research process in doing so emotional reflexivity can help to trace the researchers path through the research field and reveal the influence this can have on the interpretation and representation of data this enhances the validity of the findings and therefore should be seen as a methodological resource validity of the findings and therefore should be seen as a methodological resource this study also indicates that participants also engage in emotional reflexivity when recounting their stories which may have implications for participant retention in longitudinal studies research diaries can provide a useful vehicle for recording the emotional content of the interactions between the researcher and the researched that may not be immediately evident in interview transcripts and that negative emotions may have a more powerful influence on our field positions and interpretations than positive emotions in conclusion it seems safe to say that the complex nature of emotions and their multifarious effects on the researchers the researched and wider field relations require continuing examination and reflection notes this participant had a disability that affected his mobility

this paper demonstrates how emotional reflexivity can help researchers aspire to the benchmark of objectivity it will be argued that emotional exchanges during interviews with research participants can enhance understanding based on the authors research experiences in an interdisciplinary multimethod longitudinal study of lowenergy social housing in aberdeen scotland it will then be demonstrated that emotional reflexivity allowed the researcher to identify how his feelings of empathy with the household occupants who had had a negative experience developed and how he began to share their frustrations and disappointments with the council this allowed him to locate himself within the research field and help him understand how this influenced his representation of this group this consequently allowed him to moderate his focus on the negative experiences of some occupants and produce a more comprehensive account of the full range of the householders perspectives in conclusion it will be argued that emotional reflexivity can help researchers maintain the guiding principle of objectivity whilst locating the researcher within the field and therefore can provide an effective means of negotiating the pitfalls of the reflexive turn

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introduction as globalisation grows businesses are encouraged to set up their subsidiaries in foreign countries foreign assignments are usually challenging since several factors need effective planning and approach employees from the parent country are often required to work in foreign subsidiaries for some fixed duration according to zhou and qin these assignments are demanding for expatriates and unfortunately some of them may fail and are repatriated regardless of the problems associated with expatriation multinational corporations are still committed to sending expatriates to handle assignments in their subsidiaries they believe that parentcountry nationals not only fulfil the strategic needs of the firm but also maintain consistency of organisational culture between the parent firm and the subsidiary pcns also address the skills gap in subsidiaries particularly when host country nationals do not have relevant expertise in specialised roles 1 effective performance of expatriates is a key factor influencing the performance of a subsidiary 2 studies have illuminated various factors that influence the effectiveness of expatriates such as organisational factors social factors and individual factors notably some researchers have tried to examine the role of individual factors in the effectiveness of expatriates 3 but there are limited studies that have assessed the impact of individual factors on expatriate adjustment and role performance on average 40 of expatriates fail their assignments due to individual factors such as inability to adjust spousal issues and work efficacy 2 therefore organisations must be aware of individual factors as well as social and organisational factors that affect the success of expatriates in their international assignments the project will use the case of uk expatriates in chinas fashion sector according to holden there have been a growing trend of uk expatriates working in china particularly in the fashion sector as of 2022 there were 20000 british pcns living and working in mainland china many of them are domiciled in major cities such as beijing shanghai and guangzou 4 many british mncs send expatriates to china to handle specialised assignments and address existential skill gaps in the fashion sector these expatriates work for global fashion houses as consultants designers and managers extant literature is replete with studies on the factors that influence expatriate performance however many of these uses the case of western nations 5 in addition few studies have address the effects of individual factors on expatriate effectiveness simonelli and felix contended that studies should address this theoretical gap by investigating whether individual organisational or social factors predict success of expatriates thus the role of this research is to examine those individual social and organisational factors and their influence on expatriate performance this will help address the theoretical gap the results of the project will be beneficial in terms of decisionmaking and policy formulation managers will use the outcome of the project to develop effective strategies to enhance performance of expatriates in addition policymakers will find this project invaluable in informing their formulation of best practices that guide expatriation process the aim of the project is to investigate factors influencing the effectiveness of expatriates in their international assignments to achieve this aim the following objectives will be addressed to examine the trends of expatriates in chinas luxury fashion sector to examine the factors that influence expatriate performance in chinas luxury fashion sector to recommend ways to improve the effectiveness of expatriates in chinas luxury fashion sector this preliminary study will contribute to the project by reviewing some literature and providing the methodolody basis 2 literature review trends of expatriation in china according to holden china has witnessed increase in the number of foreign direct investment over the recent past particularly the high number of mncs setting operations in the country has led to increase in the presence of expatriates in the country foreign enterprises are setting operations in the country to tap into opportunities such as rising incomes excellent infrastructure as well as incentives for fdis availability of skilled labour and effective infrastructure according to qian and elsinga western expatriates in china prefer to live in big cities such as beijing shanghai guangzhou and hong kong these expatriates normally handle knowledge intensive assignments particularly in the supervisor and managerial levels according to the countrys national census there were at least 20000 expatriates from the uk representing about 33 of total expatriates in the country a large proportion of expatriates are from south korea the us mynammar and vietnam 6 the expatriates are mostly drawn to work in specialised roles in sectors such as manufacturing and retail however there is a rising number of expatriates in other sectors as well such as fashion logistics and pharmaceuticals among others factors influencing expatriate performance individual factors bhatti et al noted that selfefficacy of expatriates affect the extent to which they accomplish their assignments expatriates with high level of selfefficacy have been found to perform better in their roles than those with low levels of selfefficacy in particular expatriates with high selfefficacy are innovative and capable of adjusting to host countrys situations this helps them to enhance their performance bhatti et al maintain that selfefficacy strengthens performance through social networking prior international experience enables expatriates handle international assignments efficiently and effectively according to tsegay et al assignees that have been exposed to international roles do not experience cultural shock as they have the skill and expertise to adapt accordingly more specifically tsegay et al asserted that prior experience enhances traits knowledge that is crucial for job performance past studies posit that previous international assignments boost expatriates confidence and capabilities 7 8 however some studies such as mol et al found that previous international experience have no link with expatriate performance the justification for this contradictory result could be due to intermediating impacts of expatriate adjustment as asserted by guo et al an assignee may not have worked in foreign country before but their trait knowledge enables them to adjust swiftly therefore the conflicting findings in previous research motivates this research to conduct further investigations into the effect of prior international experience on the effectiveness of expatriate performance expatriate performance is also influenced by spousal adaptation various studies contend that the adjustment of spouses has significant effects on effectiveness of expatriates in handling their international assignments 9 research by taormina and gao shows that the length of stay of an expatriate was determined by spousal adaptability expatriates whose spouses adapt easily to the host country environment stayed longer in their assignments than those expatriates whose spouses failed to adapt similarly van erp et al maintained that expatriates facing family issues returned prematurely from their international assignments further van erp et al showed that accompanying spouses encounter difficulties adjusting considering that they are supposed to leave their job or realign their careers to support the expatriate and their accompanying children family systems theory shows that flexibility family cohesion and communication perform a crucial role in enhancing effectiveness of expatriates 10 on the contrary trompetter et al found no significant link between adjustment of spouse and performance of expatriates therefore the inconsistency in results demand further investigation socialcultural factors according to li and rothstein social networking enables expatriates to get a circle of colleagues and other individuals who can influence the trajectory of their careers expatriates success is based on their ability to form relationships with host country nationals fellow pcns and third country nationals in the process of adjustment collegial support is necessary for expatriates to expedite their adaptation to the host country bhatti et al asserted that expatriates with strong social networks can get relevant support and resources to deliver their assignments effectively in a similar vein ramalu et al observed that social networking improves expatriates career success by getting guidance from experienced individuals on the other hand social networking enhances expatriates intercultural adjustment and job performance a study by sven and hinju further shows that the size and closeness of social networks are related positively to the degree of social support and cultural information an expatriate receives cultural difference between the parent country and the host country has been found to have significant impact on effectiveness of expatriates 11 according to ramalu et al cultural novelty makes it difficult for expatriates to adjust hence reducing their job performance countries with similar cultures make expatriate adjustment easy whereas those with high cultural distance make adjustment difficult accordingly greater transition is needed between countries with big cultural distances which may cause culture shock among expatriates a study by fangling and ali shows that adjustment of business expatriates in china was inversely related with cultural distance similarly cooke et al stated that expatriates experienced problems in their performance due to high cultural differences between their home country and host country differences in cultural values language religion and institutions also made it difficult for expatriates to adjust successfully and handle their assignments zhu et al stated that premature return was common when expatriates failed to understand the host countrys values language andor religion organisational factors lee and kartika defined organisational support as the degree to which the parent company helps expatriates in discharging their duties such assistance include financial assistance general assistance and family support bhatti et al posit that career support enables expatriates to gain knowledge and skills so that they can handle their assignments effectively expatriates that receive career support often excel in meeting their targets encouraging them to stay for the full time of their assignment claus et al explained that psychosocial support such as guidance and counselling ensures that expatriates get the right mental attitude and psychological health to handle their assignments well they further affirm that expatriates are vulnerable to cultural shocks which disturbs them mentally and physically therefore psychosocial support is needed to alleviate their concerns and promote their ability to handle assigned tasks wurtz stated that expatriates that get necessary training could adapt easily to the host countrys environment predeparture training has been found to alleviate anxieties related to adapting to the foreign country 12 postdeparture training on the other hand gives expatriates relevant competence to work in a foreign subsidiary venkataiah suggested that language training enables expatriates to build rapport with hcns seal business deals with local partners and enhance confidence of stakeholders in the subsidiary furthermore crosscultural training have been linked to increased emotional and psychological comfort of expatriates consequently enabling them to stay focused on their assignments 13 methodology research philosophy this project will adopt an interpretivism philosophy according to saunders lewis and thornhill interpretivism philosophy is concerned with the empathic understanding of human action instead of the forces that act on it therefore an interpretive researcher is interested in getting a subjective understanding of the views attitudes and opinions of the participants towards the research topic the researcher will examine the views and opinions of interviewees regarding the factors influencing the effectiveness of expatriates an interpretivist epistemological position will also enable the researcher to understand the multifaceted aspects that influence expatriate performance research approach two popular research approaches include deductive and inductive approaches 14 the deductive approach is associated with positivist philosophy as it focuses on using existing knowledge to formulate hypotheses the hypotheses are then tested to confirm or reject the previous literature on the other hand an inductive researcher works backwards by collecting and analysing data after data analysis the researcher feeds the findings into the existing literature to either improve the theory or develop a new one 15 the inductive approach is often associated with an interpretivist epistemological position consistent with the chosen philosophy this project will adopt an inductive approach the researcher will conduct interviews to understand interviewees views on factors that influence expatriate performance following data analysis the researcher will compare the findings with the previous literature then the researcher will make specific conclusions about the topic research strategy this research will employ a case study strategy a case study involves the uk expatriates working in burberry offices in china the case study strategy will be chosen because it offers an indepth examination of factors that influence expatriate performance in the chinese fashion sector in this regard the case study strategy will allow the researcher to obtain a rigorous and contextual comprehension of the research topic importantly the chosen case study aligns with the qualitative nature of this research as well as the choice of interpretivism philosophy therefore it will enable the researcher to explore the complex relationship among individual factors social factors and organisational factors as well as how they affect their performance sampling the project will be carried out in beijing accordingly the sample will comprise burberrys expatriates working in the firms subsidiary in the city the researcher will be taking a sample of five expatriates this sample allows the researcher to get an indepth view of the expatriates effectiveness in china it is also small enough to enable the researcher to collect data within a short time the sample will be drawn from both genders to ensure it is inclusive and representative of the population of burberrys expatriates in ordrer to choose the above interviewees the researcher will employ convenience sampling this method is chosen because it is easy and costconvenient 14 it will be impossible for the researcher to conduct probability sampling since there is no point in time during which all expatriates from across burberrys offices in china can be available due to their work programs instrument selection the researcher will use online interviews to collect data interviews will be used because they are flexible quick and generate comprehensive results in addition interviews enable the researcher to get clarification of unclear responses by asking followup questions with the interview method the researcher will get a comprehensive understanding of the views opinions and standpoints of the interviewees regarding the factors that affect their effectiveness the researcher will use an interview guide to ensure that each interviewee is asked similar questions accordingly using the interview guide will promote consistency and comparability of responses across the interviewees such a high level of consistency and comparability will facilitate an easy data analysis process data collection foremost the researcher will call the hr of burberrys office in beijing to ask for permission to conduct the project this will be followed by sending preliminary emails to the expatriates who have availed themselves for an interview asking them to sign informed consent and updating them about the scheduling of the interview the interview will be conducted using wechat as it will be difficult to travel to the location each interview session will last 35 minutes during the interview the researcher will record the session for further analysis and transcription the researcher will also keep notes for further reference data analysis data will be analysed using thematic analysis using braun and clarkes framework foremost the researcher will familiarise with the data by reading and rereading the interview notes and listening to the recorded interviews then the researcher will generate initial codes by examining the patterns that arise from data coding will then be done by classifying similar themes together this will be followed by review and refining of themes the researcher will then define and name the themes lastly the researcher will generate a report that includes quotes from the data to support each theme ethical considerations the researcher will seek for informed consent of participants to ensure that their participation is out of free will as opposed to being coerced secondly the researcher will avoid asking questions that cause emotional distress to participants interviewees will be anonymised to preserve their identity and promote their confidence in answering interview questions the researcher will uphold confidentiality by not divulging data to unauthorised third parties lastly privacy and security of data will be maintained by storing recorded interviews in passwordprotected folders interview dairy will be stored in secured locker in the researchers desk conclusion to sum up the preliminary study it has delved into the factors influencing the effectiveness of uk expatriates in chinas fashion sector it help the project address the dearth of studies focusing on individual factors and contributes to a comprehensive understanding of the complex interplay among individual social and organisational factors affecting expatriate performance the trends in expatriation to chinas luxury fashion sector underscore the importance of this study given the significant presence of western expatriates in key chinese cities through an interpretivism philosophy and an inductive approach the project will eventually examine the experiences and perspectives of expatriates working in burberrys beijing offices the findings will emphasize the critical role of selfefficacy prior international experience spousal adaptation social networking cultural differences organisational support and training in shaping the effectiveness of expatriates managers can leverage these insights to develop strategies that enhance the performance of their expatriate workforce and policymakers can use the research to inform best practices in the field of expatriation while the project will provide valuable insights it is important to acknowledge potential limitations such as the small sample size and the focus on a single case study future research could expand the scope to include a larger and more diverse sample of expatriates and examine other industries or countries nonetheless this project will contribute to a deeper understanding of the factors influencing expatriate effectiveness and offers a foundation for further exploration in this field

this research proposal tries to conduct a preliminary study about investigating the factors influencing the effectiveness of uk expatriates in chinas fashion sector focusing on individual social and organisational factors this research proposal aims to build up a research project for a phd level work and it will act as an research guide and outline by using this preliminary study it will provide the later project some academic foundations and evaluates its research potential it is through this preliminary study that some academic value of the project is presented which are as follows to be specific the later project will addresses a significant gap in the literature by examining the impact of individual factors such as selfefficacy prior international experience and spousal adaptation on expatriate performance the later project also explores socialcultural factors including social networking and cultural differences as well as organisational factors such as support and training key trends in expatriation to chinas luxury fashion sector are analyzed highlighting the growing presence of western expatriates in key cities like beijing and shanghai the project will employ an interpretivism philosophy and an inductive research approach utilizing a case study strategy based on uk expatriates working in burberrys beijing offices data will be collected through online interviews with sample of five expatriates and thematic analysis is applied to identify key themes and insights the findings of this project contribute to a deeper understanding of the dynamics affecting expatriate performance and offer valuable insights for both managers and policymakers the project suggests that enhancing selfefficacy providing effective training and support addressing spousal adaptation issues and fostering social networking are critical for improving the effectiveness of expatriates in chinas luxury fashion sector

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introduction one in three older adults in the united states will die from dementia 1 the prevalence of dementia is projected to increase by 22 by 2025 which has led the us congress and the national institute on aging to prioritize dementia research and care 2 black older adults have double the risk of dementia but often receive diagnoses and treatment late and have limited access to formalpaid services and supports 3 4 5 these disparities arise from social and cultural factors such as discrimination cultural valuesnorms limited access to healthcare and stigma 6 7 8 9 similar to their usborn black counterparts african immigrants may also be at increased risk of poor dementiarelated health outcomes there is a dearth of research on dementia in african immigrants especially in the us current studies combine afrocaribbean and african immigrants and have had mixed findings three earlier studies in the united kingdom showed that african and afrocaribbean immigrants had a higher prevalence of dementia ranging from 8 to 34 10 11 12 13 when compared to white persons in a more recent study of 290 participants who received cognitive testing at a memory clinic in the uk afrocaribbean and african immigrants had lower scores on the minimental status exam and were diagnosed with dementia 45 years younger 14 in the us an analysis of the national health and aging trends study showed that black immigrants were less likely to have dementia compared to usborn black older adults 15 however these results should be interpreted with caution because they relied on instruments that have not been validated in the african immigrant community 6 and thus may not represent the true cognitive health of this population as the current african immigrant population ages and migration to the us increases the older adult segment of this population will also grow there are currently over 2 million african immigrants in the us almost onefifth of them are over 55 years and 63 are over 65 years 16 17 18 indeed the number of older adults gaining permanent residency in the us in the past ten years has doubled 1920 although african immigrants are healthier than their usborn counterparts immediately after migration a growing body of research suggests that immigrants health worsens with greater length of residence in the us 21 22 23 24 25 26 the growth of the older african immigrant population will likely result in a greater incidence of agerelated conditions such as dementia in addition to the growing population of african immigrants there is a growing burden of chronic diseases for older adults that may serve as risk factors for subsequent dementia or complicate the management of existing dementia among older african immigrants among adult african immigrants the prevalence of hypertension ranged from 83 to 40 27 28 29 diabetes from 346 to 655 283031 and obesity from 54 to 55 293233 thus there is a need to understand dementia care burden and related health outcomes for the growing african immigrant community dementia research with communities such as african immigrants is limited because historically these communities have faced many social and cultural barriers to their participation and inclusion in research 34 african immigrants reported that the following challenges limited participation in research fear or stigma surrounding mental health or cancer 35 36 37 uncertaintyfear surrounding how data will be used 37 38 39 lack of time 39 and differential beliefsperceptions about diseases 38 nevertheless in a small sample of african immigrants 91 reported a somewhatvery favorable attitude toward medical research and that medical research is important towards improving health outcomes 38 despite the growing population and incidence of chronic diseases in the african immigrants there is a dearth of research on the dementia and care needs of this population in this paper we present a communitybased participatory research project that utilized an exploratory mixed methods design 40 to identify dementia care needs and assets in the african immigrant community specifically we describe the process of working with a project advisory board to create culturally informed instruments and using these to collect data in the community this manuscript focuses on the procedures of this communityuniversity partnership related products and activities are meant to be illustrative the project was initiated prior to but the majority of project activities occurred during the covid19 pandemic subsequently we also identify challenges encountered in the process of conducting communityengaged research during a global pandemic methods communitybased participatory research project design the need for a project exploring dementia care needs and resources in the african immigrant community was first identified by our community partner african career education and resources inc acer approached the university of minnesota team based on past public health research and practice collaborations in the areas of nutrition and access to care the new team worked together to secure grant funding the goals of the project were to develop a culturally informed community conversation guide that guides community conversations about dementia care and access and use the qualitative data to design and administer a dementia care needs and resources survey with the community following grant funding the community partner identified 20 community stakeholders with diverse experiences and expertise in community health community organizing and development to form the project advisory board that meets quarterly principles policies and responsibilities of the project advisory board members were identified discussed and agreed upon by all at the november 2019 meeting project advisory members received a stipend for every meeting and refreshments were provided the meeting agendas were developed in collaboration with the advisory board members to match the project timeline and activities identified in the grant application the team prepared and submitted the project protocol for ethical review with the universitys institutional review board prior to initiation of all activities this protocol was deemed not human subject research all participant recruitment was led by the community partner and advisory board members during regular programming and inperson activities occurred at locations that participants regularly attend no identifying personal information was collected during data collection and oral consent was obtained prior to audio recordings community conversations procedures community conversations served as phase one of this project and began with the creation of a guide consisting of 12 questions about current knowledge of dementiamemory loss community needs and current resources the development of the community conversation guide was led by a committee of three volunteer project advisory board members with one university investigator the committee members met outside of regular project advisory board meetings to develop the conversation guide iteratively a draft of the guide was presented to the full project advisory board for review and approval prior to use in the field following project advisory board members approval the community partner identified locations for community conversations recruitment for community conversations was led by the community partner and project advisory board members the community partner recruited participants during regular activities such as community education events while project advisory board members spread the word within their networks andor brought interested participants with them to the community conversations when feasible conversations were led by volunteer project advisory board members three community conversations were held in person with six participants at the first two and eight participants at the third following the restriction of inperson activities due to the covid19 pandemic the remainder of the conversations were conducted virtually via zoom technology recruitment of participants for the virtual conversation was similar the community partner identified potential participants and forwarded them to the research team for scheduling of the zoom conversation community conversations were open to first and secondgeneration african immigrants residing in the community partners catchment area however attendance declined with two participants attending one conversation and two participants each who attended prearranged conversations alone were interviewed conversation durations ranged from 60 to 120 min community conversations were recorded with participants consent qualitative analysis audio recordings were transcribed by a professional transcription service and data were analyzed using thematic content analysis as described by braun and clarkes 41 six steps of qualitative analysis in step 1 analyses began with each coder reading through all transcripts for familiarization and understanding of the context in step 2 the transcripts were read for initial coding by coders using an inductive approach initial codes included taking care of family in the home not able to handle stimuli study behavior on a daytoday basis being around them constantly providers are not diverse care in a facility is a last resort etc in steps 3 and 4 the coders collated these initial codes and searched for preliminary themes which were then reviewed and defined the emerging themes and subthemes were developed through an iterative process for example 18 overarching themes and 48 subthemes identified initially were refined into 15 overarching themes in step 5 themes were named and the codes within each emerging theme were then listed in a codebook that was used to code all community conversations in nvivo11 the coders did not identify any new codesthemes at this stage two team members coded each transcript and preparation of this manuscript constitutes step 6 or reporting of study findings trustworthiness and rigor confirmability was achieved by having each transcript coded by two independent coders who met to discuss define and name the emerging themes after consensus on final themes was achieved they were presented to the project advisory board for feedback in preparation for the development of the survey about dementia care that is currently distributed in the quantitative phase of the project results twentyfour african immigrants participated in the community conversations the majority of the community conversation participants were women and 60 were over the age of 55 years participants were highly educated with 65 having a bachelors degree or higher and 79 were born in liberia or were children of liberian immigrants liberian immigrants constitute a large fraction of the residents in the community partners catchment area amongst the 15 identified themes were descriptions of the following cultural expectations around dementia care the communitys dementiarelated education needs challenges or barriers to accessing healthcare and attitudes about dementia and mental health additionally there were themes related to resources available in the community to care for a person living with dementia and a comparison of dementia care available in the us vs african country of origin only the findings relevant to the survey development process are described here to describe how the relevant qualitative findings from the community conversations were used to develop the quantitative survey we briefly present a narrative of each theme and then provide a description of the unique questions or survey sections that captured this theme care situation participants described their experiences of caring for a relativefriend living with memory loss or dementia they described whether that relative lived with them in the us as this participant noted for instance my mom is going through that memory loss and it is happening here some of these relatives lived in their country of origin or were living in a us facility in the survey this theme was explored with four questions in the demographic section it included questions such as are you currently caring for a family member or friend who is living with memory lossdementia how long have you been caring for a person with memory lossdementia and where does the person with memory lossdementia live current resources participants described numerous places organizations and resources in the community where persons living with memory loss and dementia received education social emotional and financial support transportation and healthcare for example a participant said this about local professional associations we have a nurses association we have a group of grandmas and grandpas that we meet with occasionally and provide educational materials and another noted for the liberian community here in minnesota we have these older folks program every wednesday they go and pick people up they have discussions they also described support groups and daycare programs as noted by this participant i was told there is a daycare somewhere in humboldt for elderly people resources were also captured in the background section of the survey with one main questionif you needed it for yourself or a family memberfriend where would you seek support for memory lossdementiawith thirteen subsections to identify the specific type of organization available to help dementia knowledge in all the conversations participants identified some signs and symptoms of dementia such as all of a sudden we started getting the feeling that she mom was forgetting stuff or dementia has stages i believe the stages kind of determine how bad the situation is there was very limited discussion about diagnosis and treatment of dementia but there was overwhelming agreement that community dementia education was needed i think the early education is important and crucial early detection can be helped really well but if we are not aware and have a dementia patient we will not be able to identify it and call for help from professionals and not too many africans here do doctor things like checkups dementia knowledge in the quantitative survey was captured with the validated dementia knowledge assessment scale 4243 that included questions from the following domains causes and characteristics communication and behavior care considerations and risk and health promotion in the context of dementia barriers to accessing care conversation participants described many barriers and challenges to accessing care these included immigration status as this participant stated most of the time our loved ones that come will not be part of the system right if your immigration status was questionable how would you reach out for help so those types of things and sometimes you wont be eligible for support or aid other challenges included languageaccent barriers lack of diversity in healthcare providers fear to seek medical carerelated to racism and lack of trust in the healthcare system limited finances multiple caregiving responsibilities etc in the survey these barriers and challenges were explored using a likerttype scale that incorporated this prompt indicate your level of agreement with each statement the statements were the various challenges identified in the conversations and included fear and mistrust of western medicine is a challenge to memory lossdementia care or members of my family are unable to seek care because of their immigration status or limited language or access to translation is a barrier to seeking memory lossdementia care response options ranged from strongly disagree disagree neutral agree and strongly agree additionally the validated everyday discrimination scale 4445 was used to further elucidate the experience of discrimination attitudes toward dementia and mental health finally participants attitudes and beliefs surrounding dementia care caregiving and mental health were very evident from community conversations participants described a preference for care from family members in the home as this participant stated the culture meaning the culture that we take care of our own no matter how they also described that there was stigma around dementia in the communitystigma people dont want memory loss on their chart because people treat you differently with diagnoses and seeking care in a us facility was a last resort this content was also explored in the survey using a likerttype scale as described above it included statements of various attitudes and beliefs such as families are responsible for caring for people with memory lossdementia in the family or caring for someone with memory lossdementia in my family happens at home or african immigrants are very secretive about memory lossdementia response options ranged from strongly disagree disagree neutral agree and strongly agree survey development process the university team drafted survey questions and then shared them with the project advisory board for review members were invited to edit and add to the survey using track changes in microsoft word following this the university team revised the survey to incorporate all project advisory board members feedback a revised version was then brought to a project advisory board meeting for discussion a final copy of the survey was created that incorporated all of the changes suggested during the meeting prior to implementation survey data collection began in june 2021 and is currently ongoing the community partner identified other communitybased organizations for community data collection the community partner approached the leader and coordinated a date and time for inperson data collection at these communitybased locations and events following this the team then attended these events to collect inperson surveys which were completed by hand using paper and pen or virtually on tablets due to the global pandemic a virtual survey link was also developed and distributed through community networks discussion in this manuscript we described the process of collaboration between a university and community partner to develop culturally informed instruments to collect data about dementia care needs and resources among african immigrants in the us community conversations with participants revealed five themes that warranted further exploration in the phase 2 community survey current care situation resources available to support the family current knowledge about dementia barriers to accessing dementia care and attitudes towards dementia care although there are many reasons to account for the dearth of research with african immigrants there is an urgent need for research with this community limited research participation of underserved communities affects the generalizability of study results and ultimately decisions related to best practices and clinical outcomes 3446 additionally in accordance with the tenets of health equity and distributive justice there is a need to ensure that research is representative of all communities to ensure equitable distribution of risks and benefits 47 despite current and historical challenges engaging community gate keepers addressing religious and immigration factors maximizing the research teams cultural competence and promoting altruism through health education are some successful strategies for outreach and recruitment of african immigrants into research 4849 this manuscript relates one successful approach of collaborating with a community partner and project advisory board to conduct a culturally informed project with african immigrants having limited informationdata on dementia in the african immigrant community hinders health care providers ability to provide timely diagnoses and culturally congruent care with the growing diversity of the us older adult population it is essential to understand disease trends and risk factors as well as outcomes of treatments and interventions for these populations 3450 currently forty percent of persons with dementia in the us are undiagnosed 51 studies from europe showed that a limited understanding of cultural taboos stigmas and expectations of family caregivers affects the delivery of dementia care 5253 data from this project can lead to a greater understanding of cultural perspectives around dementia and family caregiving which can inform improved dementia care for immigrant communities in addition to a limited understanding of dementia care burden in african immigrants few efforts exist to culturally adapt dementia care and caregiving interventions for racialethnic minority and underserved populations 54 55 56 57 58 moreover these efforts are not systematically documented and none of the current adaptations focus on african immigrants 57 interventions for other immigrant groups include our family journey for vietnamese american caregivers psychoeducational skill training for chinese american caregivers and webnovela mirela for hispanic caregivers 55 education delivered within the community by a trusted source has the potential to improve healthrelated quality of life and social wellbeing for family caregivers 59 research shows that culturally tailored interventions are more effective than generic health interventions for various disease contexts 586061 foundational research with african immigrants such as this study is necessary to understand the burden of dementia and also inform cultural tailoring of future dementia interventions for this growing population conducting communityengaged research in times of a global pandemic presented challenges that extend beyond research conducted in prepandemic times a major challenge of this project was the inability to safely convene inperson activities inperson community conversations and project advisory board meetings were transitioned to virtual events using web conferencing technology attendance at these virtual events decreased but it is unclear if this was related to the change in modality or the pandemic in general secondly recruitment and enrollment of older adults for community conversations became difficult virtually because of challenges accessing technology third the covid19 pandemic presented unique mental health circumstances and scheduling challenges for many on the research team and in the community flexibility in scheduling and processing space was offered as needed during virtual pab meetings following the development of the quantitative survey the data collection plan was revised to include virtual approaches due to the challenge of convening inperson data collection events at communitybased organizations this project and its findings are not without limitations although we attempted to recruit participants from more african countries the majority of the sample were liberian and community conversations conducted in one us state might not reflect the experiences of all african immigrants in the us secondly due to the pandemic the number of participants and community conversations were fewer than anticipated however data saturation was achieved after the third community conversation despite these limitations this communityengaged project provides foundational data for understanding dementia care experiences of african immigrants additionally forthcoming quantitative results will provide information on the barriers challenges and resources available for dementia care and caregiving for african immigrants conclusions to the best of our knowledge this is the first study to explore dementia assets challenges and care practices with african immigrants in the us through a communityuniversity partnership we developed culturally informed instruments to collect data about dementia care needs and resources among african immigrants community conversations with participants reveal five themes that are currently being explored in the quantitative phase of the project utilizing a communityengaged approach through a communityuniversity partnership is one approach to successfully implementing a culturally informed research project with african immigrants understanding the dementia disease and care burden of african immigrants will subsequently inform adequate tailoring of dementia education resources and interventions 1 please are there barriers that can impact african immigrants ability to get care or services c what are some reasons that someone might forgo seeking treatment for memory loss d are you aware of anyone in the community who is not able to get healthcare because of their immigrationvisa status e are there ways in which your life has changed since coming to the us that can impact the care of family members with memory loss 8 some people decide to seek care for family members with memory loss at specialized programs and services such as adult day care assisted living or nursing homes what is your zip code 4 where were you born a i was born in africa b i was born in the united states and my parents were born in africa c other 5 what country in africa are you from 6 what year did you first come to the us to live a year b i was born in the us 7 what is the primary language you speak at home get answers to all your questions about your care recipients problems e find organizations or agencies in the community that provide services to help your care recipient f get answers to all of your questions about these services g arrange for these services yourself h find ways to pay for these services section 4 openended questions 31 what are our communitys major strengths and weaknesses for addressing the needs of people living with memory lossdementia and their families 32 if you are currently providing care to a family member or friend living with memory lossdementia what type of care do you provide to them are there parts of caregiving that have been particularly easy or difficult for you if so what are they 33 in your opinion what is the ideal caregiving scenario for someone living with memory lossdementia in our community in your experience is the ideal caregiving scenario possible why or why not 34 if you are a caregiver for someone with memory lossdementia in your country of origin please describe the type of care you provide we are interested in learning more about longdistance caregiving data availability statement due to privacy issues the authors are unable to share the qualitative data for this study informed consent statement not applicable the study protocol was exempted by the irb and thus written consent was not required however participants consented to audio recording of community conversation recordings appendix a african immigrant memory loss project community conversation guide phase 1 current knowledge about memory loss

research suggests a disparity in the prevalence of dementia with black older adults having double the risk compared to their white counterparts african immigrants are a fastgrowing segment of the us black population but the dementia care needs and resources of this population are not fully understood in this paper we describe the process of working collaboratively with a community partner and project advisory board to conduct a culturally informed project specifically we describe the process of developing culturally informed instruments to collect data on dementia care needs and resources among african immigrants working together with a diverse project advisory board a guide was developed and used to conduct community conversations about experiences with dementiamemory loss transcripts from six conversations with 24 total participants were transcribed and analyzed thematically by two independent coders in nvivo these qualitative findings were used to inform the development of a survey for quantitative data collection that is currently ongoing themes eg cultural attitudes challenges and current resources from the community conversations that informed the survey are described briefly despite the challenges of conducting research during a global pandemic having trusting relationships with a partnering community organization and project advisory board facilitated the successful development of instruments to conduct preliminary dementia care research in an underserved population we anticipate that survey results will inform interventions that increase education outreach and access to dementia care and caregiving resources for this population it may serve as a model for communityuniversity partnerships for similar public health efforts in dementia as well as other chronic disease contexts

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introduction an underestimated effect provoked by the virtual mode of schooling during the covid19 pandemic was the dislocation of teachers and students from a collective education project schooling practices became sophisticatedly individual and oriented to simplifying educational goals to the core elements of the official curriculum it is in this sense that returning to high school after quarantine has been marked by emotional crisis aggressiveness and problems with navigating and negotiating shared spaces however this educational dislocation from the physical school has also made visible that contemporary youth are deviating radically away from simply filling out their educational project through school systems alone high school students are framing educational projects rooted in practical benefits and claiming educational experiences that reflect other ways of knowing this dislocation becomes more evident when one directs analytical focus on the educational projects of immigrant students and families in south american contexts because they embody a cultural diversity underestimated by the school system migration is life experience life ambitions life aspirations and efforts to transform constraining social circumstances all this places considerable pressure on domestic school systems to recognize the cultural diversity of immigrant students as a value to be integrated into formal education the development of educational responses that would address the complex dimensions of the diversity embodied in immigrant students life histories and the challenges that these present to domestic educational systems constitute an area of investigation that has been insufficiently examined by educational researchers the purpose of this article is to theoretically frame a research design to address the cultural diversity of south american immigrant students as a fund of knowledgethe assumption that peoples life experiences and transactions over the same involve competencies and knowledge that drive the formation of identities marked by the transnational forces connection and imaginations to accomplish this purpose in the first section of this article we present a summary of the community cultural wealth model then considering the relevance and limitations of applying ccw to the global south scenarios we explore two concepts used in postcolonial theory as elements to complement inquiries culturally and historically about the fund of knowledge in southsouth migration scenarios next we introduce a proposal for a qualitative research design that seeks to integrate the ccw and postcolonial theory frameworks through critical discourses analysis and testimonios a counterstorytelling technique finally in the concluding section of the article we share our reflections on the implications and potential contribution of the research design to a reimagination of the study of cultural diversity and agency of immigrant students in presentday educational contexts the community cultural wealth a model to counter the deficit thinking ideology in her article whose culture has capital tara yosso introduces scholarly readers to the community cultural wealth model arguing for a framework that would systematically recognize and apply heuristically the working notion that a community of color both constitutes and retains and produces cultural knowledge with … aspirational navigational social linguistic familial and resistant capital tara yosso extends pierre bourdieus concept of cultural capital by honoring the cultural practices and assetbased values of communities in contexts of migration or mobility that exercise permanent adaptability in navigating and negotiating societies the ccw model points out that when the cultural capital theory is articulated to or applied to the specific case of chicanos or latinx groups in the us the knowledge experiences of these groups remain underestimated in this context yosso provides a culturally situated model which includes six cultural capitals that address the experiential knowledge of communities of color honoring the cultural practices and assetbased values of communities in contexts of migration or mobility that existentially require and apply practices of permanent adaptability in order to navigate and negotiate societies the aspirational capital is related to the resiliency of brown and black social subjects in their confrontation with oppressive realities by nurturing hopes and dreams in the future and articulating new forms of cultural action and the creation of possibilities linguistic capital addresses the value of bilingual education cultural language and the context of communities of color this dimension also retrieves a strong oral tradition of knowledge that connects generations in the community and advises students on how to navigate schools the third capital the familial capital aims to strengthen the communitys wellbeing it recognizes an extended family unit that can include the nuclear family and other generations or blood affiliations the familial capital applies to communitarian institutions as well such as clubs and churches this capital promotes consciousness of care and decreases isolationrelated problems social capital instead aims to connect the community and to provide them with resources such as emotional support to navigate societys institutions the navigational capital recognizes students inner skills to pass through educational scenarios of hostility marked by racism fewer educational opportunities inequality and a dominant culture additionally navigational capital identifies the students agency as a bridge between institutional constraints and community development finally the resistance capital values the oppositional knowledge developed by communities through several strategies to take cultural pride and thus resist violence and oppression all said the community cultural wealth model extends and diversifies pierre bourdieus concept of cultural capital by pointing to a range of assets that elevate people of colors trajectories and focusing analytical acta scientiarum education v 45 e65811 2023 attention on agency and cultural maneuverability in this way ccw helps counter deficit thinking ideology so deeply embedded in educational policy and research practice deficit thinking works as a dominant normative framework that constrains theoretical and empirical efforts to retrieve brown and black peoples experiences by assuming students and parents of color are limited to white dominant societal values generally in mainstream education policy and research latinx students have been too glibly associated with educational failure founded on the stereotypical assumption of the absence of parental support for the schooling process and cultural barriers such as the lack of the english proficiency level demanded by the school in response to deficit thinking rocha explores how consejos of latinx parents with firstgeneration female students can shape educational goals that encourage persistence in obtaining a higher education degree in her study calderonberumen delves into the role of latina immigrant mothers as educators who bravely confront the prevailing cultural norms in educational environments thus the ccw responds in depth to deficit thinking by exploring alternative types of agencies and resistance and by taking into account the experiential knowledge of latinxs ccwtherefore opens a research and policy avenue that foregrounds inquiry into the conjunctures of these communities and the world and the dynamic resources and forms of action that define their encounter with dominant institutions more comprehensively validating their histories and production of knowledge examining the notion of community in ccw model yosso firmly situates ccw in a notion of community rooted in what rocha defines as educational familismo that is the fund of knowledge students derives from their families through practices such as cuentos and consejos to wisely navigate educational settings the family plays a double function by organizing the mechanism of the experientialknowledge to produce the assets of community wealth secondly racial classification has placed peoples from different continents and cultural development in a racial classification that allows the development of liberalism governance and colonialism as modern racism this racialethical classification has minoritized the nowhite groups by setting up the color line myth to align the global economy and individualistic values for instance the model minority myth addresses the racial classification to highlight the seemly assimilation practices of asian american to get success in us all of this is in contrast to african american groups that are depicted as failures in assimilation practices as we explained in the first section the ccw is far from addressing the systemic oppression of minoritized groups still what we want to stake is that placing communitys ideas in familial interactions tends to reproduce an analysis of assumptions associated with the cultural heritage that not always responded in that direction at this point we consider that some annotation about the overlapping of community and familismo in the ccw model the notion of community according to peoples singular origin is complicated and contradicted by the latin american context since our bodies have been marked by a colonial production of mestizaje and the development of national identities as peripheral versions of modern states rather than an ethnicracial development of identities around the notion of community latin america remains open to the intersection of multiple projects from the dominant western mainstream notions of civilization to indigenous schemes which have interwoven over periods of silence and struggle likewise postcolonial aesthetics literature and political projects where racialized differences find room to transgress power structures in effect latin america has been embedded in projects that create a peripherical understanding of modernity therefore community the second aspect of ccws notion of community that we want to discuss is a theoretical issue provoked by the current global migration pattern on a regional scale like southsouth migration sadly chiles mainstream discourses produced by media and the government have codified transnational migration for the last twentyfive years as a dangerous reality for the national labor market and the increment of delinquency despite the fact that chile remains with the intermediary level of migration in latin america in this sense it is difficult to identify immigrants as communities with funds of knowledge because the resentment operates in the articulation of mainstream discourses in which racism and immigration are combined to reinvent projects of control over immigrants who are seen as transnational others in the local context the mediation of immigrant life projects through discourses of poverty and racism drives back possibilities of honoring the experiential knowledge carried by the migration experience all said we suggest that researchers and policymakers complement their practices with more dynamic attention to rethinking the concept of community this rethinking of policy and research approaches to education especially bearing upon the marginalized should therefore deploy a more systematic understanding of the idea of the multiplicity that persists in the global context some concepts from postcolonial theory complement ccw in southsouth migration educational research the postcolonial theory represents a cumulative body of theories committed to unveiling and contesting colonialism and neocolonialism practices in the ongoing relationship between the metropolis and periphery centers postcolonial theory attends to cultural and historical agencies against colonialism but takes as a central organizing concern the experiences of subaltern actors their histories and expressions of modernity postcolonial theory is geographically situated in the global relationship between the global north global south and orientalism it exposed imperial strategies of domination has paved the way for a cultural and intellectual examination of the nature of racism colonial control and its violent tactics from these relationships the postcolonial reflection advocates turning up domina nt beliefs that thirdworld ways of modernity are failed historical projects instead it seeks to examine power asymmetries that frame centerperiphery relationships considering multiple directions where the agency of subalterns can indeed cave and transform metropolitan cultures and domination relationships disciplinary theoretical and methodological moves become more decisive in the coarticulation of postcolonial theory to cultural studies in the field of educational research postcolonial theory offe rs valuable insights into managing cultural and identity processes that are influenced by dominant ideologies and subalterns in educational settings and school knowledge in framing an educational research design this section reflects on the contribution of the notion of multiplicity and concrete study to place the ccw model as an organizing analytical framework for examining the dynamic entailment of southsouth migration in the education fortunes of subaltern and marginalized immigrant youth multiplicity considering halls notion of cultural identity multiplicity is related to incomplete iterations between peoples funds of belongingness with their aspirational desires conflating a common past with future spaces of reinvention this iteration from a postcolonial perspective is productive in the sense that it allows immigrants to negotiate a different way of belongingness and produce decentered identities for surviving and resisting as a community also multiplicity refers to understanding human migration concerning global processes dimitriadis and mccarthy defined multiplicity by considering largescale development the first avenue of multiplicity refers to the global enterprise of capital or neoliberal globalization that has accelerated the processes of global migration technology and cultural capital on a transnational scale social medias massive scale of imagination and representation is a second identified development at this scalar level multiplicity refers to the massive amplification of practices of selfproduction of images mentalities and possibilities driven by media cultures thirdly multiplicity refers to critical interpretative frameworks around the post that have turned theoretical and methodological approaches around education accordingly the authors identify at this level the popular language of endless possibilities of consumption that overwhelm daily lives affecting schooling and educational contexts in summary in the global age multiplicity arose as a new venue and habitat of undetermined crossroads influencing educational contexts therefore we suggest that multiplicity recognizes another mode of understanding the experiential knowledge proposed in ccw that does not necessarily depend on stable notions of community rather immigrant communities are involved in a dialogical production of meaning within a vast set of aspects in permanent transformation concrete studies according to stuart hall gramsci laid out the terms for the methodological application of concrete studies as a way to socially analyze modern forms of power as constituting hegemonic and therefore negotiated congeries of relations rather than a zerosum political game this represented a forward advance in marxist studies of power and everyday life concrete studies called attention to new historical conditions and relations informed by immigration and the new social movements that were expressing themselves in modern society in the form of new subjectivities articulated within the nation from transnational sources and connections through concrete studies hall sought to problematize race and ethnicity by calling attention to transnational realities hall works on the notion of historical conjuncture to explain concreteness where universalist theories cannot fully explain the social interaction of actors institutions and popular culture formation transnationalism this approach to analysis focuses on describing the cultural dynamics of social conflicts taking into account regional and national differences actors in these conflicts form alliances based on their historical economic and political circumstances with civil society and popular culture playing a significant role the emphasis is on empirical data rather than abstract ideas these social alliances are underlaid in the articulation principle of the development of authority over historical projects that individuals produce in particular contexts to explain this process hall maintains that attention must be paid to social articulations or moments in which the existing arena of social relations and the balance of power between contesting social groups reveal critical breaks and ruptures that might disclose new alliances and new formations these new developments both augur and precipitate critical transformations in the present and future direction of society therefore considering that southsouth migration is a relatively new phenomenon in south america and the lack of problematization of immigrant students as new social subjects with transnational experiences that are producing cultural transformation in the educational system the concrete dimension helps us pay attention to at least two aspects of inquiry cultural diversity with immigrant students in the following ways first it is important to track the history of participants and dominant discourses about migration affecting the treatment of immigrants in the media schools and society this double historical scene provides clusters of arguments to challenge mainstream notions of immigrant subjects and potentially contextbased possibilities to build alternative abstractions about the inquiry secondly concrete studies help bolster interest in and understanding of unequal scenarios via paying attention to contradictions and tensions in the research problem because historical concreteness works by overlapping different temporalities and directions contradictions and tensions are crucial to get a sense of visàvis associations where colonial mechanisms are reinvented within society by producing gradual penetrations of racism the point here is that abstraction at the lower level of concrete operations and everyday cultural transactions and experiences provides rich information to unveil current identity formation connected as it is to local conjunctures and their nexus to global conditions a qualitative research design to integrate the ccw model and postcolonial framework at this point we wanted to be concrete about a qualitative research design to translate the ccw in southsouth migration patterns to accomplish this we describe some characteristics of the research context that provided the lessons for this article then we deployed the use of critical discourses analysis and testimonios as complementary methods the research context we attempt to analyze the cultural wealth production of immigrant students and their families situated in contexts of permanent adaptability to navigate the inequalities they confront in northern chile the questions addressed are 1 how do immigrant students and their families set up alliances negotiations and resistance to develop durable educational pathways 2 what are the role of mainstream discourses in educational policies and stakeholders to reinvent immigrants governance and 3 how are counternarratives deployed by immigrant actors the research addresses a global lens to understand two cities antofagasta and arica which are enclaves of the global economy in permanent friction or exceptionalism against the national space shaping as vertical forces that are interwoven throughout the economic social and cultural domains this global nature of the economy ends up managing the local population and spaces still those relationships are distinctive and need to be unmasked to fully explore and go beneath the surface of putative homogeneity associated with globalization this requires as tsing argues validating subaltern ways of knowing and the friction and collision of global with local conditions and subaltern ways of knowing from a methodological perspective the validation of this multiplicity or imprecise ways of knowing is a critical response to social sciences fixed to uniform and finalist categories about the space or lived experience particularly in el norte grande these imprecise ways take place in the lived experiences of immigrant families who coexist in liminal spaces for access to a house or job while they materialize their project of life associated with desires for better education health and safety in this south american version of global cities the research attempts to interweave lived experiences of immigrant students and their families where multiple ways for building their life projects shed light on the circulation of transnational cultures in the educational system by intertwining social alliances via the circulation of forms styles and cultures at the same time the critical discourse analysis of educational policies related to cultural diversity aims to trace a prevalence of cultural and ideological discourses about chilean normalcy which limits the chances for honoring and validating the multiple expressions of immigrant students indeed immigrant students are mediated by normatively prescribed categories about vulnerability educational deficit and structural discrimination related to culture skin or poverty all said in the following section we introduce a complementary qualitative design that seeks to integrate the ccw and postcolonial theory frameworks via critical discourses analysis and testimonios a counterstorytelling technique critical discourse analysis intertextuality and evaluative argumentation critical discourse analysis is a qualitative analytical approach aimed at describing interpreting and explaining the role that discourses play in validating and reproducing social inequalities by focusing on the production of ideology in global contexts cda contributes to this research by unpacking neutrality and nominalization ideas sustained by educational stakeholders and institutional information that rule public schools in implementing the cda we suggest deductiveinductive coding to identify the neutral facade or nominalization of educational discourses related to public schools and their treatment of the cultural diversity the immigrant students represent from the inductivedeductive coding the next step aims to frame an intertextual analysis of master sentences to trace how educational policies contribute to the rationale of schooling practices that reinforce immigrants portrait as outsiders for instance in the study of cultural diversity in chile we analyzed educational policies that address diversity from the perspective lens special education socioeconomic background and interculturality in articulating the intertextual analysis into a globallocal reading we consider the categories of pertinency relevancy and policy context by an evaluative argumentation this analytical strategy involves movements of argument structures and denounceannounce actions to identify tension in the system and potential paths for a transformative agency thus intertextuality helps to identify dominant discourses about cultural diversity in aspects of ideology and power to implement these qualitative analytical strategies we draw on the methodological guide developed by mullet this guide includes the settled features developed by the cda network during the 1990s with an analytical strategy useful for its flexibility and simplicity mullet complements the agreed features of cda by main references in the field with a strategy to apply cda in a different field which allow an easier transferability of cda mullet 2018 characteristic in common stage of analysis cda scholars in the 1990s fairclough kress van leuuwen van dijk and wodak a problemoriented focus 1 select the discourse an emphasis on language 2 locate and prepare data sources the view 3 explore the background of the texts that power relations are discursive 4 identify overarching themes the belief that discourses are situated in contexts 5 analyze external relations in the text the idea that expressions of language are never neutral 6 analyze the internal relations in the texts an analysis process that is systematic interpretive descriptive and explanatory 7 interpret the data in applying cda the content analysis can interrogate assumptions about diversity in the educational system to establish a set of clusterdriven educational stakeholders responses the cda analysis scope is an intermediary range between global or macropolitical forces that influence states efforts to manage diversity and the everyday responses of educational stakeholders in schools the ideological information provided by cda serves as a helpful complement to narrating the life project of immigrant subjects by linking ideological assumptions in the research and providing context for sharing counter stories of immigrant students cda contributes to a more comprehensive understanding counter storytelling testimonios community cultural wealth addresses the critical race theory and latinx studies which return to inquiry with the oral and lived experiences of black indigenous and people of color to unveil ideological systems of domination the art of cuentos storytelling and testimonios give voice to oral and lived experiences and all of these methods fall under the branch of counterstories counterstories are defined as bipoc narratives that critically reframe their reality outside mainstream narratives or stock histories delgado explains that giving voices to people in oppressed situations allows the identification of daily cultural artifacts and ideologies that reproduce racism and connect the narrator with a communitys collective wisdom this double dimension of counterstories is important because the critique from below is complemented by a communitybuilding function where alternative possibilities are negotiated and a new consciousness is enacted a transformative one in this article we are proposing testimonies as the primary study approach we understand testimonies as a qualitative method that brings personal and reflexive narratives naturally oral however the difference with other story methods is that testimony is taken and written by a researcher methodologically reyes and curry define testimonio as a unique expression of the methodological use of spoken accounts of oppressions mainly retrieved by chicanx scholars who adopted a recovering approach to managing narratives this approach involves the process of translating oral accounts into qualitative analysis by taking the stories reading the narratives and creating analysis as a qualitative technique of spoken accounts thus testimonio considers the voices of oppressed communities naming or renaming injustices from the bottom and a process of awareness and empowerment that drives hope in the narrator and community in this context testimonios help contextualize the analysis of cultural diversity into an articulated analysis that involves narratives of immigrant subjects in permanent identity construction from here testimonies can retrieve oral accounts to frame narratives of whats going on with cultural diversity in everyday life in framing testimonios we collect semistructured interviews in the northern region of chile from immigrants from colombia venezuela bolivia and chile the collection of data addresses questions about personal identity educational trajectory in pastpresentandfuture tense migration experiences and social anchors in the territory regarding participants we work with twogeneration to explore nuances on the way to engage in educational projects the data analysis addresses anfaras three iterative analytical steps inductivedeductive coding individual and acrossthemes analysis and abductive coding the analytical goal is to embed testimonies in a wider context provided by cda analysis of educational policies about diversity and the analysis of relationships associated with multiplicity and the acceleration of time and spaces that neoliberal globalization brings to the cultural diversity of immigrant subjects conclusion the postcolonial theory places relevant contributions to educational researchers and educators as well as the community cultural wealth model engages an educational research agenda for honoring funds of knowledge of oppressed people in the ongoing debate about fractures expansions and openings within postcritical educational methods we attempt to contribute by developing theoretical elements that frame a complementary qualitative approach to address cultural aspects and identity formation of immigrant families in southsouth migration patterns in this conclusion we want to mention three parts firstly in addressing the expansion of methodologies social researchers cannot take away the fact that different disciplines produce different kinds of knowledge still to address the complex research problems one needs to address different methodologies that help explain a social problem that theories cannot fully provide the concrete studies framework thus contributes to engaging complex research problem because its origin took place in the debate about race and ethnicity in transnational realities secondly multiplicity invites educational researchers to embrace social phenomena from differences and ambiguities more than attempting to control social phenomena into fixed categories this postcolonial multiplicity has committed to opening new strategies to understand the agency that we think complement the ccws understanding of agency thirdly the complement of cda and counterstorytelling strategies provides important leads and openings for research on cultural diversity in educational contexts to recognize immigrant agency in uneven educational scenarios additionally we point out that taking attention to experiential knowledge the examination of cultural diversity can be translated to the elaboration of educational tactics to switch the dominant deficit thinking for discourses that embrace transnational realities in a positive sense all said we invite researchers and policymakers to give space to dig into the contextual analysis of cultural diversity to turn the dominant ideology of diversity in education contexts acta scientiarum education v 45 e65811 2023 informações sobre os autores manuel pereztroncoso is a phd candidate in educational policies organization leadership with a concentration in global studies in education and a graduate certificate in evaluation at the university of illinois at urbanachampaign his dissertation both unpacks and undoes western and colonial deficit perspectives to address cultural diversity in education marked by southsouth migration patterns in northern chile he develops the notion of culturalwealth pedagogies to explain daily life lessons of northern chile immigrant students and their mothers to navigate scenarios of marginalization his research also engages with culturally responsive research and evaluation through the university of illinois evalab where he is part of an nsf research project exploring islander scientist pathways to navigate stem careers in puerto rico the us virgin islands and guam and micronesia states in chile pereztroncoso is a member of núcleo de investigación en educación intercultural migración y fronteras a research network led by the university of tarapaca orcid email daniel f johnsonmardones is currently a faculty member at the department of education social sciences faculty universidad de chile in the area of curriculum theory and curriculum design he has a phd in curriculum and instruction from the university of illinois at urbana champaign and also a concentration on cultural studies and interpretive method a master in curriculum and educational community from the universidad de chile and a bachelor in secondary education in history and geography by the universidad de concepción orcid email nota both authors contributed to the idea of this article as well as the work on this draft and critical review of its content

nowadays it is commonly recognized that educational researchers are challenged to address the cumulatively interwoven pathways where critical theories must become complementary and responsive to developing complex research design eg critical race theory postcolonial theories in this sense have longed enriched a criticality committed to the deconstruction of western ways of knowing by interrogating and dislocating mainstream notions of science modernity and identity still it seems necessary to engage in a discussion about how it would be possible to carry out research with a postcolonial perspective on current identity formation scenarios strongly marked by new pathways of social mobility in the global south this paper focuses on two contributions to postcolonial thought 1 multiplicity 2 and concrete study analysis in it the authors seek to share their experience designing a complementary qualitative framework underpinned by these terms that serve to translate and contextualize the model of community cultural wealth yosso 2005 as applied to developing global education research about immigrant students and their emerging educational pathways in relatively new pathways of social mobility in south america by drawing on lessons learned from the ongoing research built on the testimonios of latin american students and their mothers in the northern region of chile the authors share analytical strategies that deploy postcolonial perspectives to complement the content and narrative analysis normally deployed in ethnographic educational methods finally this paper contributes to the ongoing discussion about fractures expansions and openings within postcritical educational investigations regarding methodological aspects postcolonial thought contributes to the reinvention of new ways of thinking about cultural diversity in education

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introduction commonly shared resources have the potential to be sustainably managed by the local communities and multiple stakeholders proving that the tragedy of the commons 1 can be avoided through contextspecific response mechanisms either by state interventions or through the collective action of local communities 23 people living in rural areas and using natural resources are engaged in collective action on a daily basis 4 and effective collective action for watershed management has the potential to provide multiple economic and environmental benefits to rural communities 5 the nature of water resources to create interconnections at multiple scales within watersheds imposes the necessity of looking for common solutions to waterrelated problems 6 throughout history local community groups involved in the use and management of common resources have been formed often coinciding with the cohesion of livelihoods and lifestyles however in a context where societies face changes in socioeconomic conditions as well as in resource use patterns the natural formation of collective entities might or might not happen the same is applicable to the focus of this study in the contemporary context of sri lanka a developing country facing multidimensional challenges where complex naturalresource systems demand governance interventions to foster collective action currently in the case of vtcss in sri lanka communitybased statemonitored organizations which are established at administrative villagelevel units stand as the governing body that represents paddy cultivators and facilitates limited collective functions related to lowland cultivation under village tanks the fo is an organization that deals with matters directly related to paddy cultivation and irrigation water management it is consistent with the tradition that communities have been autonomous of the tanks that irrigate their paddy fields however they are not mandated to cover all the functions necessary for the sustainable management of vtcs as a complex resource system failing to address issues at cascadelevel both in terms of membership inclusion and scope of coverage hence it is vital to envision effective future governance mechanisms for vtcs as the current institutional and policy landscape of sri lanka is highly unstable and unpredictable 7 commons research on many traditional resource management systems has recognized the importance of collective action in local communities however the effects of globalization changes in patterns of resource use and climate change scenarios have intensified the need for collective management on wider scales beyond the scope of small traditional communities as in the case of sri lanka which will be discussed in this paper this study aims to clarify the dynamics of collective action in parallel to the expansion of the scale of socioeconomic interactions and resource use patterns in vtcsbased rural communities in the context of multiple challenges the vtcs of sri lanka stand as a unique example of a complex resource system bound by hydrological and social relationships vtcs are interconnected networks of village irrigation tanks where catchment forests command areas and human settlements are organized within the microcatchments of the dry zone landscape of sri lanka providing basic needs to human floral and faunal communities through water soil air and vegetation with human intervention on a sustainable basis 89 vtcs have been a fundamental feature of civilization in sri lanka 10 serving to be the lifeblood of dry zone communities over millennia and still irrigating approximately 25 of the paddy lands in the country 11 while providing multiple ecosystem services 12 given the unique features of sustainability a characteristic model of vtcs in sri lanka has been recognized as a globally important agricultural heritage site by the food and agriculture organization of the united nations in 2017 13 the village tanks are manmade structures and they form the constituent units of a vtcs village tanks and the ecosystem components linked with them have been managed by local communities throughout history hence they have been recognized as communally managed systems by previous researchers in the traditional context local communities had ensured that the rich catchment forests and microecosystem components associated with village tanks were least disturbed and sustainably used 14 15 16 17 so that they performed as buffer zones between adjacent villagetank ecosystems minimizing the externalities but with the increased population pressure and resourceintensive agricultural production patterns that emerged as results of socioeconomic and cultural transformations as well as the impacts of climate change the ecosystem components that once acted as buffer zones have been degraded leading to the frequent occurrence of externalities across adjacent village tanks and communities ultimately disturbing the hydrosocioecological equilibrium of overall vtcss 18 19 20 threatening their future sustainability when the buffer forest catchment exists between tanks temporary abandonment of some of the village tanks would neither negatively affect the other functional tanks nor the entire cascade however since the buffer catchment forests which retain water and minimize soil runoff were subjected to degradation and disappearance the condition of one village tank directly affected the resource endowment of the adjacent tanks and ultimately the entire cascade the notion of establishing a cascadelevel mechanism to enable communities and other stakeholders to cooperate has been emphasized in recent policies and development efforts targeting the governance of vtcs in sri lanka 21 however attempts to implement such mechanisms through development interventions have failed over the past few decades reportedly since the cascade residents had not felt the legitimacy of such mechanisms that had been tried out these mechanisms have been mostly topdown approaches and have not been capable enough to address true social dynamics 22 therefore even though the communities are aware of the cascadelevel complexities and the importance of widerscale cooperation it has not been practically achieved so far we propose that identification of existing pathways where people act in cooperation might be essential before establishing legitimate mechanisms to foster collective action across multiple social and spatial scales for the governance of vtcs in the contemporary context although the collective aspects of resource management and lifestyle in the traditional context of village tanks in sri lanka have been glorified in the previous literature the relevance roles served boundaries of occurrence and limitations for collective action across multiple scales within the broader territory of vtcs in the contemporary context have been underexplored in a context that is subject to multiple changes when peoples socioeconomic interactions and resource use patterns expand beyond limited social and spatial scales the motives by which they operate might be either individualistic exploitative or collective the working hypothesis is that in a complex resource system like vtcs which is a collection of subunits that are inherently designed to be collectively managed the scale at which collective action takes place among local people in a resourcescarce context will widen in parallel to the expansion of their socioeconomic interactions and resource use patterns across multiple spatial and social scales to a wider territory within the vtcs or beyond the diverging hypothesis is that unlike in the traditional context individual land ownership and resource utilization patterns do not remain limited within a single villagetank territory or a single village but instead expand to a wider territory of resource acquisition most often within the territory of the vtcs based on these the specific objectives of the study catering to the working hypothesis are 1 to identify the crosscutting challenges that demand the collective action of people residing within the cascade territory 2 to explore the distribution of land resources owned andor used by people living in the vtcs 3 to analyze the different forms of collective action practiced by people residing in the vtcs territory their boundaries of occurrence roles and limitations for engagement study context deriving at the hypothesis the latest research on vtcs in sri lanka highlights the importance of recognizing social networks and fostering collaboration among local communities and other stakeholders at the cascade level in order to minimize future climate risks and promote the adoption of polycentric approaches for adaptive governance of vtcss 1723 in this backdrop attempts have been made to formulate different institutional arrangements that can facilitate the collective decisionmaking and action of local communities to address common resourcerelated challenges within vtcs such as irrigation water scarcity land degradation and low agricultural productivity for example certain projects have tried to formulate cascadelevel management committees with representation from fos within a selected vtcs to address crosscutting issues with the active participation of cascade inhabitants but such previous strategies have failed with only shortterm success due to a lack of legal recognition power and authority the efforts continue up to date with expectations to formulate a legitimate governance mechanism inclusive of multiple user groups and stakeholders at cascadelevel 2223 in summary one of the most pressing social and developmental issues within the context of vtcs in sri lanka is how to create a mechanism to enable a broaderscalebased collective action that extends beyond small individual tankbased communities there is an ample amount of previous literature on factors affecting collective action with evidence from cases all over the world many studies on crossscale collective action in watersheds have been nurtured by the institutional analysis and development framework 24 25 26 27 the iad framework facilitates analysis and testing hypotheses about peoples behavior in diverse situations at multiple levels of analysis and involves analysis of how rules physical and material conditions and attributes of community affect the structure of action arenas the incentives that individuals face and the resulting outcomes 24 context action arena and outcomes have been often recognized as key elements upon which collective action across different scales has been analyzed 28 29 30 31 especially with respect to socialecological systems including broad natural resource boundaries contextual factors include attributes of resources and users socioeconomic factors cultural and environmental factors as well as governance arrangements 2426 action arena has been defined as any stage for social bargaining on which different actors may choose to cooperate or not and it comprises an action situation participants and rules or conditions 28 action arenas may range from households meetings organizations villages and nations to the international level it is hard to make a clearcut distinction between factors falling under the context and action arenas for example institutions including formal and informal entities norms trust relations rules and sanctions that structure social interactions have been found to be key determinants of collective action which could contribute to defining a context as well as action arenas among the other factors discussed in the literature shared norms and social capital especially with respect to past successes working together facilitate collective action in new arenas on the other hand heterogeneity has been found to either facilitate or hinder collective action depending on the situation 29 30 31 32 since the study scope considers the participation of multiple actors in collective activities and is not limited to one type of resource users the effect of heterogeneity is relevant to the study context it has been found that people are likely to follow joint rules and arrangements only to achieve intensely felt needs that cannot be met by individual actions 33 this might explain the influence of resource scarcity on fostering collective action and serves as an important insight to probe the importance of the expected outcomes of collective action to people incentives received at private or public levels can either be considered drivers for engaging in collective action or outcomes 3435 external or thirdparty interventions play an important role especially to provide legitimacy to mechanisms that are intended to foster collective action in largescale scenarios 36 however most of the previous work referring to the above factors related to collective action on environmental resources within existing boundaries has mainly focused on the analysis of policies and institutions directly related to resource governance itself this study attempts to explore the factors that generate new cohesion and collective action among actors on a wider scale than within existing boundaries we assume that such factors will be more closely related to social relationships that are a part of the everyday lifestyle of local people and to the sense of belonging and proximity to resources based on territory of use and ownership having experienced the failure of governments to form cascademanagement organizations the process should begin with exploring the possibility of social cohesion leading to new collective action for this purpose it is important to grasp the scope of peoples physical activities such as land use as well as the accumulation of various human relationships and the scope within which their networks spread this might shed light on facilitating legitimacy for collective action across multiple scales within the broader scale of vtcs study site medde rambewa cascade system is hydrologically located in the meeoya river basin and administratively belongs to the nawagattegama divisional secretariat division of puttalam district in the north western province of sri lanka the area belongs to the lowcountry dry agroecological zone of sri lanka the cascade system encompasses two gn divisions namely moragahawewa and mahameddewa demographic information of the mrcs is summarized in table 1 there are 25 village irrigation systems within the cascade with 24 minor tanks and an anicut the average annual rainfall received in the area is 1174 mm and the average annual temperature exceeds 2829 • c the study site is one of the locations under the implementation of the climate resilient integrated water management project which is a collaborative intervention funded by the green climate fund through the united nations development programme for the sri lankan government while a civil society organization operates as the social mobilization arm of the project at field level 37 38 39 refs 3738 methodology the concept of collective action within territories relates to the perspectives of proximity that assume interdependencies among local actors based on the logics of belongingness and similarity 40 a sense of belongingness and similarity emerge among people when their interactions are facilitated by rules or behavioral routines that they follow and when they share the same origins the same systems of representations or the same objectives 41 when the hydrological and administrative boundaries of natural resource systems do not coincide the territory or units of resource management will vary depending on peoples interactions and local conditions in the case of the sri lankan village tanks although fos serve within a single or several village tank units and fragmented administrative units they cannot serve as an adequate governance entity within the broadest natural socialecological territories considering the hydrological characteristics water resource planning should be conducted at basin level but this is only possible if the local community is ready to accept a basinlevel organization as the management entity in the particular hydrological territory there have been several previous studies on the conditions that make such situations possible or in other words provide legitimacy as discussed in organizational sociology legitimacy refers to a generalized perception or assumption that the actions of an entity are desirable proper or appropriate within a socially constructed system of norms values beliefs and definitions it is given by an external audience and represents the reaction of observers to the organization as they see it 4243 legitimate pathways and provisioning of public goods are complex and contextdependent as they are subject to strategies pursued by the public collective and privateindividual actors 4445 we believe in the importance of a mechanism that is perceived by the local people as having legitimacy to foster collective action for broader resource management to this end it is important to examine which activities are conducted at the watershed level within the existing scope of crossscale collective action existing forms of collective action that are undertaken by the residents were identified at the scale of groups or subcommunities within the mrcs territory while resource ownership and use patterns participation in identified collective activities within the communities drivers and limitations for engaging in collective action were explored at the scale of households research design a casestudy research design 46 was employed and a mixed combination of data collection methods recommended for collective action studies 34 were used including focused group discussions indepth interviews participatory field observations and a household survey data collection was carried out from march 2022 to january 2023 multiple scales of data collection and analysis were included including household village and cascade levels primarily the cascadelevel and villagelevel data were collected by conducting a total of four fgds coupled with a problemmapping exercise with community members representing both villagecommunities within the cascade each fgd was held for a time duration of 60 to 90 min two of the fgds were held separately at each village the third fgd was held with the participation of members representing both villages together at a common location and the last fgd was held with the participation of community members representing both villages together with administrative officers representing local government authorities as well as staff members of development agencies operating at cascade level all four fgds were conducted by the principal author facilitated and assisted by an expert in community mobilization the background purpose of the study and objectives of the fgds were clearly explained to participants at the introductory session of each fgd repetition of the objectives was ensured during each fgd while the generated findings were summed up and reflected together with the participants before winding up each fgd these procedures were adopted in order to ensure the validity of the fgds the composition of the fgd participants is given in table 2 below the participants in fgd 01 and 02 were residents of each village participants in fgd 03 and 04 included a few members who had previously attended either fgd 01 or fgd 02 in their own villages fgd 03 and 04 provided common platforms to generate findings on issues that are experienced by local people across spatial scales fgd 04 led to the generation of findings on crosscutting challenges experienced across social and administrative scales from the perspectives of local people and local government authorities respectively in a common forum a problem mapping exercise was coupled as a part of each fgd in order to diagnose the challenges experienced by cascaderesidents that demand collective action across multiple social and spatial scales participatory field observations were conducted and thick description notes were taken during the visits as well as during attending the events organized by the community members throughout the authors stay at the research site secondary data sources such as annual reports of regional administrative institutions government statistics and project reports were retrieved and used for analysis household survey and indepth interviews a household survey was conducted using a structured questionnaire with a representative sample of residents within the cascade territory from december 2022 to january 2023 prior to administering the survey with the study sample the structured questionnaire was pretested with a sample of 15 randomly selected respondents residing within the mrcs territory in order to ensure the effectiveness and validity of the questionnaire the survey process was carried out by the principal author supported by a team of four enumerators surveying at each household was followed by an indepth interview with the household head or a responsible adult in the household the total process of data collection at each household consumed a time range of 40 to 90 min depending on the readiness of household members to provide information during the indepth interview according to the census data a total of 809 households reside in the two villagesgnds belonging to the mrcs but only 456 households reside within the mrcs territory based on the village tanks during the data collection 158 out of 456 households residing within the mrcs territory were surveyed coupled with indepth interviews within the abovedefined time frame of two months the sampling procedure was twostaged involving stratified sampling followed by convenience sampling stratified sampling was conducted at the first stage to identify the strata within the mrcs accordingly three strata representing the upper middle and lower elevations of the mrcs were selected followed by the selection of six hamlets for conducting the survey while three hamlets belonging to moragahawewa village represented populations concentrated towards the upper and middle elevations of the mrcs the three hamlets belonging to mahameddewa village represented the lower elevationbased population residing within the cascade territory this step was used to avoid the errors of bias in sampling and to ensure the representation of the vtcsbased community given the high possibility of the absence of residents of any household during the time of visit for the survey convenience sampling had to be utilized when visiting the households within each hamlet in cases where the household head was absent or engaged at field work either the enumerators located the household head at the field with their consent or the spouse or an adult of the household who could provide information were engaged with their informed consent in cases where none of the household members of the originally selected nth house were present the immediate neighboring house was visited but most importantly the team of enumerators ensured surveying a representative sample from each hamlet it was ensured to cover the entire area of each selected hamlet and to make a second visit to households and collect data in cases where their exclusion might have caused biased results in this way the sampling method supports minimizing the errors of bias and missing out on data by ensuring a balanced representation of hamlets nested within the two main villagecommunities that constitute the bigger cascade community the structured questionnaire used for the household survey consisted of five main sections section one consisted of questions on basic household information including socioeconomic characteristics section two explored the dependency of the household on village tank ecosystems and farming information the third section included multiplechoice questions to explore the households experience with changed climatic factors followed by questions on the direct impacts of climate change and the types of climate change adaptation actions followed by the households section four was used to explore the participation of the household in specified collective activities identified through the qualitative findings the role played by the household drivers and limitations to their engagement a followup question on the determinants by which each household defines the boundary of the community to which they belong was included at the end of completing the structured questionnaire an indepth interview was held with each respondent by probing special facts revealed during the survey and by asking openended questions on engagement in collective action at multiple scales data analysis was mainly qualitative and exploratory and the findings were substantiated with statistical analysis of quantitative data using descriptive statistics the chisquare test for homogeneity spearmans correlation tests to analyze associations and mannwhitney u test for comparison of engagement in collective action of the two village communities were performed using ibm spss version 290 results and discussion crosscutting challenges that demand collective action of people residing within the cascade territory prior to making efforts to foster collective action for cascadelevel resource management it is essential to diagnose whether there exist pressing challenges experienced by people living within the vtcs territory that truly demand the need for such collective action across spatial and social scales the first objective of this study has been formulated based on this proposition based on the analysis of fgd findings challenges that demand cooperation of people across the could be categorized into two main aspects related to natural environment and social life the main challenges related to the natural environment were found to be water scarcity and the unpredictability of rainfall the threat of wild elephants and the occurrence of flash floods the situations linked with social life demanding cooperation were a funeral organizing religious functions and cultural events and events at the local school natural environmentrelated challenges water scarcity and unpredictability of rainfall water land and forests are the main resource bases that provide shared benefits to the villagetankbased communities given most of their dependency on natural resources for agriculturebased livelihoods most of the vtcss of sri lanka are located in the dry zone where the annual average rainfall is less than 1750 mm 4748 sri lanka receives rainfall associated with two monsoons namely the northeast monsoon and the southwest monsoon that determine the two main paddy cultivation seasons of the year ie the maha and yala seasons respectively the maha season receives the most precipitation while the yala season receives relatively less precipitation intermonsoonal rains occur in between these two main rainfall periods 49 while some of the agrarian communities in the dry zone have access to other major or medium irrigation water distribution schemes as well others who do not have to highly rely on the limited rainfall and water storage of smallvillage tanks to irrigate their croplands the study site has no direct access to a medium or major irrigation scheme as of now other than the interconnected network of village tanks and an anicut deviated from a water conveying channel they are the only sources of irrigation water for lowland cultivations while the uplands are mostly rainfed this makes the local communities highly dependent on village tanks since water turns out to be a highly scarce resource for them however the irrigation potential of most of the tanks has become insufficient to cater to the requirements of both seasons usually most tanks will have enough potential to only irrigate the major cultivation season according to farmers water storage in most of the tanks will be insufficient to irrigate the next cultivation season after utilizing the tank water for the maha season so they often have to make adaptation decisions on adjustments in the water sharing practices or shifting to the cultivation of lowwaterconsuming field crops other than paddy in the lowlands both of which have to be carried out collectively …the potential to irrigate existing command areas under village tanks become more challenging year by year we hardly manage to cultivate maha season but it is impossible to irrigate the command area during yala season not only the water storage capacity of village tanks but also the water holding duration has been obviously reduced than in the past this is not an issue faced only by farmers of our village but a common problem faced by all farmers in both villages… says a 68yearold traditional farm leader from mahameddewa according to the residents the unpredictability of rainfall has worsened the situation than ever before the fact was confirmed by all participants who stated that the duration and frequency of rainfall have become highly unpredictable unlike in the past according to a female participant in one of the fgds …before 5060 years there were no limitations in access to clean drinking water in the area we can remember our parents fetching water from the village tanks as well as from natural water springs inside the forest unlike today… …before storing the fetched water from tanks or natural streams our mothers were used to the habit of putting a special type of plant seeds to the bottom of the clay pots known as ingini seeds rubbed on stones this special type of seeds has the ability to remove hardness toxins and impurities from water in the past ingini was a very common plant found in the rich interceptor zones of village tanks but with the encroachment of interceptor zones by paddy farmers the plant species also has become rare now… this reflects the nature of the closely interwoven lifestyle of local people that existed with the abundance of forest and water resources in the past unlike at present the underlying story of these expressions by residents reveals how the cascade resource endowment has been altered at present thus not only irrigation water but also the scarcity of drinking water is a critical challenge faced by residents of both villages the scarcity of drinking water within the cascade area is mainly due to poor water quality and a lack of sources since there are no rural water supply schemes available to provide water at household level most people buy drinking water cans daily or weekly the government and project officers confirmed the severity of the drinking water scarcity while stating that it has been really challenging to provide a sustainable solution due to the lack of suitable water sources in the area according to these insights water scarcity is one of the main challenges faced by the inhabitants of mrcs irrespective of administrative or social boundaries at present threat of wild elephants another of the most critical problems faced by the cascadecommunity members irrespective of administrative borders is the loss and damage to crops property and lives caused by elephant attacks according to the community members the temporary solutions given by relevant government authorities are insufficient to eradicate or minimize the problem hence in the event of an elephant invasion of a cropland or a home garden those who first catch sight of an elephant attack will communicate the message to the neighborhood in order to seek help and to make others in the community prepared neighbors will get together and use firecrackers make loud noises and try to chase away the elephants they will also make efforts to rescue any member of the affected household who is injured by an attack even though some community members have made efforts at the individual level that has been found insufficient to prevent the problem …we anticipate elephant attacks during any time of the day now every effort we put in farming or landscaping either in lowlands or uplands can become invain at any instance we can never rely on the support of government officers during sudden attacks by elephants so we always help each other through communication and gathering together to rescue anybody affected this is not a problem limited to only one village but affects the whole area in proximity electricelephant fencing is no more an effective solution to eradicate the problem… stated a 35years old participant from mahameddewa even though the wildlife department has appointed officers to attend to humanelephant conflict issues in the area community members do not tend to highly rely on the service therefore a majority of community members rely on the mutual support of their neighbors or villagers when encountering elephant attacks flash floods the lowlying plains of the cascade system bordering the two villages are affected by flash floods created by the overflow of a canal that runs across the upstream area according to the community members this condition has been aggravated during the past 10 years due to fluctuating rainfall patterns as well as upstream blocking by various constructions changed land uses and other human activities these floods mainly occur during the major rainfall season almost every year and cause severe crop loss and force the affected members to temporarily move out of their residence places as a remedy the government has allocated slots of upland fields to affected community members to compensate for their losses due to flash floods but not only is it just a temporary solution but it has also triggered another serious issue of upland catchment encroachment beyond the allocated land as a result however the community members who are unaffected by these flash floods collectively act to provide support to the affected fellow community members they provide food drinks and sometimes temporary accommodation to affected families who lack another shelter to move to this collective action is mostly voluntary and spontaneous in response to the crisis although sometimes backed by the planned support from fos as well social liferelated situations in a vtcsbased community in case of a deathfuneral support from others during the loss of a family member was found to be very important to every member of the community since it is a difficult life event faced by every household irrespective of any social or economic gaps among each other there are strong deathbenevolent societies established in the two villages while most community members were found to have membership in more than one unlike the fos all community members bear the membership and the functioning is selfgoverned at the village level without the influence of any external party there is a committee of office bearers elected upon the votes of all community members they hold monthly meetings maintain a welfare fund raised by community members themselves organize certain events within each village and mandatorily attend the tasks and fulfill the responsibilities in the event of a funeral at a members household the rules imposed by dbs on participation in monthly meetings and contributions are strictly internalized by all members despite the formal membership in dbss on most occasions the community members attend funerals that occur in both villages which is an indication of a mutual sense of belongingness to a community beyond spatial boundaries organizing religious and cultural events religious ceremonies at temples and performing traditional rituals related to villages shrines receive high voluntary contributions from community members in the case of flagship events related to village temples and shrines most of the community members from both villages get together irrespective of economic or administrative boundaries usually the monks in charge of the village temples are recognized as having a respected advisory role in these community activities access to education the study site being an area with minimum access to infrastructure and other facilities the local school in the area is the common option available for parents from both villages to provide their children with a high school education therefore school acts as an important focal point that unavoidably builds the cooperation of residents from both villages within the cascade territory nevertheless the sunday school held at the village temples is another platform that brings the children and adults from both villages together not only regularly but also during cultural celebrations distribution of land resources owned or used by vtcsbased residents catering to the hypothesis made on the expansion of individual resource ownership and usage patterns the distribution of land resources owned by the vtcs respondents was explored in the household survey according to the findings 56 of the households held ownership to paddy lands irrigated under village tanks located in both villages moragahawewa and mahameddewa as evident from the above unlike in the traditional context where common people had ownership to paddy lands typically under one villagetank in proximity to their residence in the current context the majority of households own and manage land within a broader territory according to a 70yearold farmer from moragahawewa he holds positions as an office bearer in two fos representing village tanks located in both villages within the mrcs and the total extent of paddy lands owned by him is approximately 10 acres distributed under six village tanks located within the cascade territory although the technical concept of cascade emerged in discussions in the recent past interlinkages and relationships between adjacent tank communities have existed since ancient times as a thin link in history 50 very limited previous research has attempted to scientifically validate some of the biophysical and hydrological attributes of lateral and longitudinal connections among tanks within cascade systems 8 adding to but not limited to this existing knowledge on connectivity at the cascadelevel we emphasize that although the widely distributed resource ownership and usage patterns exhibit individual resource acquisition they can serve as evidence of peoples engagement across a wider spatial scale within vtcs on the other hand enhance the territorial proximity and belongingness felt by individualshouseholds to resources and institutions within the broader territory of vtcs household participation in collective action at the scale of village tanks reflecting on the findings of fgds and indepth interviews held with community members the collective responses of people that have emerged in response to intensified challenges resulted from impacts of climate change could be recognized as forms of collective adaptation the main adaptationoriented activities identified were tank water sharing during scarcity collective decisionmaking on farming activities and participation in ecosystem restoration activities executed through fos the fo members comprising a committee of office bearers elected as representatives from the same community collectively hold seasonal cultivation meetings with the participation of local government officers and officers from development agencies when needed the decisions on water sharing sharing agrometeorological forecasts and cultivation planning are made on this collective platform in the past fos could be regarded almost as an exact representation of the entire community but at present although fos account for the dominant majority of farmers within the community it cannot be considered an exact representation of the cascade community since other resource users are excluded from fos the collective practices of water sharing seasonal cultivation planning and cleaning and maintenance of village tanks as explained below are limited to the paddy farming community while cascade ecosystem restoration anticipates the inclusion of all user groups not just fos collective water sharing during irrigation water scarcity bethma in cases of prolonged drought which makes irrigation water scarce to cultivate all paddy lands under a particular village tank fo members decide to adopt a traditional watersharing practice in order to share the limited amount of irrigation water available in the village tank by proportionately sharing the optimum irrigable paddy land extent among the number of farmers under the tank in this case the closest accessible extent of land that can retain water supply from the village tank will be selected with the consent of land owners and each farmer will receive a proportionate area of paddy land to be cultivated in that particular season although there is a tradeoff between personal economic gain and collective welfare intention for the paddyland owners who agree to provide their own land to be shared among other fellow farmers it could be observed that most of them prioritize the social value of sharing limited water resources in times of scarcity according to the analysis of survey data the majority of the total sample of respondents have adopted bethma practice during water scarce time periods out of them while 90 of the respondent households from moragahawewa village adopted bethma a comparatively lesser proportion of the respondent households from mahameddewa village had adopted the practice on analyzing the role played in contributing to the adoption of bethma practice a majority of the total respondent households were contributors of land shared during the adoption of bethma practice on analyzing the driving factors for their engagement in sharing tank water and paddy lands significant positive correlations were found with economic incentives r p rules and fines imposed by the fo r p and awareness on the shared negative consequences of not sharing limited water resources r p this shows evidence that community members make choices about adapting collective measures when they are inevitable and imposed under a monitored set of rules along with proper awareness this adds to the evidence from previous research suggesting that farmers are more willing to manage and share resource systems when water supply is relatively scarce rather than when absolutely scarce or abundant 5253 seasonal cultivation planning in general fos hold monthly meetings as well as two main seasonal cultivation planning meetings annually per cropping season the members make schedules for cleaning and maintenance functions of village tanks discuss problems and disputes and suggest solutions that are important for farming and resource sharing during the monthly gatherings during the seasonal cultivation planning meeting farmers make informed decisions collectively on the cultivation operations including deciding upon the crop types and varieties to be grown schedules for land preparation and release of irrigation water from the tanks etc at present a seasonal weather forecast published by the collaboration of the departments of meteorology and agriculture of sri lanka is issued targeting to disseminate advanced climate information to the farmers to be used in cultivation planning on the study site the process is accelerated and facilitated by the intervention of the criwmp project in order to make the information available to farmers on time through the coordination of local government authorities this could be recognized as an adaptive effort generated through the coordination of government nongovernment and community organizations in response to the exposed risk and uncertainty faced by farming communities to the impacts of climate change based on the findings of fgds held with community members and key informant discussions held with local government officers this initiative has facilitated the seasonal cultivation planning process by enabling the farmers to make more informed decisions on irrigation water sharing as well as planning for the cultivation of lowwaterdemanding other field crops during scarce rainfall conditions or for midthirdseason cultivation during excess rainfall conditions it was found that all fo members attend the seasonal cultivation meetings due to the high importance of the decisions made related to farming operations as well as the distribution of fertilizer subsidies and any other economic incentives given by the state or ngos rules sanctions and economic incentives showed strong associations with the participation of farm household representatives in the seasonal cultivation planning meetings cleaning and maintenance of villagetank infrastructure as stated under agrarian act no 46 of 2000 maintenance and cleaning of tank bunds field canals and irrigation infrastructure are mandated functions of the farmer organizations based on the results of the household survey 94 of the respondents were found to compulsorily attend the cleaning and maintenance of tank bunds and canals for which the main driving factor for participation was found to be rules and sanctions imposed by the fo villagetank ecosystem restoration even though tank water use for irrigation purposes is a limited privilege for fo members the ecosystem services of village tanks and the ecological components are commonly shared by all community members which makes it a shared responsibility of all to conserve and restore the ecosystem therefore cascade rehabilitation programs are designed with the objective of engaging all community members for the restoration of tank ecological components and ultimately the whole cascade ecosystem from the sample 68 of the respondents were found to be participating in collective villagetank ecosystem restoration activities and kattakaduwa of them the rate of participation was found to be higher in the mahameddewa community than that of moragahawewa the influence of development projects implemented in the area followed by a sense of selfsatisfaction were found to be strongly correlated factors with participation driving factors for household participation in collective action the driving factors associated with household participation in collective activities that are directly related to village tank resource management and activity coordination were analyzed through spearmans correlation test ten driving factors were tested for associations with collective action engagement economic incentives were found to be the most common factor which was significantly correlated with participation in all four types of collective activities related to village tanks which obviously reflects peoples rational choice in engagement rules and fines were found to be strongly correlated with household participation in all activities directly coordinated by fos except for ecosystem restoration since there are no rules or fines to mandate participation in ecosystem restoration activities the strongest factor correlated with household participation in ecosystem restoration was influence from an external party followed by all other factors except rules and fines this highlights the void created by the absence of a legitimate mechanism for ecosystem restoration even though thirdparty involvement is present selfsatisfaction social norms and awareness of negative consequences were found to be closely associated with the adoption of bethma practices the cleaning and maintenance of village tank infrastructure and ecosystem restoration feeling for others was correlated only with the adoption of bethma and involvement in ecosystem restoration social rewards respect for community leadership and externalthirdparty influence were correlated only with involvement in ecosystem restoration previous work on collective action has recognized the importance of the resource for local peoples livelihoods the longer time horizon of resource use the large enough size of the management units so that they cannot be captured by individuals a history of cooperation and networks and recognition of local leadership as factors promoting cross scale collective action in watersheds institutional organizers or mobilizers and enabling legal frameworks have been identified as catalysts to facilitate such broaderscale collective action 54 most participatory watershed management initiatives adopt a communitybased approach erroneously assuming that people living within a particular geographic region will have strong shared common interests but it is important to consider the different interests that clusters of people share as well as their relative power to assert those interests 5556 hence as long as legitimacy is not felt by the people through an effective mechanism collective action for ecosystem restoration would not be achieved except for the participation of a limited proportion of residents depending on a range of conditional factors that are perceived by each household as important table 4 presents the spearmans correlation matrix on the association of driving factors with household engagement in collective activities directly related to village tank resource management and activity coordination the mean level of participation of households in each collective activity was analyzed using the survey data and the results are as shown in table 5 based on the results peoples participation in collective activities is evidently higher when affiliated with a specific institution than when it occurs spontaneously a mannwhitney u test was performed to determine if there is a difference in the engagement of community members in selfgoverned collective action between the two villagebased subcommunities within the cascade territory a cumulative score for the engagement of households in selfgoverned collective action was used as the dependent variable scores were assigned for participation in each of the collective activities namely in the case of a funeral cultural and religious events related to village temples shrines and tanks in the case of wild elephant attacks flash flood emergencies and labor sharing the score distributions in both subcommunities were similar when visually inspected the selfgoverned collective action engagement score between two subcommunities was found to be not significantly different between moragahawewa and mahameddewa u 28010 standardized test statistic z 106 p 0291 this proves the fact that the engagement of people in existing collective action arenas that are entirely communitydriven shows no difference at the village level ence in restoration engagement this observation provokes the need to reflect on the different rates of engagement of community members in projectdriven cascadeecosystem restoration actions 57 that are implemented with expectations of largerscale cascadelevel community participation limitations for engagement in collective action identifying the limiting conditions for cascade inhabitants to engage in collective action is equally important as understanding the existing collective action arenas in order to gauge the possibility of fostering collective action on a broader scale within the cascade territory from the perspective of local community members three main limiting conditions for engaging in collective action in the contemporary context were identified through fgds and indepth interviews and triangulated with the survey findings first due to the risk and uncertainty associated with multiple environmental stressors and a severe economic crisis individualistic priorities have limited the time available for community members to engage in voluntary collective actions based on the survey findings although the majority of households still rely on villagetankbased farming as their main income source 23 of households rely mainly on nonagricultural income sources especially the younger generation tends to prioritize financial independence through diversified income sources rather than relying on villagetankbased farming and community members stated that the temporary solutions provided by the government or external parties have not been capable of solving their longoverdue recurring common problems hence they should find their own ways secondly free labor contributions for collective actions create an economic loss for individuals since labor has become an expensive commodity within the community even though labor sharing and free labor contributions for collective actions were a very common scenario in the traditional context labor has become a highly priced limited resource nowadays thirdly the community members identify the decline of traditional leadership and shared values on the use and conservation of common natural resources within the communities as another cause for the lack of voluntary engagement of inhabitants for collective action unless it serves an essential need in previous research attributes of heterogeneity such as economic wealth access to land and common pool resources disagreement of authority in leadership and being emotionally distant from the resourceissue of concern have been identified as barriers that counteract successful collective action 2754 58 59 60 61 the study findings comply with these factors while adding emphasis on the influence of risk and uncertainty on limiting the potential for collective action future research potential exists to indepth explore the possible legitimate and socially sensitive mechanisms that can foster meaningful collective action at the vtcs level conclusions collective action arenas within the selected vtcsbased community were found to have been generated as responses to crosscutting common challenges experienced by the local people related to the natural environment as well as social life these collective action arenas were found to serve main roles in climate change adaptation livelihood support riskemergency preparedness and response establishing a mutual sense of belongingness and sustaining social identity along with shared culturalreligious values economic incentives and rulesfines imposed by communitybased organizations were found to be closely associated with the participation of households in collective activities related to village tank functions engagement of people in collective actions seemed to be higher when affiliated with a wellestablished institution the only collective activity that showed a strong association with external influence was ecosystem restoration which had a comparatively lower mean level of participation than other communitydriven activities related to village tanks with respect to fostering collective action for the restoration of vtcss in the contemporary context we conclude that although it might be less challenging with farmers in contrast it would be more challenging to foster inclusive crossscale collective action with nonfarming community groups unless the true common problems faced by community members are addressed through legitimate actions therefore existing institutions through which collective action occurs such as fos dbss village templesshrines and local schools should be recognized as focal points in instrumenting an inclusive cascadelevel governance mechanism without exclusively limiting it to the farming community any new legitimate mechanism should be have the potential to minimize risk and uncertainty high opportunity costs in contributing free labor and involve strategies to make effective use of traditional community leadership and recognize shared community values which were found to be the main limiting conditions in the current context to engage in collective action from the peoples perspective it is evident that collective action can occur beyond the scale of individual village tanks when governed by strong community institutions shared resource uses and social relationships among actors yet individualistic and exploitative actions occur in the absence of legitimate regulatory mechanisms we pitch the conclusion through peoples voices …we are aware that our collective participation for cascadeecosystem restoration and sustainable resource management is vital but it does not make an urgent sense to engage in temporary actions while we continue to suffer from uncertainty and critical common challenges which remain unsolved and unattended by the authorities throughout a long time… with this the study highlights the need for legitimate scalesensitive solutions to longoverdue common problems experienced by vtcsbased communities in order to foster meaningful collective action on a broader scale according to the research hypothesis the diagnosis of vital social interactions and resource use patterns of local people is essential to facilitating legitimacy in collective action arenas that can surpass spatial and social boundaries in order to foster collective action into a reality rather than limiting it to a developmental illusion data availability statement data is unavailable due to privacy restrictions existing forms of collective action in the vtcs territory participation drivers and limitations for engagement 431 existing collective action arenas the existing collective action arenas of local people in response to experienced or anticipated challenges were explored in the study to this end the internal and external actors who are engaged in particular collective activities the spatial or ecological boundaries and the institutions through which they are coordinated were explored as summarized in table 3 especially the dynamics of existing collective action arenas for water and ecosystem management of village tanks will be discussed in detail since it directly serves to understand the issues of scale and extent of existing legitimacy for fostering collective action in cascadelevel resource governance however the mean rates of engagement of two communities in development projectdriven ecosystem restoration actions vary from each other according to descriptive results the mean participation level of moragahawewa villagecommunity is lower than that of mahameddewa villagecommunity for projectdriven ecosystem restoration activities the higher dependency exhibited by mahameddewa community members on village tank resources than moragahawewa community members might be one cause for this differ informed consent statement informed consent was obtained from all subjects involved in the study

collective action has inevitable importance for sustainable governance of shared resource systems with interactions across multiple social and spatial scales village irrigation tanks in sri lanka have been recognized as shared resource systems sustainably managed through the collective action of local communities throughout history increased population pressure on shared resources and expanded socioeconomic relationships over time have led to extended resourcebased interactions between people this occurred beyond village tanks within the broader scale of villagetankcascade systems vtcs in which village tanks are constituent subunits this demands the crossscale collective action of local communities for sustainable governance of vtcs which has become a challenging endeavor in the current context this case study explores the dynamics of collective action across multiple social and spatial scales within a vtcs by identifying existing collective action arenas drivers and limitations for the local community to engage in collective action through a mixedmethods approach with reference to the medde rambewa cascade system in the dry zone of sri lanka findings reveal that collective action arenas of vtcsbased local communities occur in response to common challenges posed by disturbed environmental equilibria and as a part of peoples lifestyle with outcomes contributing to climate change adaptation livelihood support risk or emergency preparedness and promoting social identity economic incentives rules and fines imposed by farmers organizations fos were found to be drivers of currently adopted collective activities at the scale of village tanks while collective action prevails beyond the scale of individual village tanks when governed by community institutions shared resource uses and social relationships among actors individualistic resource uses occur in the absence of legitimate regulatory mechanisms the study highlights the need for legitimate scalesensitive solutions to longoverdue common problems experienced by vtcsbased communities in order to foster meaningful collective action on a broader scale

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the relationship among modern nation states capital and people endures as foundational to most theories of social progress and social justice the socalled end of faith in the possibility that western nation states might adopt communism or socialism or even a robust welfare state as alternatives to liberal capitalism raises a whole host of challenges and questions about how we might conceptualise existing forms of life and work towards some vision of a better world we anchor this special issue to this infamous phrase to signal a need to revisit how social work thinks about history and freedom progress and loss and accountability to the shifting conditions of existence and possibility through which we each reproduce and adapt the project of social work from one generation to the next state and professional discourses of progress or improvement regularly work through the omission and erasure of ongoing histories of struggle and disagreement including how popular claims about redistribution and recognition centre colonial temporalities and logics and how welfare restructuring weaponises time to delay distributing the material conditions of survival the necessity to speak of history and temporalities is bound to how conceptualisations of justice can be thinkable or possible this special issue therefore foregrounds connections between genres of history or storytelling and temporal logics engaging questions of memory colonial chrononormativity disciplinary perceptions of radical potential social work education the politics of remembrance carcerality and the fieldshaping power of origin stories the collection opens with a contribution from susanne maurer who in social work as memory of conflicts reflections on a historiographical figure of thought extends for an englishspeaking audience her work on social work as memory of conflicts and an open archive that contains multiple responses to the debates and perceived issues of specific times and places for maurer the activities of social work are materials through which we can consider evolving contested questions of social and political change as she argues the idea of social work as memory of conflicts or open archive itself can be characterised as one specific answer to the dispute over history and memory while at the same time providing new approaches to understanding social works present and future maurers contribution will be of particular interest to readers located in contexts where histories of our applied science and debate about historical narrative and method are less common jennifer m poole and samantha zerafa engage a critical discussion of temporal logics in social work in no more deadlines tracing transcarceral time in critical social work education their contribution questions compliance with historiographical reproductions of colonial chrononormativity by offering analyses from critical perspectives on temporalities via crip queer and pandemic time the authors offer analyses that embed attentions to abolitionist struggles the violence of policing time and a suggestion for refusing transcarceral time deliberately encouraging us to think beyond its punishing and confining temporal criminalisation the analyses proposed provide a frame from which to appreciate the possibilities for liberation that may arise from temporalities that resist acquiescence to the transcarceral in lost futures doomed timelines and unwanted inheritances how we are handling painful time in social work stephanie davies turns to the rhetorical structure and temporal logics of social works historical narratives as a means to reconsider engagement with end of history debates davies identifies three noteworthy relations to time in narratives about social works radical and progressive potential a lost future benchmarked against the optimism of an earlier time and place a doomed timeline in which progress care and domination are inextricably entwined and the unwanted inheritance of an earlier generations perception of what is or should be desirable drawing on debates in cultural theory and feminist philosophy davies argues that social work might shift from care grounded in national progress narratives to care grounded in the ambivalences ambiguities and discomforts of the everyday the labour of social work shows its commitment to staying in contact with realities that are in some sense stuck suspended or recurring this way of living the present may well be difficult at times because it assumes that only by continuing to endure the partial collapse of relations plans arrangements worlds histories and so on can social workers stay in a caring relation to them this includes as she demonstrates through her analysis careful engagement with state and event anchored histories of social work that generate narratives of loss doom and refusal in social works complex cloth teaching hard history in an antebellum cotton mill jane mcpherson contends with matters of national and regional identity and the importance of engagements with difficult political and historical work to catalyse analyses that might offer pathways to liberatory practice in social work the interwoven histories of cotton mills racism and womens charitable work are offered as an example of a method for holding historiographies of the university of georgia school of social work together as interwoven hard histories this work via teaching and learning offers a perspective on confronting the positions of social work as socially just while it is also a profession discipline and set of practices that has advanced exclusion and division and obstructed social change in dealing with a contested past the belgian decolonisation debate ruwayda said salem kris rutten and lieselot de wilde link national identity with professional identity and argue that social work must engage more directly with contemporary debates about colonial pasts and presents formal apologies for state violence are increasingly common and comprise part of the intergenerational memory and remembrance work of making sense of the present for salem rutten and de wilde however national apologies and decolonising public space by renaming institutions and removing statues are only the beginning of reckoning with colonial nostalgia competing interpretations and unprocessed history in the belgian context social work they argue is part of the histories and structures of colonisation and must engage more directly with the shifting politics of remembrance in disrupting the carceral narrative of genderbased and sexual violence maddie brockbank critically explores the ways in which colonial carceralities shroud historiographies of genderbased and sexual violence that advance individualising criminalising tropes via the gazes of whiteness specifically the othering of perpetrators of genderbased and sexual violence is analysed for complicities with individualisationcriminalising logics alongside an analysis of the centring of white womens narratives to advance carceral logics and the ways in which this carceral gaze is extended through social work brockbanks contribution leaves us with the hopeful possibilities that arise from abolitionist and anticarceral social work via critical historiographical resistance the final article by samantha rose ruth zerafa mapping trajectories of fatness a critical account of fat studies origin story and the reproduction of fat normativity offers a perspective on field origin stories zerafa explores the contours of fat studies as a criticalhistoriographical project with aims to rewrite subvert and resist modernist claims of biodeterminism and their use for surveillance and control while querying the erasure of the racial origins of fatphobia via a focus on the activism and scholarship of white and whitepassing women the analytical intervention presented suggests an international shift towards intersectional fat studies as a criticalhistoriographical entry point for activism and analysis temporal logics are embedded throughout social work activities including our historical stories our research approaches and our teaching and learning practices

history is what hurts jameson 1981 88 history hurts but not only berlant 2011 121 for this special issue of critical radical social work we take declarations of the end of history as a reminder of the ways in which established ideas and noted events are linked into historical narratives that structure the temporalgenerational and spatialgeographic nature of the various imaginations that shape professional social work in different times and places the phrase the end of history alludes to german philosopher george wilhelm hegel who argued for a linear and teleological model of historical stages inevitably progressing towards greater human freedom via the emergence of the liberal state form achieving human freedom via liberalism would mean we have reached the end of history this model of history was adapted by marx into a theory of historical development that would instead end with the emergence of communism a theory that underlies some critical and radical traditions in social work the concept of historys end gained widespread media attention when the us political scientist francis fukuyama 1992 boldly proclaimed that the end of the cold war in 1988 was in fact the end of history liberalism qua capitalism had won out over socialism and communism fukuyama 2022 recently doubled down on this claim in addressing the economic success of strong states russia and china not bound by liberaldemocratic legal infrastructures and styles of governance arguing both that these states are too fragile to endure forever and that their existence is in part responsible for the growth of antiliberal populism in the us usstyle liberalism and its relationship with global capitalism remains for fukuyama the only viable way to realise human freedom special issue • critical temporalities in social work after the end of history

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introduction the first case of coronavirus disease was detected in wuhan china in december 2019 soon after it became a global pandemic and public health threat 1 morbidity and mortality rates from covid19 are increasing daily according to the world health organization coronavirus covid19 dashboard 2 there have been 151803822 confirmed cases and 3186538 deaths as of 2 may 2021 the covid19 pandemic has high morbidity and mortality rates that will negatively impact societies and economies worldwide if not brought under control 3 the virus is highly contagious and spreads by direct and contact transmission 4 since the beginning of the pandemic people have relied on various preventive measures such as social distancing hand hygiene and wearing masks accordingly researchers around the world have conducted numerous trials to develop an effective vaccine to combat the pandemic 5 a few countries have succeeded in producing a covid19 vaccine including the united states china russia and the united kingdom 6 in addition several regions have been able to identify communityspecific needs recognize selfreliance coordinate public health policies and develop a sustainable comprehensive healthcare approach to overcome the covid19 pandemic 7 a high covid19 vaccination coverage rate is essential for a successful pandemic response research estimates that more than 70 of the population will need to be vaccinated against covid19 to achieve herd immunity worldwide 6 7 8 however reluctance to get vaccinated with the covid19 vaccine is one of the main problems facing public health organizations worldwide as they try to control the pandemic and limit its undesirable effects on health society and economies around the world 56 in 2015 the who defined vaccine delay as a delay in accepting or refusing immunizations despite the availability of immunization services 2 according to who vaccine hesitancy has been ranked as one of the top ten global health threats in 2019 in several countries this poses a major challenge to achieving immunity in the community and raises pandemic concerns worldwide vaccination acceptance is the decision of an individual or group to agree or disagree with a vaccination when the opportunity to be vaccinated presents itself 9 it might also be considered as accepting covid19 as a real threat not only the value of vaccination 10 we felt that healthcare professionals were knowledgeable about drugs and their associated effects on subjects were likely to reject the covid19 vaccine because of its accelerated development phase and lack of clear information about its efficacy and safety literary evidence has shown that the low uptake of vaccination may be related to peoples doubts about the need for vaccination apart from their concerns about the safety and efficacy of the vaccine 5 6 7 8 9 10 11 12 peoples knowledge attitudes and beliefs about covid19 vaccination and barriers to vaccination are also a reason for hesitancy 1314 the most common reasons for not accepting the covid19 vaccine included concerns about adverse health effects after vaccination and the acceptance of information disseminated via social media 15 it is necessary to study these factors to address the problem of vaccine hesitancy in the population to increase vaccine acceptance and increase the levels of covid19 immunity in the population 11 12 13 14 15 16 since the beginning of the pandemic several studies have examined covid19 vaccine acceptance in a specific population group as well as knowledge about the vaccine and peoples attitudes and beliefs toward the vaccine 5 6 7 8 9 10 11 12 13 14 15 16 studies were conducted to evaluate the acceptability of the covid19 vaccines 12 13 14 15 16 17 18 19 20 21 a systematic review was conducted to provide an uptodate assessment of the acceptability of the covid19 vaccines worldwide and it included results from 33 countries 17 it was found that covid19 vaccine acceptance is low in several regions including the middle east notably the lowest covid19 vaccine acceptance was found in kuwait followed by jordan and saudi arabia another study examined covid19 vaccine acceptance in kuwait and reported low acceptance 21 several studies have been conducted to determine the associated factors 18 19 20 21 22 23 studies have shown an insufficient willingness to be vaccinated with the covid19 vaccine and have identified several factors associated with this hesitancy these include demographic factors such as age education level gender income residence occupation marital status raceethnicity peoples concerns such as the perceived risk of covid19 2021 trust in the health care system health insurance vaccination recommendations insufficient data on the adverse effects of the vaccine perceived effectiveness of the covid19 vaccine concerns about the safety of the vaccine personal factors such as testing for covid19 in the past attitude toward the vaccine vaccination history presence of a chronic illness and working in health care 17 18 19 20 21 22 23 24 25 studies have also examined factors that increase vaccine acceptance and influence peoples decision to get vaccinated factors include the availability of the vaccine at zero cost positive beliefs and attitudes about covid19 vaccination 2223 confirmation of the safety and efficacy of the covid19 vaccine 22 compulsory vaccination by the government or employers 22 or if recommended by physicians 22 23 24 25 26 27 other factors could include a higher level of education working in government institutions high trust in the health care system lack of previous covid19 infection experience possession of the latest covid19 vaccine information being a male subject access to shared information through government websites and trusted news outlets vaccines being available in multiple locations high levels of health literacy and a sense of responsibility for containing the current pandemic despite the aforementioned evidence the decision to accept or reject covid19 vaccines may vary depending on peoples geographic location and culture therefore this study is unique in the sense that it examines the factors that might influence the acceptance and use of covid19 vaccines in the kingdom of saudi arabia we therefore intend to investigate covid19 vaccination coverage among healthcare college employees and students determine their attitudes toward the vaccine and identify the factors that influence their decision to be vaccinated and their correlates in the ksa this is because vaccine hesitancy may be the main problem facing public health organizations worldwide as they attempt to control the covid19 pandemic or similar pandemics to achieve herd immunity it is also necessary to understand the reasons for low vaccine uptake in order to overcome the challenge of vaccine hesitancy through a comprehensive vaccination campaign thus the results of this study might illustrate the methods that governments can use to increase public confidence and willingness to vaccinate materials and methods the study was based on a quantitative crosssectional survey using a convenient sampling technique to determine perceptions of and attitudes toward the covid19 vaccine among staff and students at health colleges in ksa all participants were able to read english or arabic and agreed to participate in this study this allowed us to maximize recruitment and cover a wider geographic area the data collection period was from april 2021 to april 2022 using a selfreport electronic questionnaire and qualtrics software survey items were developed by the researchers and guided by the literature to meet the research objectives measures the survey consisted of four parts demographic information including age nationality gender education level region college name and occupation covid19 vaccination information including the source of information about covid19 availability of a covid19 vaccination center at current workplace previous covid19 infection the severity of symptoms previous covid19 infection of family members number of covid19 vaccine doses received reasons for nonvaccination covid19 and brand name of the vaccine section contained ten questions on attitudes toward covid19 vaccination we used a fivepoint likert scale ranging from 5strongly agree to 1strongly disagree the questions included i feel there is no such virus and therefore no need for receiving the vaccination i am hesitant to receive the covid19 vaccine because it has serious side effects and might lead to hospitalization or death i do not trust the covid19 vaccine benefit i feel the reasons for promoting the covid19 vaccine is for the financial profit of pharmaceutical companies i feel no need for the vaccination of people who had coronavirus because they are immune i am very concerned that i might have covid19 virus at the time of vaccination i think receiving the covid19 vaccine will increase the immunity in the community i support receiving covid19 vaccine because it will enable to remove all restrictions and going back to normal life pattern it is important to receive the covid19 vaccine to control the spread of the disease and it is important for me to receive the covid19 vaccine to protect others and myself the higher scores chosen indicated higher levels of positive attitudes toward vaccination however because the scale contains a mixture of positive and negative items we reversed the negative items before analysis the total score of attitude was calculated as the mean score of ten items section contained nine questions on factors influencing the uptake of covid19 vaccinations this includes fear of the unforeseen future effects of the covid19vaccine would decrease the tendency to receive it mandating vaccine for haj and umra would increase the tendency to receive it free vaccines would increase the tendency to receive it some people prefer natural immunity this may decrease the tendency to receive covid19 vaccine providing education about the covid19 vaccine and its benefits and side effects would increase the tendency to receive it mandating the covid19 vaccine by law would increase the tendency to receive it seeing a family member or friend receiving the covid19 vaccine would encourage others to receive it if their experience were positive people with risk factors tend to receive the covid19 vaccine and the safety and effectiveness of vaccines would encourage people to receive it ratings were conducted using a fivepoint likert scale ranging from 5strongly agree to 1strongly disagree data analysis spss version 25 ibm spss statistics for windows version 250 ibm corp armonk ny usa was used for data analysis categorical variables were expressed as frequencies and percentages quality control of responses was performed using qualtrics software survey item options were enforced by the system during data collection to obtain the most complete responses possible however incomplete surveys were subsequently deleted a fivepoint likert scale ranging from 5strongly agrees to 1strongly disagree was used for ratings the higher the selected values the more positive the attitude toward vaccination the overall attitude score was calculated as the mean of the ten items we classify the attitude as either positive or negative based on blooms cutoff point method the original blooms cutoff points of ≤60 as poor 6079 as moderate and 80100 as good were adopted and modified 30 aiming for the best outcome we classified attitude as positive if it was 80 and negative if it was 80 sociodemographic data were analyzed using frequencies and percentages logistic regression was used to examine the association between the independent variables and the dependent variables pearsons chisquare test was used to assess differences between categorical data sets in this study statistical significance was defined as a pvalue 005 first we examined the association between demographic factors and attitude scores we then examined the associations between demographic factors and uptake of the first or second dose of vaccination results demographic data as shown in table 1 a total of 173 people participated in the survey most participants were saudi nationals however 3699 of the study population had phds and 4798 were faculty members most participants were female and 7225 were from the western region most participants obtained their information about covid19 mainly from social media in addition 8786 of participants reported that there was a covid19 vaccination center at their workplace prevalence of covid19 infection evidence from this study has shown that 8497 of the participants had never been infected of those who had ever been infected with covid19 8077 had only mild symptoms almost half of the participants reported that none of their family members had been infected with covid19 8902 of the study population had received covid19 vaccines with 6558 receiving a second dose pfizer appeared to be the most used vaccine when those who received the first dose of the covid19 vaccine were asked about the reasons for not receiving the second dose safety concerns lack of intent and other reasons were reported 3 attitude toward covid19 vaccination a significant relationship was found between male and female participants the difference in attitude scores was found between demographic variables specifically the mean total attitude score was significantly higher in the west region than in the other regions p 0030 however the results for age were not significant of all demographic factors only education was significant specifically holders of masters and doctoral degrees are most likely to comply with the vaccination requirement while the holders of bachelors degrees are less likely to receive the required two doses of vaccination 1533 p 0004 we also found a relationship between the participants occupation and their main source of information covid19 although the three professional groups reported social media as the most frequently reported source of information administrators were more likely to receive information from the moh than other professional groups similarly faculty members were more likely to receive information from colleagues and journals than the other two professional groups finally the perceived benefits that the covid19 vaccine could increase immunity and the possible control of the spread of the disease the possible removal of limitations leading to a return to normal life and the desire for selfprotection are likely some of the factors influencing their attitudes discussion it is our understanding that this study provides evidence of perceived factors influencing covid19 vaccine acceptance in the kingdom of saudi arabia professional affiliation with health care might contribute to vaccine acceptance in this cohort therefore exploring peoples knowledge of this disease their attitudes toward it and their intentions to get vaccinated is critical to curbing the spread of covid19 protecting communities and promoting the health of the future generation the results of this study showed that the number of participants who received the covid19 vaccine was relatively high this result supports the study 15 which found that covid19 vaccine acceptance in saudi arabia was 647 in addition a study found that the acceptance of vaccination and the intention to be vaccinated was 792 in the saudi population 28 compared to other countries we found a high uptake of covid19 vaccinations in saudi arabia this result may be due to the tremendous efforts of the saudi government to raise awareness of the vaccine by offering covid19 vaccination free of charge and mandating covid19 vaccination in the country with strict monitoring and followup policies such as before entering stores centers workplaces schools and hospitals and before traveling regarding the availability of a covid19 vaccination center in the workplace the majority of participants reported that there was a vaccination center near their workplace and most had already received a second dose of the vaccine one study found that people are more likely to get vaccinated if vaccines are offered by a government health agency in multiple locations and are free 27 another study found that vaccine availability increases peoples acceptance of the vaccine 1 this finding suggests that governments may seek to provide free covid19 vaccines to people in inaccessible locations to increase the number of people vaccinated as for the attitudes toward covid19 vaccination our study findings showed that female participants accepted covid19 vaccines more than males compared to previous studies one study showed that female participants refused to be vaccinated or had no intention to be vaccinated 28 another study also found that males were more likely to have intentions to be vaccinated than females 24 however the reason for the high acceptance rate of females in the result of our study may be explained by the fact that our study had more female participants than males this could be due to the distribution of sample size where more than 75 of the study population was female similarly the results showed that participants attitudes toward covid19 vaccination were significantly greater in the western region as they were the majority among the participants on the contrary it was found that participants who lived in the southern region of saudi arabia were more willing to be vaccinated than participants who lived in other regions 22 the results of our study support the findings of other studies 517232628 this suggests that the population in saudi arabia has a positive attitude toward covid19 vaccination this attitude may be due to the saudi governments efforts to raise peoples awareness of the vaccine and encourage them to vaccinate however the reason for the high acceptance rate in the western region in the result of our study may be explained by the fact that our study had more participants from the western region than other regions our results also suggest a relationship between the level of education and the number of vaccine doses received we found that holders of masters and doctoral degrees were most likely to comply with the vaccination requirement while holders of bachelors degrees were less likely to receive the required two vaccine doses similarly one study found that individuals with a university or postgraduate education were more likely to receive the covid19 vaccine than those with a high school education 26 the results of our study suggest that the level of education has a positive influence on the acceptance of vaccination although an association was found between occupations and main sources of information about covid19 three occupational groups indicated that social media was the most frequently used source of information however administrators were more likely to receive information from the ministry of health than other occupational groups it has become apparent that healthcare administrators must incorporate a large continuous stream of information into their assessment of an everchanging situation such as covid19 it is therefore not surprising that they have better access to information compared to others this clearly suggested that social media can be considered one of the quickest and most convenient methods to raise awareness about the vaccine and get the message out to the community especially for college students staff and academics therefore it is very important for the ministry of health to ensure the reliability of the information published on social media the ministry of health should also conduct comprehensive and reliable educational programs through the media to provide accurate information dispel public misconceptions about vaccines allay public concerns about vaccination and increase societys support for vaccination this is because inadequate knowledge and misconceptions influenced by social media can reduce the uptake of covid19 vaccination faculty members were more likely to receive information from colleagues and professional journals than the other two professional groups this could be due to their involvement in academic activities and the fact that all of them taught healthrelated courses in their respective institutions participants agreed that most of the factors influenced their decision to vaccinate with covid19 vaccines however the factor most frequently mentioned by participants that affected their decision to vaccinate was education about the covid19 vaccine and its benefits and side effects followed by the prescription that the vaccine is required for haj and umra visas the factor that was mentioned less frequently was peoples preference to obtain natural immunity many previous studies 1718 20 21 22 23 252728 have indicated that inadequate information about the safety and side effects of the covid19 vaccine may reduce population acceptance of vaccination among many other factors therefore educational programs and increased public awareness of the covid19 vaccine and government vaccination regulations could increase the number of vaccinated and achieve the desired goal of increased herd immunity in the population to defeat the pandemic the results of this study highlight some strategies that can be used by governments and agencies to overcome vaccine hesitancy for pandemic diseases these strategies include raising public awareness of the vaccine offering free vaccination in inaccessible locations when possible and mandating incountry vaccination with strict monitoring and followup policies when necessary a positive attitude toward vaccination could have a positive effect on the acceptance of vaccination and the educational level of the population however this studys results might not be generalizable to the general population particularly in understanding the factors that might promote vaccine acceptance in a population this may be due to the fact that the samples were individuals who were highly educated in health matters therefore governments need to implement comprehensive and reliable education programs through the media to provide the right information dispel the publics misconceptions about vaccines allay the publics concerns about vaccination and increase societys support for vaccination inadequate knowledge and misconceptions influenced by social media can reduce vaccine acceptance therefore education programs and increased public awareness of the covid19 vaccine and government vaccination requirements can increase the number of vaccinated and achieve the necessary goal of increasing herd immunity in the community to defeat the pandemic this study focused on academic staff and students in health colleges in saudi arabia which are considered a highly educated population as most of the research focuses on the general population focusing on such a population may highlight the factors that assist in boosting vaccination acceptance strategies in case of other future pandemics this study had some limitations a selfreported electronic questionnaire was used to collect data and this may present some bias in the result additionally it was aimed only at students faculty members and staff of health institutions mainly in the western region of saudi arabia who may have a high level of awareness of the covid19 vaccine as well as convenient access to it such as the availability of free vaccines at a vaccination center at their universities therefore a study conducted in other locations with a less privileged population might yield different results another limitation was that most participants were vaccinated at the time of data collection because vaccines were widely provided by the government and mandated by authorities especially for all healthcare workers and students unless exempted by medical opinion therefore we were unable to investigate associations with the receipt of the vaccine moreover at that time the health authorities had already given enough time to those working in the medical field to obtain the vaccines which were free and easily accessible therefore we assumed that the people who had received their first dose of the vaccine were somehow reluctant to receive the second dose it is quite possible that they waited some time to receive the second dose however given the recommendations of public health authorities and the demands of the workplace at that time we could not relate this delay to the timing factor in addition given the relatively small sample the results of this study cannot be generalized therefore it is recommended that a research study be conducted with a larger sample covering a wider geographic area finally we have not investigated the association between attitudes and uptake of the first or second dose of covid19 vaccines therefore future studies are needed to explore this niche conclusions covid19 vaccine acceptance in the kingdom of saudi arabia appears to be relatively high this could be due to the fact that the vaccines are available in the workplace or are prescribed by the relevant authorities females were more willing to accept the vaccines than their male counterparts the coverage was more in the western region of the kingdom compared to others the vaccine coverage was higher in the western region of the kingdom than in others and higher educational attainment is correlated with compliance professional affiliation eg in healthcare correlates with access to information and social media appear to be the most important sources of information about covid19 knowledge of the benefits and side effects as well as fulfillment of religious obligations such as haj or umrah might encourage people to accept the vaccine covid19 institutional review board statement ethical considerations were taken into account and compliance with the declaration of helsinki was ensured the scientific research committee of the faculty of nursing of kau reviewed and approved the ethical and scientific merits of this study in the survey an informed consent form was presented at the beginning of the questionnaire to ensure that participants gave informed consent to participate in the study brief information was provided about the purpose and process of participation in the study and the need to provide informed consent before completing the questionnaire was clearly stated study participants were assured that their anonymity would be maintained their data would be kept confidential and they could withdraw from the study at any time informed consent statement informed consent was obtained from all subjects involved in the study data availability statement the data that support the findings of this study are available on request from the corresponding author funding this study was funded by the deanship of scientific research king abdulaziz university jeddah saudi arabia under grant number the authors thank the dsr for the technical and financial support

background the availability and access to covid19 vaccinations are critical to a successful pandemic response more than 70 of the population reportedly needs to be vaccinated against covid19 to achieve herd immunity worldwide however the reluctance to get vaccinated with the covid19 vaccines is holding up the process of vaccination and efforts to control the pandemic and its negative consequences for the global health system society and economy previous studies have shown low uptake of vaccination in some middle eastern countries due to negative attitudes toward vaccination including concerns about safety and efficacy and doubts about the need for vaccination aim the aim of this study is to investigate the prevalence attitudes and factors influencing covid19 vaccine acceptance among healthcare workers academic staff and students in saudi arabia after the vaccine was made widely available by the government method a crosssectional survey was conducted to determine the prevalence attitudes and association between demographic factors and uptake of the first or second dose of vaccination among saudi arabian health workers and students data were collected using an online questionnaire administered and distributed through the qualtrics platform results the study recruited 173 participants from different countries and from different saudi regions most of whom were faculty members n 83 results indicated significant differences between regions the mean attitude score for the western region m 323 was significantly higher than that for other regions m 308 p 0030 there was also an association between education level and number of vaccine doses received thus the participants with higher education were the most compliant with national vaccination requirements p 0004 although the three professional groups reported social media as the most frequently reported source of information p 0021 administrators were more likely to receive information from the moh than other professional groups similarly faculty members were more likely to receive information from colleagues and professional journals than the other two professional groups conclusions government officials should build public confidence through vaccination campaigns and devise effective health education programs to increase vaccination uptake authorized institutions can effectively use social media platforms to encourage vaccination and promote awareness among all audiences

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introduction in the uk the pattern of political support is becoming more territorially uneven devolution did not create political differentiation and segregation but rather expresses and entrenches it while never a simple northsouth divide the geographical isolation of conservative support is an increasingly pronounced feature of uk electoral politics a process confirmed by the 2010 general election support for conservatives increased wherever they were already strongly placed the most affluent constituencies in england above all south east england in contrast even affluent voters in scotland rejected the electoral appeal of revived conservativism which has proven singularly incapable of recovering from the electoral disaster of 1997 then the percentage vote for conservatives was almost halved and they failed to win a single seat after 18 years of steadily declining representation at the may 2011 scottish elections conservatives failed to improve on their existing poor performance with their share of the constituency vote declining further from 17 in 2007 to 139 in a desperate gamble to arrest decline murdo fraser deputy conservative leader at holyrood recently proposed abolishing the scottish conservative and unionist party altogether and replacing it with a less toxic brand threatening a damaging split in the leading party of uk cogovernment while conservatives are in political crisis and unable to command wide support in scotland scottish nationalism exerts minority if growing political traction at uk general elections the scottish national party consistently poll around one in five voters but gained almost fortyfive per cent of constituency votes for the scottish parliament in 2011 enabling them to form the first majority government since devolution was introduced in 1999 nationalists anticipated a westminster breakthrough at the 2010 uk election as a prelude to forcing the pace of political independence instead the labour party won two out of every five votes in scotland consolidating their position as the official opposition in scotland to the conservativeliberal democrat uk coalition government at least at uk level in making sense of these shifts we extend our gaze beyond the relatively narrow discussion of contrasting electoral fortunes electoral results reflect profound changes in scottish society requiring an understanding of the structuring shaping and alteration of social relations social class above all however in many of interpretations of devolution and scottish society the structuring effects of class relations are largely absent for example tijmstra usefully explores how issues of legitimacy helped to fuel the rise of regionalist demands and a rising sense of scottish national identity but neglects to account for the part played by the restructuring of social classes in the dialectic of nation and state in other accounts scotlands peculiar political arithmetic seems to defy the electoral logic of a society seen by some to be possessed of a transformed predominantly middle class social structure a new open and upwardly mobile social system in scotland appears to strongly favour the symbolic transclass appeal of the snp the fluidity of the class system opens up further possibilities to a party without a historic class profile taken in its subjective form class is often treated as an identity interchangeable with other markers of difference such as ethnicity age community gender or nation in this form class is reduced to data about attitudes to work and consumption in its objective form it is equated with the market position of aggregated individuals however class is reproduced neither through the perfect competition of equal agents in markets nor as a voluntary identity following bourdieu class is accumulated history as such class is an enduring condition that persists as a series of constraints through an economy of practices relative amounts of economic capital holdings which can be directly converted into money remain central to this conception of class but only as a special case of more general processes of class formation through unequal exchange any totality of class practices must also include other forms of capital their distribution volume and composition famously bourdieu calls these forms of class practices and resources cultural capital social capital and symbolic capital variegated marketisation strategies enable the value of different capitals to be reconverted say using social capital of elite networks to access economic capital through market advantage extraeconomic forms of capital fail to be recognised as class domination as such indeed the success of class reproduction depends precisely on the misrecognition of class interests as the disinterested practices and spontaneous attributes of national social agents each form of capital is both embodied in the durable dispositions of people and objectified in particular forms for instance in cultural goods like books or home furnishings importantly for our purposes each form of capital also acquires an institutionalised state form set apart from the initial investment of time and effort in the home and school initial investment in class reproduction is sanctioned and legitimated by the state in a continuing process table 1 table 2 table 3 in this paper we revisit state theory and bourdieus approach to the social sources of state power to account for the active role of the devolved scottish government in shaping the unequal conditions of class reproduction here the devolved state in scotland functions as a power container filled by specific kinds of class content but where state legitimacy derives from a transclass peoplenation although the scottish state lacks full sovereign power it nevertheless exercises considerable economic cultural and symbolic power with profound consequences for the reproduction of class relations each type of capital in bourdieus sense corresponds to different state containers economic capital to the wealth container cultural capital to the cultural container social capital to the social container and symbolic capital to the power container territorial politics is filled with different often contradictory class content not least in the appeal to values of social justice at the same time as enacting neoliberal policies in the service of global economic competitiveness the nationalisation of scotland the conundrum of class nation and territorial politics in scotland requires closer examination nationalism is not a unified thinglike substance as philosophers of language claim it is not the meaning of a word like nation that makes it useful but rather only in its use does the word become meaningful while nation has become increasingly meaningful in scotland class has been rendered relatively meaningless as political discourse in social attitude surveys the more scottish that people felt the less that they identified with nonscots of a similar class while a quarter of respondents in scotland surveyed in 2006 identify with those from the same class but a different nationality more people around half identify with people of the same nationality from a different class compared to only a third in england that place national identity before class identity one explanation for the 2007 and 2011 election successes of the snp is that devolution has shifted the focus of territorial politics more emphatically from class to nation as a collective frame of reference before the 1990s social class played a significant role in political beliefs and collective identity across scotland and england since their socioeconomic structure was broadly similar scotlands tribal loyalty to labour and visceral hostility to conservatism at least from the 1960s was typically explained as reflecting first the national egalitarian values of an industrial nation and later the rapidly deteriorating conditions for the industrial working class in the 1970s and 1980s surplus labour expelled during scotlands crisis of manufacturing in the early 1980s was only haltingly if at all reabsorbed by service employment as an extended form of class reproduction in the past two decades this has been replaced by an expansion of highly qualified professions mainly in public services and financial services today the traditional classes on which political support depended landowners industrial bourgeoisie and organised labour have undergone radical transformation losing the social weight to shape electoral preferences there is no longer a cohesive ruling class of the kind that once delivered the votes of skilled and unskilled protestant workers for the conservative party who remained the dominant force even in industrial glasgow until the mid1950s at the same time organised labour is increasingly confined to the public sector now experiencing severe contraction following decades of growth and expansion with the general growth of public sector employment in scotland until recently a new interest coalition was constructed as a potential electoral bloc over which new labour and the snp contend fiercely much has been made in this account of the legacy of administrative mesolevel autonomy of the scottish substate around the scottish office and the distinctive institutions of scottish civil society principally law religion and education as reproducing a distinctive national fraternity here british identity was limited to a pragmatic statenation identity attributed historically to an internal british market for goods and services the british empire and british militarism a shared protestant religion and since the 1940s a british welfare state scots thought of themselves as equal partners in the union a condition which produced a dual sense of national identity scottish and british as the banal nationalism of britishness as a statedefined way of life began to lose its lustre in scotland with the impact of relative industrial decline and conflict in the 1970s and 1980s the unitary british state appeared to be too small to cope with globalisation but too large to deal with the demands of its constituent national populations state authority depends on a special claim of competence to transform the arbitrary arrangements of its own power into something necessary and essential … powers based on force can only obtain their legitimation through powers that cannot be suspected of obeying force and that the legitimating efficacy of an act of recognition varies with the degree of independence of the agent or institution that grants it the state imposes the symbolic apparatus through which it is itself to be perceived above all as the embodiment of the nation through the structuring it imposes on practices the state institutes and inculcates common symbolic forms of thought social frames of perception understanding or memory state forms of classification or more precisely practical schemes of perception appreciation and action hence state legitimacy does not depend mainly on propaganda or selfconscious collective deliberation outside of an exceptional crisis legitimacy is generated routinely through the nationalising dispositions inscribed in things institutions and bodies symbolic power rests on the everyday appeal of nationalism concealing conflicting social interests behind the disinterest of national unity welfare nationalism and competitive nationalism while there has been a marked consolidation of scottish national identity alongside growing electoral support for the snp this does not necessarily translate into guaranteed support for full independence for scotland as voter surveys suggest here the policy content of the relationship between class nation and state requires more precise modelling first welfare nationalism generates support for devolution it is claimed because the scottish state is smaller more responsive and accountable and can experiment with the various policy instruments under its control to reduce class inequalities however operating against the amelioration of class inequalities in the overall interest of the nation stands the fact that the main instruments of redistribution taxation and social security remain centralised reserved matters not devolved powers figure 1 second competitive nationalism in contrast mobilises the resources of the devolved scottish state within a neoliberal political economy as the national economic strategy indicates to attract mobile global investment and secure the accumulation of indigenous capital competitive nationalism offers various capitalfriendly incentives including lower relative wage costs flexible labour supply and infrastructural requirements through higher public spending here class inequalities are likely to worsen since redistribution pushes in the opposite regressive direction towards private capital in the long run competitive nationalism projects that private capital will raise the absolute standard of living even if wealth and income distribution become grossly unequal within and across regions a process identified in southern italy some time ago by stuart holland a third position holds that devolution has made little difference to the classstatenation nexus since constitutional change in a peripheral substate is unlikely to affect the global structures of capital accumulation this perspective has little to commend it scotland has some of the widest powers of any devolved state while it has little direct control over redistribution considerable policy discretion is exercised over the competing priorities of social justice and capital accumulation class reproduction is bisected by the vectors of competitive nationalism and welfare nationalism devolved policy in scotland combines unevenly with reserved policy to actively structure class relations albeit in contradictory ways competitive nationalism envisions the devolved state as an enabler for capital accumulation welfare nationalism envisions the devolved state as an enabler of social justice successive devolved governments in scotland have used their powers to affect a number of original policy developments some tending towards welfare nationalism and others to competitive nationalism the former includes free personal care for the elderly and land reform while the latter is apparent in neoliberal programmes for public services urban regeneration and successive economic strategy documents competitive nationalism and welfare nationalism are rarely identified as specific types of class project this neglect of the class structuring effects of state power excessively restricts analyses of territorial politics both are nationbuilding projects both advance an image of scottishness of authentic scottish values and interests beyond narrow class interests and ideologies as a key part of its nationbuilding endeavours snp social imagery pictures scotland as a vibrant competitive north atlantic society a new scotland in the making transforming the dominant labourist image of scottishness in the process this important and all too frequently overlooked shift crucially entails an ideological assault on the remaining vestiges of an unnamed yet simultaneously widely understood problematic working class culture and way of life resistant to behavioural reform and the entrepreneurial spirit class relations are actively recomposed in scotland through a stateimposed vision of the competitive nation though scotland is not unique in this respect shortly after it assumed governmental power the snp mobilised the symbolic power of a single unified national purpose in the government economic strategy reinforced by the second snp governments economic strategy scotland has real strength in the most vital factor for modern economies the human capital offered by our greatest asset scotlands people we need to build on this strength and importantly make more of it in broadening scotlands comparative advantage in the global economy in these and other statements the economy is mobilised as a neutral means to realise the greater symbolic end of a shared national interest just months before economic crisis overwhelmed neoliberal ireland first minister alex salmond argued that the scottish states one central purpose was to transform scotlands comparative advantage in the global economy into a celtic lion economy matching and then overtaking the irish tiger its unifying national purpose envisaged opportunities for all of scotland to flourish through increasing sustainable economic growth scottish government 2007 12011 scotland as a power container in his critique of marxist accounts of the state anthony giddens developed the idea of the state as a bordered power container to account for the historically complex relationship between class state and capitalism first while capital and labour have conflicting interests they are also mutually dependent on each other and second the capitalist class do not personally populate the functionary positions of the state while the states revenue is dependent upon the accumulation process it does not control this directly the state concentrates power through technologies of surveillance and communications it monopolises the use of internal and external violence private capital and with it class conflict is formally divorced from political institutions and industrialism concentrates private means of production in particular locations at the heart of giddens definition of the state as power container is the exclusive capability for organised violence within the postwestphalia interstate system here militarypolitical states gradually transmogrified from an apparatus of warmaking to an apparatus in defence of bounded populations clearly the scottish state does not possess the full panoply of sovereign powers it cannot declare war or set up independent border controls in the devolved settlement the organisation of military violence and border control rests with the uk state within the context of the european union scotland might still be characterised as a stateless nation since it lacks geopolitical power to assert the interests of its ruling groups assuming that these could be disaggregated from british or transnational capital nevertheless the scottish state does possess some core features of the power container in its distinctive legislative and criminal justice system scots law for instance is taken to reflect the compassionate values of the nation illustrated by the controversial release of the convicted lockerbie bomber the libyan national abdelbaset almegrahi by the scottish justice secretary kenny macaskill in august 2009 macaskill used the powers available and defended his decision by appealing to the transclass humanist values of the scottish people in scotland we are a people who pride ourselves on our humanity it is viewed as a defining characteristic of scotland and the scottish people the perpetration of an atrocity and outrage cannot and should not be a basis for losing sight of who we are the values we seek to uphold and the faith and beliefs by which we seek to live more broadly devolution politicised the scottish criminal justice system challenging its welfarist assumptions as it converged more closely with the class biases of populist punitivism in england and wales scotlands growing prison population one of the highest in europe shows a near absolute correlation between the rate of imprisonment and the worst areas of urban deprivation legaljuridical powers apart the scottish state is not a classic power container moreover giddens institutional separation of state and capital seems naïve in light of the marketconstituting practices of the neoliberal state devolution possesses many of the features that michael mann characterised as infrastructural power by this mann means a much wider range of powers through which the state regulates social life by deploying communications political participation welfare rights and economic planning peter taylor further developed the idea of the state as a power container to account for other functions of the state as a wealth container as a cultural container and as a social container combined the territorial shape of the state container is twisted in different directions to produce a triple territoriality as a power container the state attempts to preserve its territorial integrity as a wealth container the state tries to extend its territorial reach within the world system as a cultural container it restricts recognition to smaller territorial nations or regions conceiving the multiple spatiotemporal logics of the devolved state seems a useful point of departure for tracing different interrelated sources of class reproduction a devolved uk state in pursuit of neoliberal policies is subject to the storms and stresses of multiple and leaky territoriality contrary to giddens false opposition of the bounded state and the borderless economy the uk state has always been a leaky container it shed some institutional power externally to the worldsystem and ceded other powers to internal nationalist movements as the central state becomes more porous devolution does not mean the loss of state capabilities as such but their territorial redistribution and recombination in different magnitudes however taylor tends to naturalise state power as a linear process where the state first captures politics then economics followed by culture finally absorbing society to become a fullyfledged nationstate devolved scotland is a leaky container as a power container it encompasses controls over law home affairs and the police second as an economic container it exerts some control over agriculture fisheries planning economic development training and tourism third as a social container it controls health social work housing and local government and fourth as a cultural container it controls education the arts and sport and the natural and built environment of course these functions may pass between two or more containers for example education is not only about cultural transmission but also socialises subjects into economic values or civic behaviours this requires us to examine the substantive class content of devolved state containers scotland as a wealth container any conception of the devolved state as a wealth container of economic capital has to address the relative degree of integration between capital and state in the twentieth century the british state assumed overall responsibility for economic activity this transformed the meaning of political economy from adam smith onwards wealth containers are caught in a never ending cycle of renewing the basis for their existence state infrastructural power depends on the extent of its reach into society to generate revenue through taxation which depends on the size of gdp which in turn depends on state spending on infrastructure locational incentives social policies education stable currency and so on such multiple interdependencies make the wealth container among the most leaky of all state containers economic activity flows across borders and global conditions limit the room for manoeuvre nevertheless the uk state remains a significant wealth container although the scottish state has scope for raising taxes and economic development it stands in a dependent relationship to the unitary uk state and its relationship to financial institutions in the city of london this was demonstrated graphically by the bail out in 20082009 of scotlands major clearing banks rbs and hbos as a wealth container inequalities are less pronounced between the nations of the uk than they are within them where absolute levels of paid employment are taken as an indicator of economic success scotland manages to score relatively well compared to other uk nations and regions only london has a higher level of fulltime employment clearly some groups do better than others median hourly wages of £1084 for men and £878 for women in scotland in 20068 are roughly comparable to england and are higher than wales and northern ireland moreover the relative value of earnings is also higher thanks mainly to lower property and rental values in scotland than other uk regions with the exception of wales yorkshire and north east england after housing costs are factored in household income is more evenly spread across the uk but inequalities become more pronounced within regions especially london at the same time the capitalenabling devolved state is also marketconstituting where the relative value of income fails to keep up with the cost of culturally essential commodities personal and social needs are increasingly met through processes of financialisation including historically high levels of personalised debt in scotland traditionally classimposed sobriety and asceticism was inscribed in scots law for debt recovery and enforcement until 2002 debt enforcement in scotland relied on the public humiliation of poindings and warrant sales creditors need to be protected from default but in ways which do not call the foundations of the wider creditdebt economy into question in 2003 the scottish executive issued contradictory proposals to reduce the stigma of bankruptcy but at the same time encourage responsible risktaking higher levels of class deprivation in scotland are often explained by higher public spending than england such levels of public sector dependency it is argued are perpetuated by a selfinterested political bloc creating national disincentives for entrepreneurial activity in an article titled welcome to the peoples republic of scotland the sunday times commissioned a report from the centre for economics and business research to demonstrate that scotland is entrenched in state dependency comparable to china cuba and iraq while claims about public sector feather bedding are fiercely contested public sector workers in scotland are seen by some as a relatively privileged class of employees who enjoy higher average wages and pensions better terms and conditions compared to private sector employees and are protected by high trade union densities in 200910 labour cost around 52 per cent of devolved spending of 620000 public sector jobs 83 percent relate to devolved bodies and 17 percent to reserved bodies such figures conceal the uneven public sector penetration in urban areas like dundee where it accounts for 40 percent of all employment leaving it highly vulnerable to cuts in public finances growing disparities in earnings are apparent within public administration education and health the latter two sectors with high concentrations of female labour fare worse across the bottom deciles than average earnings in scotland as a whole higher qualifications needed for public administration health and education helps explain increased earnings for higher deciles in a study by the scottish governments advisor on public sector pay david bell found that public sector workers in scotland are paid less on average than the uk overall public sector workers with a higher degree earn 7 percent more than private sector workers in scotland but 5 percent less than the uk public sector overall public sector pay compares favourably to the private sector in scotland because of lower levels of investment by private capital in the scottish economy particularly in higherskill upper knowledge labour insert table 4 insert table 5 a consensus exists across the political spectrum for greater fiscal autonomy for the scottish state in 2006 the liberal democratsponsored steel commission proposed a system of fiscal federalism in 2009 the calman report argued for a system of fiscal devolution based on equity implying no fiscal disadvantage to scotland autonomy to raise taxes political accountability and public transparency at the same time the snp government reflected the growing consensus with what they called a national conversation for full fiscal autonomy as a prelude to political independence from the uk state in june 2010 business interests and academics formed the campaign for fiscal responsibility to end scotlands dependency culture and ease institutional tensions in the uk by making the devolved state responsible for raising all taxation claims and counterclaims about scotland as a subsidy junkie have persisted since the 1980s despite large concentrations of urban deprivation and responsibility for the administration of one third of the uk land mass competitive nationalists claim that scotland is a net contributor to the uk state based principally on oil and gas revenues and before 2008 the financial success of companies such as the royal bank of scotland in their state of the nation 2010 report the cebr concluded that high public spending in scotland has been financed largely by stronger market economies of south east england particularly london this is complicated by the cebrs own evidence that the share of gdp represented by public spending increased since devolution by a greater amount in london than scotland even with added costs of creating a new system of government official public expenditure statistics reveal that public spending per head of population is broadly similar across london and scotland table 6 such arguments revisit the old canard that public spending crowds out the entrepreneurial spirit in scotland even some mainstream commentators in scotland accept that a large public sector inhibits the energetic efficiency of private capital as the journalist iain mcwhirter put it an economic cold bath could perhaps shock scotland out of its postindustrial torpor and boost private investment which many economists believe is being crowded out by the state here the scottish state is seen as more of a wealth constrainer than a wealth container yet this voids the extent to which the scottish state functions as a neoliberal enabling state attempting to crowd in marketed wealth assisting nurturing and promoting private capital in every conceivable way from labour supply to roads to buildings to contracts to subsidies to education to enterprise agencies in keeping with the scottish governments one central purpose of territorial wealth containment scotland as a cultural container while the scottish state has little geopolitical authority as a power container and limited economic autonomy as an integrated statecapital wealth container this is compensated by a surplus of collective sentiment as a cultural container it is the states duty to express or constitute the collective will through cultural social and educational policies and so preserve the apparently spontaneous autonomy of civil society much store is invested in educational capital in scotland as a means to equalise class inequalities for more than a century educational access and qualification achievements have been celebrated as central components of scotland as a meritocratic nation education is widely seen as one of the distinctive egalitarian national institutions of scottish civil society alongside law and religion yet it reflects reinforces and deepens class entrenchment in scotland two facets of educational policy are particularly important for equalising initial class inequalities in scotland a more inclusive public comprehensive system and higher participation rates than elsewhere in the uk despite this class inequalities in educational outcomes are persistently higher than in england and wales a wider gulf exists within scotland for secondary neighbourhoods than for comparable results in england in the 1990s children from the service class in scotland entered higher education in much greater proportions than their counterparts in england as higher education expanded middle class groups in scotland were strategically positioned to colonise it faster and more deeply in the most affluent neighbourhood decile in scotland even more people attained degree qualifications than in england it is well understood that higher education valorises the arbitrary practices and values of middle class habitus education reflects a classspecific habitus where working class speech is internalised as inferior and marginalised by a scottish education system that consecrates standard english in a predominately middle class academic environment an additional factor behind middle class entrenchment is the way that the employment and educational fields intersect in scotland affluent households in scotland overinvest in educational attainment because of the higher proportion of credentialed employment opportunities in middle class public sector labour markets compared to the greater opportunities for lessqualified private sector employment in england yet middle class labour markets do not exist in an undifferentiated way both public and private service sector employment is increasingly fragmented but also polarised experiencing work intensification and growing precarity in much of what once was regarded as secure and rewarding middle class employment scotland as a social container as a social container the state underwrites the social morphology of class reproduction through the appeal of citizenship the social container generates social capital in cohesive and useful populations to meet the economic and military requirements of the wealth and power containers sustainable communities is one of the scottish governments five strategic objectives yet according to scottish household survey findings enduring communities already exist throughout scotland most people around 90 percent consistently hold that their neighbourhoods are generally good or very good places to live not surprisingly the most deprived neighbourhood deciles are significantly less likely to perceive their neighbourhoods as pleasant safe friendly or communityspirited and more likely to experience vandalism difficult neighbours and drug misuse or dealing they also have less access to greenspaces and parks and are less likely to own or have access to a car poorer sections of the working class find that their social networks are confined to their immediate locality to address the social capital deficit the scottish government aims to develop personal skills and confidence through voluntary activity only around one in five households earning under £15000 volunteered in 2008 for some unpaid role whereas almost half of those earning more than £40000 claimed to have done so the scottish government also seeks to attract international graduate labour to scotland to compensate for national population decline and generate high skill labour supply for the knowledge economy nevertheless the largest group of migrants typically arrive via the long established twoway employment routes between scotland and england surveys show that a large proportion of english migrants are professionals and managers here the imbrication of class and nation is perceived as pervasive geographically mobile professionals reject the fixity of traditional social categories of national historical tribes and employ more fluid contingent identities this releases them from becoming absorbed by scottish identity national duality british or scottish is therefore strongly imprinted by class affiliation senior managers and professionals tend to emphasise britishness perhaps reflecting their greater geographical mobility and proximity to national centres of decisionmaking elites a strong british identity corresponds to a middle class habitus of career prospects collegiality and intrinsically worthwhile employment in contrast people who forefront scottish identity tend to share a working class habitus that sees paid work in instrumental terms of labouring for lifes necessities and distractions behind such policy interventions lies a scottish variant of the white working class discourse here a bastion of unenlightened lower class prejudice circulates against outsiders and operates as a significant barrier to competitive nationalism in scotland a negative collectivist working class are deemed to lack appropriate social and cultural capital and fail to develop necessary tolerant and aspirational values expressed in the socalled scots crisis of confidence another expression of subaltern intransigence is a negative attitude to cultural markers like speaking with what is considered an upper class accent one study into students at the university of edinburgh attributes antienglishness in the city to a lack of cosmopolitan mobility aspiration and cultural intolerance among a recalcitrant working class culture negative perceptions may repel highly qualified migrants from settling in scotland and suggests a need for class correctional policies as the edinburgh researchers advised the scottish government this highlights the need for scotlands political classes to further address working class attitudes to migrants and minorities if they are to meet their demographic objectives by attracting and retaining talented people scotlands political classes upon whom responsibility for social containment falls form a compact selflegitimating network consisting of a relatively small number of people clustered in the central region with its nodal point in edinburgh with devolution associational networks became an even more valuable currency as social capital and political capital were more readily converted into the economic capital of market advantage through access to and contact with business insiders charges of mccronyism followed lobbying scandals in the early years of the labourdominated scottish parliament involving family relatives and friends pr companies and labour politicians organised around the parliament which business interests in scotland had largely opposed elite networks created an incestuous personal and professional blurring of roles between business lobbyists advisors and politicians academic insiders are also embedded in policy networks since scotland is said to have the right scale social capital and communities of trust required for effective knowledge exchange and research use conclusion in such ways the active infrastructural power of the scottish state attempts to naturalise competitive nationalism and nationalise class divisions that the scottish state is a leaky container does not lessen the power social cultural economic and symbolic of dominant groups overall the spatial effect of class reproduction under a neoliberal polity is to expand the territorial reach of the devolved state even if it falls short of complete independence as a legaljuridical power container with considerable infrastructural reach the devolved state accentuates its territorial integrity despite converging with wider criminal justice regimes of uk punitivism as a wealth container an emerging consensus exists for greater fiscal autonomy this not only recalibrates the territorial politics of revenue distribution between the uk and scotland it also aims to extend the scottish states capacity to crowdin global capital beyond its existing capitalenabling functions as a cultural container scotlands educational system reproduces class positions even as it consecrates territoriallyspecific educational traditions as a social container dense policy networks exercise territorial capture and seek to mobilise infrastructural power to secure national solidarity among the population through inclusionary interventions in such ways devolution entrenches enabling forms of dominant power through flexible trusted interpersonal networks blurring giddens ideal separation of state and market power the impact of far reaching budget reductions as part of the uk governments austerity measures together with cuts implemented by the scottish government will work to increase latent and manifest class and national tensions that are at the heart of the devolution project in scotland in this context as we have seen the snp have since their reelection in may 2011 mobilised a contradictory selfimage of scottishness in policymaking pronouncements realising this vision will mean overcoming growing opposition to cuts in public sector jobs and services envisioning devolved scotland not as a consensual order where class has been made redundant by a common national purpose but as field of social retrenchment fraught with tensions is therefore a crucial and necessary starting point for critical analysis of territorial politics and devolved statehood change and the options for reform edinburgh the scottish government scottish government

devolved government in scotland actively reconstitutes the unequal conditions of social class reproduction recognition of stateled class reconstitution draws upon the social theory of pierre bourdieu our analysis of social class in devolved scotland revisits theories that examine the state as a power container a range of state enabling powers regulate the legal economic social and cultural containers of class relations as specific forms of what bourdieu called economic social and cultural capital the preconditions of class reproduction are structured in direct ways by the scottish state as a wealth container but also more indirectly as a cultural container and a social container competitive nationalism in the devolved scottish state enacts neoliberal policies as a classspecific worldview but at the same time discursively frames society as a panclass national fraternity in terms of distinctive scottish values of welfare nationalism nationalism is able to express this ambiguity in symbolic ways in which the partisan language of social class cannot

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introduction reproductive health is a topic that has been widely discussed in indonesia since around the early 2000s partly as a result of the incessant holding of regional and international meetings which discussed population and development issues more thoroughly reproductive issues present facts about reproductive health both positive and negative encouraging various parties including the government individuals the private sector and nongovernmental organizations to take an active role in socializing as well as providing appropriate solutions to reproductive health problems that occur adolescence is also called adolescence adolescence is marked by puberty which is when a girl is able to experience conception namely her first menstruationmenstruation and the presence of wet dreams in boys during this period adolescents experience sexual development including maturity of the sexual organs starting to function both for reproduction and recreation at this time it is hoped that adolescents will begin to pay attention to personal hygiene especially health according to who personal hygiene personal hygiene genetalia is the maintenance of individual hygiene and health which is carried out in daily life so as to avoid reproductive disorders and obtain physical and psychological wellbeing as well as increase the degree of reproductive health personal hygiene during menstruation can be done by changing pads every 4 hours once a day after bathing or defecating the vagina is dried with a tissue or towel so that it is not damp use of good underwear made of materials that absorb sweat based on the results of previous research it showed that the majority of respondents had a good level of knowledge about personal hygiene during menstruation namely 43 respondents from the results of a survey conducted at rw 007 desa gaga pakuhaji district by direct interviews with 10 young women with the results 2 young women who knew about personal hygiene during menstruation and 8 who did not know about personal hygiene during menstruation this is due to various factors namely the lack of knowledge about personal hygiene especially during menstruation the purpose of this study was to determine the level of knowledge of young women about personal hygiene during menstruation in young women in rw 007 desa gaga pakuhaji district method this type of research used descriptive research descriptive research is a method used to describe or analyze a research result but is not used to make broader conclusions with a crosssectional approach namely data collection for independent variables and dependent variables at one time the population of this study were 121 young women in rw 007 desa gaga pakuhaji district the total sample used was 44 people the sample in this study were young women in rw 007 gaga village pakuhaji district the sampling technique uses the accidental sampling method which is a sampling technique based on coincidence that is anyone who happens to meet the researcher can be used as a sample if it is deemed that the person who happened to be met is suitable as a data source the variables in this study were age status education and information sources for young women in rw 007 gaga village pakuhaji district in this study the authors conducted a validity test on 30 respondents at kp kebon rampog gaga village pakuhaji district data analysis used in this research is univariate analysis based on the results of the research in the table above it can be concluded that the majority of 545 of young women in rw 007 gaga village pakuhaji district have good knowledge based on the research results in table 42 above it can be concluded that the majority of young women in rw 007 desa gaga pakuhaji district are 1114 years old by 50 of respondents the majority have low education of 568 of respondents the majority of information sources were 455 mothers based on the research results in table 43 above it can be concluded that in rw 007 desa gaga pakuhaji district the majority of young women who have good knowledge are 90 namely teenagers aged 1821 years based on the research results in table 44 above it can be concluded that in rw 007 desa gaga pakuhaji district the majority of those with good knowledge 632 are teenagers with secondary education based on the research results in table 45 above it can be concluded that in rw 007 desa gaga pakuhaji district the majority of young women who have good knowledge are 100 namely teenagers who get information from print media result 1 distribution of knowledge frequency of young women frequency distribution of age education information distribution of knowledge frequency of young women by age distribution of knowledge frequency of young women based on education knowledge frequency distribution of young women based on information discussion knowledge of young women in rw 001 gaga village pakuhaji district based on the results of the research conducted the results obtained from 44 young women with good knowledge were 24 respondents the majority of respondents have good knowledge according to the results of research conducted by nur rahmawaty agra a good level of knowledge about personal hygiene during menstruation was 43 respondents meanwhile according to lis lianawati the results of the research on the level of personal hygiene knowledge during menstruation were 7 respondents sufficient knowledge about personal hygiene during menstruation was 25 respondents and knowledge was insufficient about personal hygiene during menstruation menstruation as many as 3 respondents according to notoatmodjo 2010 knowledge is the result of knowing and this occurs after people perceive a particular object sensing of objects occurs through the five human senses namely sight hearing smell taste and touch alone at the time of sensing to produce knowledge is strongly influenced by the intensity of perceptual attention to the object most of human knowledge is obtained through the eyes and ears personal hygiene is knowledge attitudes and proactive actions to maintain and prevent the risk of disease protect yourself from the threat of disease knowledge of feminine personal hygiene is very important for most women to know because all women need to take good care of their genitals this is because the knowledge of young women about menstrual hygiene tends to be inadequate especially related to genetics age based on the results of the research conducted the results obtained from 44 respondents were mostly young women who had 90 knowledge namely teenagers aged 1821 years and less knowledgeable is at the age of 1114 years according to notoatmodjo that age affects the level of information acceptance that is the older a persons memory the less memory conversely the younger the age the easier it is to receive the information obtained and the more interested in knowing something according to the results of research conducted by indida leli indah the results with the low knowledge category were found at the age of 13 of 19 respondents this can be caused by the age factor that plays a role in someone acquiring knowledge the cognitive maturity factor is still lacking compared to late adolescents education based on the results of the research conducted the results were obtained from 44 respondents the majority of whom were wellinformed 632 namely teenagers with secondary education the education provided by these experts although editorially different is essentially a unity of elements or factors contained in it namely that the notion of education shows a process of guidance guidance or leadership which contains elements such as educators students goals and so on education according to the poedagogic dictionary means the making of educating educating means guiding the development of children physically and spiritually on purpose in mpr decree no 11mpr1988 regarding gbhn it is stated that education lasts a lifetime and is carried out in the household school and community environment information based on the results of the research conducted the results obtained from 44 respondents the majority of young women who had good knowledge of 100 were teenagers who got information from print media according to the results of research conducted by indida leli indah results were obtained with a low knowledge category that respondents received from the first information namely from parents 12 respondents high knowledge was also received by respondents from their parents 6 respondents the second information on personal hygiene knowledge was obtained from friends with sufficient knowledge namely a number of 3 respondents high knowledge also comes from information obtained from friends by summary the majority of young female respondents in rw 007 desa gaga pakuhaji district have good knowledge namely 24 people the majority of respondents were young women in rw 007 gaga village pakuhaji district the frequency of age education and sources of information namely 1114 years old was 22 people low education was 25 people information sources were 20 people the majority of female respondents in rw 007 gaga village pakuhaji district based on age the majority of female adolescents who have good knowledge are 90 namely adolescents aged 1821 years the majority of female respondents in rw 007 desa gaga pakuhaji district based on education the majority of female adolescents who have good knowledge 632 are adolescents with secondary education the majority of female respondents in rw 007 desa gaga pakuhaji district based on sources of information the majority of young women who have good knowledge 100 are young women who get information from the print media

the purpose of this study was to determine the level of knowledge of young women about personal hygiene during menstruation in young women in rw 007 desa gaga pakuhaji district this type of research used descriptive research descriptive research is a method used to describe or analyze a research result but is not used to make broader conclusions with a crosssectional approach namely data collection for independent variables and dependent variables at one time the population of this study were 121 young women in rw 007 desa gaga pakuhaji district the total sample used was 44 people the sample in this study were young women in rw 007 gaga village pakuhaji district the sampling technique uses the accidental sampling method which is a sampling technique based on coincidence that is anyone who happens to meet the researcher can be used as a sample if it is deemed that the person who happened to be met is suitable as a data source the results of this study concluded that the majority of young female respondents in rw 007 desa gaga pakuhaji district have good knowledge namely 24 people 545 the majority of respondents were young women in rw 007 gaga village pakuhaji district the frequency of age education and sources of information namely 1114 years old was 22 people 50 low education was 25 people 568 information sources were 20 people 455 the majority of female respondents in rw 007 gaga village pakuhaji district based on age the majority of female adolescents who have good knowledge are 90 namely adolescents aged 1821 years the majority of female respondents in rw 007 desa gaga pakuhaji district based on education the majority of female adolescents who have good knowledge 632 are adolescents with secondary education the majority of female respondents in rw 007 desa gaga pakuhaji district based on sources of information the majority of young women who have good knowledge 100 are young women who get information from the print media

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introduction the ebola outbreak that began in 2013 in west africa was the largest in recorded history the region faced many challenges in addressing the emerging infectious disease contributors to the rapid spread of ebola included poverty poor healthcare systems and services inadequate surveillance systems community distrust of outbreak response key questions what is already known about this topic ▸ there is currently little information available about the experiences behaviours and attitudes of ebola survivors ▸ the latest westafrican ebola outbreak led to an unprecedented number of ebola survivors who have been shown to suffer from physical and mental sequelae ▸ studies have now started to investigate the extent and characteristics of those ebola complications and a few studies have also identified that ebola survivors may face discrimination and stigmatisation from their communities and their loved ones what are the new findings ▸ owing to the recent nature of the outbreak there is still a lot unknown about the experiences behaviours and attitudes of ebola survivors ▸ this study addresses those issues in sierra leone and aims to improve our understanding of survivors experiences during and after ebola infection ▸ it extends our knowledge of issues that have not yet been discussed extensively such as community acceptance of survivors attitudes towards sexual transmission or the role survivors can play in ebola outbreak control activities recommendations for policy ▸ the results from this study will inform responses to future ebola outbreaks by increasing our understanding of the patient experience and challenges faced by survivors ▸ by understanding the experience of persons infected with ebola virus epidemic control measures can be adapted to reduce mistrust and increase cooperation with affected communities teams and contact with infected people at home in healthcare facilities and during traditional burials 1 2 identifying and addressing the knowledge attitudes and practices of the public played a key role in addressing some of these contributors in sierra leone the outbreak was declared in may 3 and peaked in november 2014 4 but the outbreak response varied from one district to the next as each district faced the disease at different times and intensities 5 though mortality associated with this outbreak was high there have never been so many ebola survivors before in sierra leone alone there were over 14 000 cases with an estimated 4051 survivors 6 many survivors are suffering from physical and mental sequelae 7 postebola virus disease syndrome characterises these complex symptoms which may affect survivors daily functions and ability to work and may include chronic joint and muscle pain fatigue hearing and vision loss depression and memory problems 8 9 surveys have also identified that ebola survivors may face discrimination and stigmatisation from their communities and their loved ones in august 2014 a national household survey conducted in sierra leone showed that 96 of respondents held at least one discriminatory attitude towards ebola survivors 10 although declining 46 of respondents still held at least one discriminatory viewpoint in july 2015 11 12 13 14 in sierra leone the comprehensive program for ebola survivors has been developed to protect ebola survivors the who together with partner organisations involved in the ebola response offered technical support for the development and implementation of this program it aims to ensure ebola survivors access the health and social welfare services they require it includes programs that target stigmatisation and the healthrelated complications of the disease and also aims to prevent further transmission especially through sexual intercourse it includes counselling and access to health services such as eye clinics sexual health counselling for individuals and couples and semen testing 15 16 in aprilmay 2015 a qualitative evaluation was conducted to assess survivors knowledge attitudes practices and experiences related to ebola in sierra leone in order to understand survivor needs and stigma directed towards them these findings may help inform national and local efforts to strengthen services for survivors address identified barriers and reinforce trust in the healthcare system in a postebola environment in sierra leone methods this evaluation followed a mixed method design consisting of qualitative interviews followed by short postinterview surveys the postinterview survey was conducted in order to quantify key thematic areas from the indepth interviews triangulating the short survey data with the indepth qualitative findings aimed to provide a more accurate narrative of survivors experiences perceptions attitudes and practices sampling and selection of participants the evaluation consisted of 28 idis with survivors at least 18 years of age followed by a short survey conducted immediately after each idi the researchers discussed data saturation and estimated it to be reached at or after 20 interviews five districts of sierra leone were purposively selected to cover all four geographic regions of the country and to include survivors with varied ebola treatment units discharge dates western urban and western rural kambia and port loko kono and moyamba four interviews were conducted in each district except in kambia where eight individuals participated to include survivors from the guinea border area survivors from guinea were excluded and only those who were infected in kambia and were treated in an etu in kambia or port loko were included in the study etus psychosocial counsellors and survivor psychosocial networks present in each district were contacted to purposively identify survivors which were interviewed in their homes alone snowball sampling was also used to ask participants to refer other potential ebola survivors diversity in participants sex discharge date rural versus urban setting and age was ensured in the selection process no relationship with participants was established prior to study initiation and all participants provided informed consent for their participation in this study participants had to be ≥18 years old and had to present an ebola survivor certificate issued by the government of sierra leone no participant refused to participate or dropped out of the study data collection data collection occurred between april and may 2015 facilitators and notetakers both males and females were trained during a 3day workshop on how to conduct the idis they were led by a senior program manager of focus1000 the interview guide and protocols were first developed by two behavioural scientists with field experience of working in the ebola response in sierra leone the draft instruments were then reviewed by a senior scientist with extensive experience working with hiv populations in subsaharan africa local contextualisation and cultural appropriateness were ensured by a second review from a partner from a local nongovernmental organisation with experience in conducting knowledge attitude and practice assessments in sierra leone the instruments were then pretested by the behavioural scientists with three survivors from the western area and feedback was used to revise and finalise the instruments each idi was directly followed by a postinterview survey which was administered facetoface by the idi facilitator using a paperbased instrument interviews were conducted in krio the most widely spoken language in sierra leone to ensure consistency of the interview questions and to help standardise questions and probes however some keywords were translated to the dominant local languages and participants were given the opportunity to express their views on particular subjects in their local languages if necessary all survivors interviewed were fluent and agreed to be interviewed in krio interviews were taperecorded and supplemented with handwritten notes facilitators and notetakers transcribed and translated the recordings into english all transcripts were reviewed by a separate supervisory team to ensure accuracy coding and data analysis through a deductive coding process two of the authors developed and reached consensus on parent codes drawn from the idi guide subcodes were developed using an inductive process evaluators coded transcripts using dedoose a webbased qualitative analysis software package and achieved consensus on a final codebook which was used to code all transcripts key themes were then identified and summarised the methodological orientation underpinning the study was a phenomenological inquiry no repeat interviews could be carried out and transcripts and findings could not be returned to participants for feedback due to the ongoing ebola outbreak at the time of the interviews however after each interview major points discussed were repeated to participants for concurrence postinterview survey data were entered into open data kit and subsequently uploaded to kobo collects webserver for aggregation the data repository was then imported into spss v22 for analysis the analysis included the generation of descriptive statistics using frequency tables as well as crosstabulations using contingency tables ethical approval the sierra leone ethics and scientific review committee approved the protocol and the us centre for disease control institutional review board determined the project to be public health nonresearch this indicates data collection with human participants was done as a routine public health practice in the context of an unprecedented epidemic and therefore does not require ethical approval results participant characteristics participants included 14 males and 14 females with a mean age of 31 years survivors were discharged from etu an average of 4 months prior to the interviews indicating that many were infected and treated around the outbreak peak unemployment among participants rose from 71 prior to ebola infection to 393 at the time of the interviews with a decrease in the number of private business owners petty traders students and teachers and an increase in the number of medical or health professionals and government employees the increase in the number of health professionals was due to the recruitment and involvement of some ebola survivors in ebola control activities survey results the survey found that 25 of the survivors interviewed moved home after their return from etus and 428 of those moved to a new district 893 lived with their relatives at the time of the interviews of which 88 had lived with the same people before getting sick when questioned about potential sources of transmission 607 of participants stated that they had taken care of sick individuals 464 were living in the same household as someone suspected or confirmed to have ebola 143 had participated in a burial or funeral and 71 were unsure of their source of infection 615 of those released 57 months prior to the interviews had shared a household with someone suffering from ebola compared to 385 of those released 24 months prior to the interviews 75 of survivors interviewed first sought treatment from a medical professional at a healthcare facility with only 214 of participants having sought treatment from a medical professional outside a healthcare facility and 36 from a traditional leader the mean number of days it took for participants to seek treatment after feeling sick was 336 participants described their daytoday interaction with community members since their release from an etu as very good good not good or very bad more women than men had negative experiences with 285 of women describing a negative community interaction compared to 142 of men furthermore 666 of those who described a negative experience and 545 of those who described a positive experience were released from an etu 24 months prior to the interview a minority of survivors interviewed stated that they had engaged in sexual intercourse since their etu discharge with 50 of them also reporting not having used a condom during their last intercourse the results showed that 875 of those sexually active and 75 of those who did not use a condom were released from an etu 57 months prior to the interview survivors emotional and physical state regarding illness on diagnosis nearly all survivors recalled feeling terrified about the uncertainty of what would happen to them and being sick with ebola made them feel depressed a few survivors also acknowledged feeling shocked as they had initially believed ebola did not exist in sierra leone i never believed ebola was real so i was emotionally confused i thought nothing was wrong with me after learning of their diagnosis most survivors thought death was inevitable while some felt they were already dead having seen others die from ebola the prospect of a similar fate was reported to be emotionally challenging they also explained they were afraid of changes in their physical appearance many reported being extremely weak and unable to stand speak sit walk or work they felt helpless and tormented beliefs on how infection occurred most survivors believed they contracted the disease by helping or caring for a sick family member i believe i got infected when i was caring for my sick wife when she was sick she couldnt do anything on her own i used to clean her and helped her when she wanted to do anything some also discussed attending burials or funerals before contracting the disease one survivor stated after the burial mourners and other people within the compound got sick and started showing signs of ebola i as one of them also fell sick beliefs and experience with care seeking as national response coordination consolidated individuals were instructed to report suspected ebola cases to the national 117 telephone hotline or local call numbers before alerting health officials many survivors tried selfmedication such as oralrehydration therapy a common practice used for cholera and other endemic diarrheal diseases a few survivors also described calling the 117 helpline or informing community leaders to report illness as a mean of survival one survivor described first seeking care from a traditional healer survivors reported their family community members or sometimes staff working in a quarantined area calling 117 for them without giving them a choice since i was under quarantine there was no way to seek help elsewhere survivors described varied experiences with the ambulances that took them to the ebola holding units many reported being afraid especially of the smell and use of chlorine to disinfect the vehicles a woman from western area also explained i went straight to the ambulance but when i touched the door one of the ambulance guys shouted at me and sprayed where i touched the door i was not happy a minority of survivors also expressed dissatisfaction with the ambulance services because the ambulances were reportedly too hot and had locked windows some were scared of the health workers personal protective outfits or of the negative image associated with the ambulances my mother and sisters were all crying bitterly falling on the ground and giving remarks that i will die if i enter the ambulance however many survivors talked positively about the ambulance services and praised the health workers who started counselling me saying that i should not be afraid and i will be ok and nothing is going to happen to me experience with the ehu and etu following an initial assessment patients were generally transported to ehus where blood samples were tested if positive patients would be transferred to an etu ideally results were given within 24 hours but early in the response this process was sometimes delayed by several days while about half of survivors reported positive experiences at the ehus and felt that they were well taken care of the other half described ehu staff as unkind inattentive and refusing to be in close physical contact with patients in retrospect a few survivors believed staff at ehus lacked knowledge of ebola because they told them there was no treatment available to cure the disease and yet they survived some survivors reported that they did not receive counselling did not have enough food or drugs and were left alone in an unsafe and untidy environment one survivor mentioned because of the poor treatment by the doctor i was afraid to eat the food they served me in the holding centre i thought they wanted to kill me individuals who tested positive for ebola at the ehus were transferred to an etu nearly all interviewed survivors commented that etu staff was kind and supportive and they were treated like kings survivors described being pleased with the free food and medication and appreciated counselling from health workers including international staff they frequently expressed enjoying the company of polite and friendly facility staff they also mentioned being treated fairly and equally independently of their race colour or tribe emotional state after discharge from the etus most survivors explained they were relieved after being discharged from the etus felt like heroes and thanked god for their survival some saw their recovery as a new start to life once there is life there is hope a dead man cannot work a dead man cannot move however feelings of sadness depression and anger were also expressed by a lot of survivors and they reported feeling unsupported since i was discharged i have been crying for help but nobody helps me some survivors also expressed frustration after being discharged because their everyday life had deteriorated there are times i have the feeling that life is worthless as i now dont engage in anything and now some community people are neglecting me a few also reported feelings of loneliness and alienation due to loosing family members to the disease family relationships most survivors described living happily and having a good relationship with their families before becoming infected with ebola they further shared that such relationships did not change after their return from the etus even though some households were grieving loss of other family members who had died all interviewed survivors reported that their families welcomed them back with joy and treated them well additionally families took the roles of carers for interviewed survivors providing either health financial or housing support their lives were described once again as normal as if nothing had changed my brothers are very much happy to see me back and do things together as we used to do partner relationships several survivors who had a partner at the time of the interviews did not report any major changes in their relationships only a few survivors mentioned that their partners mostly boyfriends or girlfriends did not treat them well when they returned from the etus or were afraid of or embarrassed by them since the day my boyfriend knew i was ebola positive he stopped picking up my calls i know he was afraid or ashamed of me because i was infected with ebola while some partners ended their relationship with interviewed survivors others reunited after counselling sessions with social work staff sexual behaviour and knowledge of potential risks of ebola sexual transmission at the time of the interviews messaging on sexual transmission of ebola recommended abstinence or condom use out of caution as it was unknown whether ebola could be sexually transmitted all survivors reported being counselled to not have unprotected sexual intercourse for the first 90 days on discharge from the etu which was consistent with who interim advice given to survivors prior to may 2015 many survivors conveyed that it would be risky for their partners to have sexual relationships with them they overwhelmingly emphasised that they do not want others to go through what they had suffered some of the survivors reported that they decided to wait longer than the recommended 90 days and used condoms to make sure that their partner would not be exposed to ebola through sexual transmission in one instance a male survivor from port loko expressed that all ebola survivors should be quarantined for 3 months so they will not be infecting people with the disease through their sexual activities other survivors mentioned that they advised their community members not to have sexual intercourse with survivors a handful of survivors expressed that this was mostly important for males or for people who have sex with multiple partners finally a few survivors experienced a loss of libido and some women felt guilty about not having sex with their husbands one male survivor also mentioned my wife denied me sometimes because of the fear of the disease community relationships the potential negative reaction of community members sometimes including loved onesemerged as a major concern for interviewed survivors when they initially suspected ebola which led some to deny feeling ill however the relationships between survivors and their communities were described positively both before and after ebola by the majority of survivors survivors described themselves as social individuals who were interactive and good religious members of their communities attending either the church or the mosque i am a muslim observing my prayers i have been a very good social person mingling with people in my community after they were discharged from etus many survivors mentioned they were welcomed back into their communities and continued good relationships and interactions with community members including religious and local leaders people living in my community have no problem with me as we interact together attend community meetings play games together and do things together survivors shared that community members expressed their sympathy especially if they had also lost members of their families and prayed for them however a few survivors also experienced discrimination from members of their communities they felt people were afraid of them provoked them and stigmatised them as survivors most of my neighbours abandoned and refused to accept me they were deeply affected by the discriminatory attitudes of their community and felt abandoned stressed and lonely due to provocations and stigmatisation some survivors also described being evicted from their houses by landlords who were scared of possible contagion some had reduced their interactions at the church or mosque and others stated that people actively avoided them and their children survivors financial and employment situation survivors described their lives before becoming infected with ebola as normal comfortable doing good business however most survivors reported losing their jobs facing financial difficulties and being unable to take care of their families before i was employed but now i am not employed the more you earn the more you live well with your family reasons for inability to work were lack of strength and lack of finance to continue or start their businesses most of those shifting to unemployment were previously engaged in petty trade and business after discharge from the etu one survivor became a healthcare worker and another one a government official other problems mentioned were difficulties paying for their childrens school fees and feeling dependent on others i find it difficult now to take care of my children because i have no money no business i have to beg for our survival but how long would that continue for moreover although most survivors reported having received financial benefits from various organisations after being discharged from the etus some reported having received insufficient assistance to help them become financially independent improving the situation of survivors almost all survivors suggested that the government of sierra leone should help them by providing jobs microcredit or training so they could develop necessary skills for employment they also discussed the need for financial help and their desire to receive money scholarships and other incentives they mentioned their need for livelihood support including the provision of food and supplies as well as housing finally some survivors stated that the government should help in engaging communities and households on the discrimination of survivors a woman from moyamba explained that it is important to sensitise community members on the issue of discriminating ebola survivors another survivor said that the government should pass laws in the parliament that no one should discriminate against any survivor improving the healthcare system in addition to improving their own situation a few survivors suggested the need to improve health centres to help the country end the outbreak in their opinion health facilities are currently not well equipped with insufficient drugs and other resources and are difficult to access i believe if the health workers have the right skills facilities and the community have access to the needed resources it will contribute to moving the country to ebola free survivors also recommended improving sanitation including drinking water latrines and hand washing survivors contribution to the ebola response all the survivors considered it their role to help their country end the ebola outbreak and they should be used as partners in the ebola fight a few of them mentioned that their firsthand knowledge of ebola and their lack of fear due to perceived immunity would support their involvement they strongly believed that they should become involved in social mobilisation one survivor explained multiple ways in which ebola survivors could become active in the fight against ebola we can talk to people in our communities on contact tracing we survivors can go and meet with people that might have come into contact with ebola infected persons and have ran away and we can explain to them how we survived because we got early treatment we will encourage them to comply with the quarantine many were already involved in sharing their personal experiences with the community in churches and mosques restaurants schools or markets they reported that they had an important role in ebola prevention and control and also that this role could help financially and emotionally sustain them as they adjust to being a survivor some also thought that they should be involved in contact tracing and others saw themselves as informal enforcers of ebola response efforts discussion our findings suggest that survivor experiences emotions and attitudes changed over time as they moved from disease onset to treatment discharge and to life postdischarge major themes identified across the interviews included acute fear and depression linked to ebola diagnosis negative experiences with ehus positive experiences with etus feelings of joy and thankfulness on discharge altruistic motivations for the prevention of ebola through sexual transmission and concerns about their financial situation and discrimination from their communities the findings demonstrate that survivors knowledge and attitudes about sexual transmission risk largely reflected counselling messages to abstain or use condoms it should be noted that messaging guidelines on sexual transmission evolved during the outbreak as more information became available which could have led to misperceptions and distrust of information in survivors it could also explain why interviewed survivors released earlier in the outbreak from etus engaged more frequently in sexual activities as survivors were first told to use condoms or abstain for 3 months after their release which later changed to 6 months and the 12 months accurate evaluated and consistent messages on sexual transmission and appropriate condom use need to be developed and delivered to survivors and their partners targeted approaches to hiv and sexually transmitted infection prevention have proved to be highly effective in sierra leone and could be applied to the prevention of sexual transmission of ebola 17 one recent study has shown that ebola virus rna can persist in semen for 284 days after the disease onset and evidence on viral persistence in other body fluids is still emerging 18 19 in light of this new evidence semen testing and counselling services may help reduce the possibility of resurgence having survivors registered and part of a longer term care and support system sustaining community engagement to reduce ebola exposure risks while minimising stigma of survivors may also reduce future risk 20 while all interviewees reported supportive attitudes from family members about a third faced discrimination and stigma from their communities after their discharge continued promotion of the integration and acceptance of ebola survivors in communities could reduce stigma and improve health seeking behaviours an example of a successful reintegration strategy is the firestone project in liberia where teams travelled to survivor homes before their discharge to meet with communities and engage them in plans to welcome survivors home 21 these types of strategies were replicated in some regions of sierra leone and some ngos such as partners in health also supported employment opportunities for survivors in the response 22 the sierra leone association of ebola survivors was created in january 2015 to seek and ensure protection and welfare of its registered members including ebola survivors orphans widows and widowers 23 such organisations can strengthen the voice of survivors giving them more power to demand financial and emotional security and support from governments they can improve the visibility of survivors help raise awareness about their experiences and struggles lobby government and international partners for improvements to services offered to survivors and provide a forum in which survivors can support each other the government of sierra leone collaborated with the united nations development programme for the implementation of the social rehabilitation and payment to ebola survivors project which aims to prevent conflict and build resilience by addressing social marginalisation and discrimination of survivors 24 local ngos such as focus1000 and international ngos such as partners in health and wold hope international have implemented interventions to support survivors these interventions have already shown that by addressing issues of stigma and discrimination at both the community level and the national level individual attitudes and actions towards survivors may shift from the need to exclude to the need to include it is important to maintain and improve these existing activities as well as to ensure they are implemented to cover all survivors across west africa communication strategies that support survivor reintegration into the community need to be evaluated and further developed interviewees emphasised that the improvement of health services is important for ending ebola transmission the westafrican ebola outbreak has shed light on issues related to existing medical and epidemiological capacity to respond to emerging disease outbreaks including problems with the organisation and performance of health systems 25 furthermore challenges around building community trust and confidence in the healthcare system persist efforts to understand and address trust and confidence in the healthcare systems within particularly heavily affected communities are critical for future planning this could start with the empowerment and engagement of survivors and entire communities in their health and ensuring government and international actions are transparent and well communicated to the public this study revealed that half of interviewees reported negative experiences in ehus these may have been influenced by the fact that they were ill earlier in the outbreak when services were not yet fully functional and misconceptions about the disease and its transmission where common these misconceptions especially when strengthened by fear might have impacted beliefs attitudes and behaviours of staff working at ehus towards ebola patients on the other hand nearly all survivors were positive about their etu experiences the difference in experiences at ehus and etus could be explained by the lower staff to patient ratios poorer pay and lower levels of qualifications of staff in ehus compared with etus etus were restricted to ebola patients and had therefore higher levels of expertise and preparation to take care of ebola patients 26 27 ending an ebola outbreak evidently requires coordinated efforts between government public health systems and community structures including strong involvement from trusted community leaders survivors were strongly motivated to help end ebola and to improve the healthcare system they could serve as valuable resources in connecting the national ebola response teams to local communities some studies have also shown that survivors have a role to play in engaging communities by teaching others how ebola is transmitted and by helping families understand the need for isolation of individuals with symptoms 28 29 a previous ebola outbreak saw survivors working alongside safe burial teams contact tracers and community educators which to some extent also happened in sierra leone 11 they can potentially contribute to sierra leones readiness to prevent detect and respond to future outbreaks as well as in strengthening public confidence in the healthcare system ways of incorporating survivors into response leadership roles also need to be identified acute fear and depression emerged as a major theme among interviewees when discussing their initial experiences with the disease many survivors were still facing substantial emotional challenges financial difficulties dealing with having lost family members and decreased normal interactions with community members at the time the interviews were conducted coupled with some persistent discrimination survivors faced myriad economic social and health challenges addressing these concerns could facilitate survivors reintegration into communities the medical and social service interventions offered within cpes target these issues 16 emotional challenges faced by survivors could first be addressed by listening to survivors at an individual level and a community level it is also important to address stigma in communities by seeking support from community leaders organising talks and discussions or publicly supporting survivors in the media finally there could be a benefit from empowering survivors by including them in future outbreak response activities and giving them an active role in preventing ebola in their communities 21 30 more research is needed to identify gaps in the health systems as well as the education religion business and government systems which may contribute to survivor isolation and stigma evaluation of current activities referred to in this discussion will also be important to assess their actual impact on survivors and identify strengths weaknesses opportunities and threats many of the issues revealed in this evaluation are similar to those identified among survivors from previous ebola outbreaks 11 31 ensuring that lessons learnt from this and previous evaluations are translated into ebola response recovery and health protection activities is essential and could help not only sierra leone but also liberia and guinea limitations while this evaluation aimed to provide a detailed understanding of the experiences of ebola survivors to inform ebola recovery strategies and preparedness for future outbreaks in sierra leone the findings may not be representative of all survivors in sierra leone the outbreak has already lasted over 17 months and impacted all 14 districts and some of the attitudes and experiences identified in this evaluation may be specific to their geographic location the etus and ehus they attended and time of infection additionally survivors were invited to participate in the interviews through local leaders who may have selected the most aware and informed members of the community and also those who may have had the most positive experiences finally ehus and etu experiences of those who did not survive are not captured by these interviews conclusion this evaluation provides a description of the diverse experiences of survivors following many months of intensified ebola response efforts and gives an insight into beliefs of survivors about sources of transmission healthcare seeking behaviours life at ehus and etus acceptance by communities and loved ones and understandings of sexual transmission this study also stresses the importance of empowering survivors and having them contribute to sierra leones preparedness to face future outbreaks addressing the myriad and diverse challenges survivors face such as discrimination stigma loss of employment and health problemsshould form a centre pillar of an ebola outbreak recovery strategy author affiliations

background in sierra leone over 4000 individuals survived ebola since the outbreak began in 2014 because ebola survivorship was largely unprecedented prior to this outbreak little is known about survivor experiences during and post illnessto assess survivors experiences and attitudes related to ebola 28 indepth interviews and short quantitative surveys with survivors from all four geographic regions of sierra leone were conducted in may 2015 results survivor experiences emotions and attitudes changed over time as they moved from disease onset to treatment discharge and life postdischarge survivors mentioned experiencing acute fear and depression when they fell ill only half reported positive experiences in holding centres but nearly all were positive about their treatment centre experiences survivor euphoria on discharge was followed by concerns about their financial situation and future while all reported supportive attitudes from family members about a third described discrimination and stigma from their communities over a third became unemployed especially those previously engaged in petty trade survivor knowledge about sexual transmission risk reflected counselling messages many expressed altruistic motivations for abstinence or condom use in addition survivors were strongly motivated to help end ebola and to improve the healthcare system key recommendations from survivors included improved counselling in holding centres and longterm government support for survivors including opportunities for participation in ebola response efforts conclusions survivors face myriad economic social and health challenges addressing survivor concerns including the discrimination they face could facilitate their reintegration into communities and their contributions to future ebola responses

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introduction the world health organization declared the 2019 novel coronavirus disease a global pandemic in march 2020 following a first wave primarily affecting the elderly population in spring 2020 and a respite in transmission during summer 2020 many canadian provinces and territories implemented strict public health measures starting in november 2020 to avoid overwhelming the health care system and reduce deaths as the second wave was growing 1 the list and stringency of public health measures varied by province and region and included discouraging international travel closure of nonessential businesses selfisolation of those with symptoms suggestive of covid19 until testing negative the measures also required citizens to selfdistance wear a face mask and avoid indoor crowded space moreover measures such as forbidding private indoor gatherings implementing curfews and encouraging all to work from and stay at home were put in place 1 these measures have resulted for some people in increased social isolation loneliness and anxiety which could have led to negative impacts on quality of life and mental health 23 research has shown a lower proportion of canadians reporting excellent or very good mental health during the covid19 pandemic when compared to the previous years 4 moreover many canadians reported their mental health to have worsened after the onset of physical distancing and most reported at least one symptom of anxiety 5 several studies have assessed the association between risk factors and poorer wellbeing qol and mental health during the pandemic in canada and worldwide gender visible minority groups relationship status socioeconomic status chronic illness disabilities and age were found to be associated with anxiety and poorer mental health 4 6 7 8 9 10 another factor possibly affecting mental health during the covid19 pandemic is pet ownership a crosssectional online survey conducted among a convenience sample of 1297 pet owners in spain during the first wave showed that almost half of the respondents perceived their companion animals helped them more during the lockdown than before 11 however the authors also reported in their adjusted analyses that those perceiving that their companion animals supported them more through the confinement were less likely to have felt that their qol had remained the same or improved since the preconfinement period in other words those most affected by the confinement were also the ones who felt more supported by their pets during that time the impact of pet or dog ownership on mental health has also been assessed since the beginning of the pandemic in australia and the uk and in a multicountry study 12 13 14 these studies found that companion animal owners perceived that their mental health improved due to their dog or the ability to walk them 1213 they also perceived that their mental health and loneliness had not worsened as much as that of nonpet owners 12 however the australian study found that pet owners had worse qol than nonpet owners and found no difference for resilience and loneliness 14 these discrepancies could be due to different methodological factors or to differences in the populations studied while the average selfreported mental health scores of the canadian population has worsened since the beginning of the pandemic 4 it is unclear if the mental health of pet owners differed from that of nonpet owners during the covid19 pandemic period a recent survey suggests that 38 and 41 of canadian households have at least one cat and dog respectively 15 many animal owners perceive that humananimal interactions have a positive impact on their physical and mental health 131617 however the reported effect of pet ownership on the mental and physical health of elderly populations 18 or people living with mental health problems 16 has not always been positive moreover dog ownership was not associated with lower levels of stress and depression in a longitudinal study conducted in the general population prior to the pandemic 19 qualitative work has found that the species of the number of the perceived friendliness of and attachment to companion animals are factors that could influence the association between pet ownership and health the positive impact of pet ownership seemed to be most important in times of crisis but negative impacts can be caused by the financial practical and emotional burden of ownership or by the pain of losing a companion animal 20 the objectives of this study were to assess the association between pet ownership and the qol overall health loneliness anxiety stress and mental health of canadians during the confinement measures put in place in response to the second wave of covid19 in canada materials and methods study design study population and sampling strategy a crosssectional study was conducted using an online survey administered in collaboration with leger opinion from 14 april to 5 may 2021 potential participants were randomly selected from the firm panel and participants received points that could be exchanged for cash gift cards or donation to be included participants had to be adult canadian residents and had to complete the whole survey questionnaire development the questionnaire was developed in english by a multidisciplinary team the questions were selected to assess the outcomes of interest as well as the potential confounders identified using directed acyclic graphs created with dagitty 21 validated questions and scales as well as questions previously used by statistics canada were used whenever possible to ensure the repeatability comparability and accuracy of the collected data the final questionnaire included 80 closeended questions and was translated into french the questionnaire was available to participants in both french or english languages 23 measurement of the outcomes of interest qol overall health loneliness anxiety stress and mental health many validated tools have been used to measure qol loneliness mental health and wellbeing before and during the covid19 pandemic the eq5d5l developed by the euroqol group to assess qol across different populations 22 including canada 23 was used this tool includes five questions regarding mobility selfcare usual activities pain and discomfort and anxiety and depression as well as one question on overall health the eq5d5l was used to assess qol in china during the pandemic 8 but has not yet been used for this purpose in canada for the present study the combined results across the five questions were translated on a standardized scale validated for canadians the participants selfrated overall health measured in the euroqol with a vertical visual analog scale from 0 to 100 was also assessed 22 loneliness was assessed using a 3question scale 24 the scale showed satisfactory reliability and validity among the elderly population each question can be answered with three options which when summed over the three questions is considered as the participants score questions used by statistics canada during the covid19 pandemic to assess the perception of mental health and stress were used in addition to the generalized anxiety disorder score 2526 here the participants were asked to selfassess the amount of stress in their life and their mental health since the start of the covid19 pandemic in two distinct multiplechoice questions for stress and mental health the participants anxiety was assessed using the gad7 score briefly the answers for each of the seven questions were scored as 0 1 2 and 3 scores of 5 10 and 15 were used as thresholds for mild moderate and severe anxiety respectively 25 together these questions generated six scores which were analyzed as continuous outcomes overall health and loneliness 24 or categorical outcomes exposure and potential confounders and effect modifiers the exposure of interest was pet ownership while the companion animal species were recorded analyses were conducted with pet ownership as a dichotomous variable based on the initially developed dags participants demographics physical and mental health current social support attitude towards companion animals and recent changes in ownership and employment status and change were considered as potential confounders for the relationship between pet ownership and the outcomes of interest the health questions were previously used during the pandemic to assess the impact of the covid19 pandemic on canadians 26 they included longterm conditions and disabilities as well as physical and mental health perception since the beginning of the pandemic and exposure to or illness from covid19 in the past 6 months the social support of the participants was assessed with three questions previously used as covariables to measure the impact of alcohol consumption on the mental state in a study conducted in canada 27 participants were considered to have social support if they answered yes to the three questions or no social support if they answered yes to 0 to 2 questions finally the attitude of people towards companion animals was quantified using the modified pet attitude scale the results were summed on an 18 to 126points scale 18 being the least and 126 being the most favorable attitude towards companion animals sample size and statistical analyses a sample size of 1500 participants was calculated to identify a 1point difference for the gad7 score 25 between pet owners and nonpet owners as was found for physical activity levels in a recent canadian study accounting for covariables as the participants were meant to be equally distributed between pet owners and nonpet owners panel members were not eligible to participate when a total of 750 participants in either category was reached statistical analyses were conducted using r with the r studio interface descriptive statistics for each outcome the exposure and the potential confounders were first generated bayesian hierarchical multivariable ordinal and linear models were run for each outcome for all bayesian models the brms package was used as the interface to the programming language stan which implements hamiltonian monte carlo sampler and the nouturn sampler 32 continuous scores were assessed using bayesian hierarchical gaussian linear regression models 32 and categorized scores were assessed using bayesian hierarchical cumulative ordinal models provinces and territories were grouped in geographical regions as follows british columbia prairies and territories ontario québec and atlantic all models were run with the geographical region of the participants as a randomeffect intercept and using weakly informative priors briefly priors for βs were normal distributions centered on 0 with sigma 1 while priors for sd or sigma were half cauchy distributions centered on 0 with sigma 2 the hyper distribution for the randomeffect intercept was also a half cauchy distribution centered on 0 with sigma 2 intercepts in linear regressions were normal distributions centered on the mean of the outcome variable with sigma sd y and intercepts in cumulative ordinal models were normal distributions centered on 0 with sigma 1 univariable models assessing the association between pet ownership and the six outcomes were first generated stratified models were built to assess if gender disability social support and age modified the effect of pet ownership on the six outcomes but no effect modification was identified the dag initially developed to identify potential confounding variables to include in the questionnaire was updated by validating the conditional independence the dagitty interface 21 was used to identify the minimal sufficient adjustment sets for estimating the total effect of pet ownership on the six outcomes of interest final multivariable models were built including adjustment for the minimal sufficient set the final models were generated using three chains with a length of 3000 in which the first 1000 iterations were used as warmup 34 convergence was monitored through the visual inspection of trace plots of variance components density plots and by obtaining effective sample sizes an ess of 1000 or greater was considered sufficient for reaching convergence 32 linearity and homoscedasticity of the residuals were verified for the three linear models for the three cumulative ordinal models the absence of categoryspecific effect and equality of variance were assessed and models were adjusted to meet these assumptions 35 stratified models using only pet owners who reported having a dog a cat or both were also built to assess if pet owners of uncommon species influenced the results results the targeted 1500 participants were recruited with an average completion time of 15 min a total of 1826 people started the survey but 326 were not included as they did not consent to participate in the study were under 18 years old were not from canada initiated the survey after the pet ownership quota had been reached or did not complete the survey the participants who did not complete the survey or started after the pet ownership quota was reached were from all provinces and territories except nunavut and yukon and from all age groups table 1 describes the distribution of variables included in the dag to identify the minimal sufficient sets for the six outcomes of interest among pet owners and nonpet owners as expected the demographic and socioeconomic indicators were similar to that of the canadian population about half of the participants did not see a change in their household income since the start of the pandemic but a decrease was reported by a little more than a quarter approximately 5 of respondents reported that at least one person had tested positive for covid19 in the past 6 months in their household the participants attitude toward pets ranged from almost least favorable to most favorable with a higher median in pet owners than in nonpet owners based on the eq5d5l the participants qol utility score ranged from 001 to 095 with a median selfassessed overall health score of 77 the participants loneliness score ranged from 3 to 9 participants perceived their mental health since the start of the covid19 pandemic as excellent very good good fair or poor and their life to be not at all not very a bit quite a bit or extremely stressful the anxiety level of the participants using the gad7 was categorized as minimal mild moderate or severe the distribution of these variables among pet owners and nonpet owners is described in table 2 the pet owners owned mainly dogs and cats but also birds fish rabbits rodents amphibians reptiles ferrets and horses and most of them had at least a cat or a dog most pet owners were the main caretakers of at least one of the companion animals in the household most pet owners reported no difference in their relationship with their companion animals since before the covid19 pandemic while 37 reported that their relationship had improved thirteen percent of the pet owners acquired at least one of their animals after the beginning of the covid19 pandemic and 12 of all the participants lost at least one animal in the year before the survey the univariable models showed that pet owners had poorer qol utility scores selfrated overall health and mental health and greater loneliness selfreported stress and anxiety descriptive statistics also suggested that pet owners were younger and that they had a lower level of education than nonpet owners moreover there were more women caucasian participants people reporting no social support and people with disabilities who owned a pet compared to those who did not the multivariable models adjusted for the minimal sufficient adjustment sets resulted in posterior distributions not showing any strong associations between pet ownership and the different outcomes suggesting that the observed univariable associations were due to confounding for example in the unadjusted model for loneliness pet owners had on average a score of 031 higher than nonpet owners however there was no difference between pet owners and nonpet owners in the adjusted model similar results were found for all outcomes for mental health the prevalence odds of being in one worse category level of mental health increased by 125 for pet owners compared to nonpet owners in the crude model such association disappeared in the multivariable model models including cat and dog owners separately found similar estimates to the full models table 3 crude and adjusted 1 estimated median of the effect of pet ownership on quality of life utility score overall health score and loneliness score using crosssectional data from a survey of 1500 canadian univariable models multivariable models reference nonpet owners 1 bayesian gaussian linear regression models including geographical region as a randomeffect intercept the multivariable model included the minimal sufficient adjustment set for estimating the total effect of pet ownership 2 estimation of the effective sample size table 4 crude and adjusted 1 posterior odds ratio and 95 bayesian credible intervals of the effect of pet ownership on perceived mental health selfreported stress and anxiety using crosssectional data from a survey of 1500 canadian 2 estimation of the effective sample size univariable models discussion our study demonstrated that when the analyses are appropriately adjusted for confounding pet owners did not report worse indicators of mental health and wellbeing than nonpet owners during the second wave of the covid19 pandemic in canada moreover our results clearly show that a set of confounding factors are involved here that if ignored would have given the impression that pet owners have worse outcome than nonpet owners this is because a greater proportion of pet owners were more often females less educated without a social network and with disabilities all characteristics documented as risk factors for anxiety and poorer mental health 4 6 7 8 9 10 studies measuring the association between pet ownership and mental health or wellbeing status during the pandemic have found conflicting results two studies reported that pet owners perceived that their mental tensions diminished due to the presence of their dog and the ability to walk them in addition to reporting a smaller decrease in mental health and a smaller increase in loneliness during lockdown 1213 in contrast another study found pet ownership to be associated with poorer qol but not with resilience and loneliness 14 multiple reasons could have led to these differences including different studied populations and contexts use of different mental health and wellbeing scales and the inclusion of different confounder sets in the final models 1214 a longitudinal study conducted prior to the pandemic found no difference between dog owners and nondog owners for stress and depression 19 in other studies the positive impact of pet ownership was limited to specific situations such as managing mental health conditions 36 37 38 considering the covid19 pandemic a time of crisis we expected that pet owners would in general cope better with the situation and have better qol and mental health than nonpet owners multiple mechanisms have been suggested to explain the positive impact of pet ownership on mental health indeed companion animals are providing social support that can act as a buffer against stressors moreover it has been suggested that humananimal interactions are associated with hormonal changes such as the release of oxytocin and a decrease in cortisol when humans interact with their companion animals having a dog also leads to increased physical activity through dog walking and leads to positive human interactions however the crosssectional nature of our study meant that it was impossible to determine if pet ownership dampened the impact of the pandemic on mental health and qol or not a longitudinal study assessing the changes throughout an ordeal such as a pandemic or assessing changes following the adoption of a pet would have allowed for a better understanding of the underlying patterns our findings showed that there was no difference for mental health and qol when pet owners and nonpet owners were compared while the mechanisms underlying these results were not explored in the present study previous studies showed there are concerns associated with pet ownership including financial logistical and emotional stressors 4041 given the pandemic context at play here it is possible that such concerns and worries could have negatively influenced mental health issues and offset or attenuate the positive effects of pet ownership the inclusion of the minimal adjustment sets was likely important in our findings as their association with mental health and wellbeing status have been identified in multiple contexts including since the beginning of the pandemic 42 43 44 this highlights the complexity of the humananimal relationships and their impact on mental health future research should aim at unraveling the complex patterns underlying this relationship and include variables likely to act as confounders intermediaries or effect modifiers the target population was the canadian population during the pandemic in this study the panel used to recruit participants resulted in a representative sample of the canadian population with a proportion of gender age household income and ethnicity similar to the 2016 national census 45 even though the sampling was such that the same number of pet owners and nonpet owners were included there was however a greater proportion of people with a university degree and a smaller proportion of people without a high school diploma or certificate in our sample than in the 2016 census 45 it is unclear how this discrepancy could have influenced our findings but our conclusion might not be generalizable to the whole canadian population another indicator that the sample of participants in the present study might differ from the canadian population is the results from a questionnaire on mental health conducted by statistics canada during the beginning of the pandemic 5 while a similar proportion of participants to both surveys perceived they had a fair or poor mental health a smaller proportion of the participants of the present study reported having a high level of stress or had symptoms of moderate or severe anxiety several pet owners tried to enter the survey after the quota of participants for that category had been reached which was not the case for nonpet owners this could have happened because there are more pet owners in the canadian population than nonpet owners 15 which could have resulted in a selection bias our results could have been affected by selection bias if pet owners with poorer mental health and quality of life were more prone to participate in the survey though possible the impact of this bias is likely to be limited since the invitation to participate in the survey did not mention pet ownership but did mention mental health and qol in addition through our thorough identification of potential confounders factors that could have pushed a larger proportion of pet owners with poorer mental health or qol to participate in the study would have been measured and adjusted for in the analyses 515 our results could have also been affected by misclassification and measurement error since mental health qol and wellbeing are difficult to measure some of the tools included in the present study have been validated but other questions were not while we collected valuable information with these tools and questions we could have missed subtleties of mental health and wellbeing that could be assessed with qualitative work moreover the eq5d5l utility score has been shown to be influenced by the heterogeneity in respondents ordinal preferences which suggested that small differences are negligible to support a difference in qol 46 the impact that information bias could have had on our results is difficult to predict and may have been differential indeed perhaps pet owners are more prone to admit to mental distress or more aware of limitations in their quality of life which could have hidden a positive association between pet ownership and mental health or quality of life our findings could have also been influenced by the humananimal bond as the strength of this bond was associated with poorer mental health 1112 this was not directly assessed in the present study but the pet attitude score was included as a confounding variable in all minimal adjustment sets and is likely a proxy for the humananimal bond the pet attitude scale is a tool that assesses favorableness of attitudes toward pets 29 and even though it has not been evaluated people with stronger humananimal bonds may also be more favorable towards companion animals finally none of the included covariables were identified as effect modifiers and the results remained the same when analyses were conducted on separately for cat and dog owners this suggests the results are similar across the sample and no subgroup benefited more or less than the whole sample previous studies showed there was a positive impact of pet ownership on the mental and physical health of the elderly population and the population living with mental health problems 1618 it is unclear why these associations were not found in the present study as the positive impact of pet ownership seemed to be most important in times of crisis 16 conclusions overall pet ownership was not associated with mental health and wellbeing indicators during the covid19 pandemic there were however multiple factors associated with both pet ownership status and mental health outcomes resulting in spurious crude associations suggesting pet owners had decreased qol mental health and overall health and increased level of stress anxiety and loneliness it remains unclear if pet owners benefited from the presence of their companion animals during the pandemic which could be assessed via longitudinal and qualitative designs data availability statement the data and r code used to produce this manuscript are available in the supplementary materials informed consent statement informed consent was obtained from all subjects involved in the study after the description of the nature of the study the measures in place to ensure confidentiality and the risk inconvenient advantages and benefit of the study participants had to choose yes to the question do you consent to participate in this survey

the objective of this crosssectional study was to assess the association between pet ownership and quality of life qol loneliness anxiety stress overall health and mental health of canadians during the covid19 pandemic using a one health perspective an online bilingual survey was completed by 1500 canadians in aprilmay 2021 sociodemographics health qol stress and anxiety loneliness social support pet ownership and attitude towards pets data were collected crude and adjusted associations between pet ownership and mental health and wellbeing indicators were estimated the 1500 participants were from all provinces and territories half were women half of the participants were pet owners by design the crude association estimates showed that pet owners had poorer qol overall health and mental health than nonpet owners and were lonelier more stressed and more anxious than nonpet owners adjusted estimates showed that these associations disappeared with the inclusion of the confounders socioeconomic demographic health and petrelated variables our results suggest that there was no association between pet ownership and the mental health and wellbeing indicators measured in the present study

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access hiv and sexual and reproductive health information 4 5 6 7 8 9 a growing body of evidence shows that people with disabilities are more likely to be victims of violence and abuse which have been shown to be significantly associated with an increased risk of hiv infection 2 1013 disadvantages such as a lack of education and resources as well as social exclusion that are often experienced by people with disabilities in resourcelimited countries have a negative impact on their ability to maintain good health these factors and others contribute to creating a global risk environment 14 15 16 although this vulnerability was first recognised 10 years ago and stressed in several international statements 17 18 19 20 21 22 people with disabilities have often been left behind with regard to the prevention and treatment of hiv aids 1 13 23 a potential explanation for that is the lack of reliable epidemiological data measuring this vulnerability results from various reviews including a recent metaanalysis of studies conducted in subsaharan africa suggest that adults with disabilities have at least the same risk of hiv infection compared to the general population in this part of the world 2 3 24 25 however given the limited quality of available studies and the variety of methodologies used 24 more epidemiological research is needed to establish firm evidence and to better understand the complex links between disability and hiv in order to help decisionmakers prioritise their interventions this paper presents the handivih study design as well as the methodological challenges of research aiming at providing such quantitative evidence multiple definitions of disability and implications for research according to the world report on disability people with disabilities represent around 15 of the worlds population with 80 living in resourcelimited countries 13 however large variations in disability prevalence are observed between studies which could be explained by the different definitions of disability used 26 disability is complex dynamic and multidimensional 13 27 28 as a result instead of a single objective and easytomeasure definition of disability there are multiple approaches that only partially overlap 29 30 the medical approach that prevailed for decades focused only on impairments and their causes this approach has been challenged by people with disabilities and several academic writers 31 a conceptual shift was operated through the social model in which people are viewed as being disabled mainly because of environmental barriers that prevent full participation in society 32 integrating all these thoughts the socalled biopsychosocial model promoted by the who proposes that disability is constructed of three connected components and results from the interaction between individuals and environmental factors 13 33 this model requires different levels of information to capture the disability experience and necessitates that researchers use and combine different methods and approaches people with disabilitiesa hardtosurvey population people with disabilities living in resourcelimited settings can be considered as a hardtosurvey population because of the technical challenges in identifying them 34 difficulty in establishing a sampling frame and the existence of widespread exclusion mechanisms most studies available on hiv try to overcome such difficulties by using nonprobabilistic sampling methods such as snowball sampling 35 however these methods do not allow for valid statistical inferences and lead to selection biases one available alternative is a twophase random sampling design with people with disabilities screened from the general population during the first phase and their eligibility confirmed during the second phase 36 37 however particular attention needs to be paid to the screening questionnaire that should have acceptable sensitivity specificity validity and accuracy 36 38 this could be challenging in the context of disability first the wording of questions can create stigma and as a result people may be reluctant to identify themselves as disabled or household members may experience shame at having a member with a disability and thus avoid identification 39 second the questions themselves may identify some disability types better than others third the research communication process itself may be inaccessible for some groups of people with disabilities such as those with intellectual disabilities or the deafblind methods to investigate the vulnerability of people with disabilities the vulnerability of people with disabilities to hiv and srh adverse outcomes might be multifactorial involving individuals as well as contextual factors that occur at different times during their life course therefore to understand the link between disability and hiv infection it is necessary to move beyond a static crosssectional analysis and adopt a lifecourse approach such an approach aims to collect information on events and experiences over the lifetime in order to identify sequences of risks and patterns of lifecourse trajectories and to examine their association with health outcomes 40 41 although longitudinal studies are the gold standard approach for lifecourse research they are difficult to implement in lowincome contexts particularly because of high sample attrition and relatively high implementation costs alternatively retrospective lifecourse studies have been shown to be useful and to provide data with adequate accuracy 42 43 44 objectives and assumption of the handivih study this study aims at improving our understanding of the situation of people with disabilities in subsaharan africa in relation to hiv and their srh the primary objectives of this study are to compare quantitatively the risk of hiv infection among people with disabilities to those without and to analyse the factors associated with their vulnerability to hiv to do that the study will compare the hiv prevalence among people with disabilities and matched controls explore in detail their lifecourse events and knowledge attitudes and practices as well as their access to informationservices in relation to hiv and srh including their ability to negotiate safer sex and their exposure to violence as the social environment is thought to be an important determinant of the vulnerability to hiv 45 46 the study will examine some aspects of people with disabilities social environment namely their social network and social participation additional information on people with disabilities will be obtained through two substudies assessing people with disabilities begging in the streets and those who are members of disabled peoples organizations they aim to explore the boundary of the main study population and to assess the vulnerability to hiv of people with disabilities from these two groups methods and design study strategy and design this research project aims to combine qualitative and quantitative data on people with disabilities the quantitative component a crosssectional survey currently conducted in yaoundé constitutes the backbone of the research additional dataqualitative and quantitativewill complement the backbone component providing complementary insight on the research question an initial exploratory qualitative survey has been implemented to inform the subsequent quantitative work other qualitative research will be conducted after the quantitative survey to explore in more detail some of the quantitative findings the two substudies on people with disabilities begging in the street and from disabled peoples organisations use an exploratory quantitative design since the second qualitative research will be defined only after the analysis of the quantitative data this article focuses on the crosssectional component of the study along with the exploratory work and the two substudies recruitment started in october 2014 and the estimated date of the last participants recruitment is november 2015 backbone crosssectional component washington group questionnaire to overcome the practical and conceptual difficulties in measuring disability a group of experts set up by the un statistical commission has proposed an operational tool for the identification of people with disabilities in surveys with good accuracy and reproducibility from one setting to another 26 47 48 this tool based on the international classification of functioning disability and health framework includes a small number of questions covering six functional domains or basic actions seeing hearing walking cognition selfcare and communication each question asks the respondent to rate on a fourpoint scale how much difficulty heshe has experienced in the domain the washington group questionnaire is available in various forms a short set questionnaire includes six questions and is recommended for use in national survey because of its simplicity additional questions are available from the extended set to supplement those from the short set and provide more detail on functional limitations study population all people aged 1549 years with severe difficulties in at least one domain or some difficulties in at least two domains of the washington group questionnaire are considered as living with disabilities and therefore are eligible for the study 47 48 for each person with a disability included in the study a control of similar age group and sex living in the same enumeration areas and without functional limitation criteria is also recruited sampling methods and disability screening the sampling procedure consists of two phases in the first phase 177 enumeration areas in yaoundé were drawn from the national sampling frame provided by the central bureau of the census and population studies each drawn enumeration area is enumerated again in an exhaustive way to update the data in the second phase up to 200 households are randomly selected in each of the enumeration areas all members of the selected households aged 15 years and above are then screened for disability using eight questions from the washington group disability questionnaire 47 48 the two additional questions from the extended set were included in the screening tool to better capture people with intellectual andor mental disabilities sample size sample size was computed to detect with a power of 80 and alpha risk at 5 a prevalence ratio 17 under the assumption that hiv prevalence in the controls is 6 in yaoundé and that 10 of the participants may refuse the hiv test a total of 850 persons with disabilities and 850 controls will be recruited with this sample size it is expected that each subgroup defined by impairments will include at least 100 participants this is based on the assumption that the smallest subgroup will constitute at least 12 of the study population as it has been observed in other studies 49 50 outcomes hiv prevalence the primary outcomes are the prevalence of hiv among people with disabilities and the prevalence ratio compared to the control group prevalence and prevalence ratio will also be computed for subgroups defined by the following impairments hearing visual mobility intellectualmental knowledge attitude and practices knowledge attitudes and practices on hiv and aids sexuality and reproductive health are assessed by questions derived from the illustrative questionnaire for interviewsurvey with young people designed by cleland et al 51 in addition main events of their sexual and reproductive life are recorded during the lifeevent interview disability given its complexity two dimensions of disability activity limitation and social participation restriction are examined the extended set of the washington group disability questionnaire is used to assess activity limitation 48 although social participation is central to the definition of disability there are many challenges in measuring social participation as defined in the icf framework 52 53 54 55 much of the issues result from the lack of a consensual definition of the social participation construct 55 in this study difficulties in participation in communityfamily events and in the decisionmaking process are rated on a fourpoint scale using questions based on the work by sintef 56 and handicap international 57 environmental factors questions derived from sintefs work based on the validated craig hospital inventory of environmental factors shortform are used to assess the effect of environmental factors on functioning and social participation 58 59 social support is assessed for all participants using questions adapted from the social network index 60 lifecourse trajectories detailed information on the participants environment history of employment resources relationships and reproductive health is collected during the lifeevent interview it provides important information on the lifesituation aspects of social participation as mentioned in the icf 33 it will be used to compare lifecourse trajectories between people with and without disabilities as well as people with disabilities across different types of impairments and their potential association with hiv status and adverse srh outcomes 61 health services utilisation a short set of questions is used to determine the nature of srh services used by the study respondents satisfaction with the last service used is also assessed this topic will be investigated in more depth during the forthcoming qualitative component of the survey interviews and methods facetoface interviews are organised with eligible participants identified from the screening stage after informed consent is granted these interviews are conducted in a confidential environment in the participants homes or in a specific place set by study interviewers specifically trained for this purpose eligibility of the participant is first confirmed with the washington group questions participants eligible as people with disability are asked additional questions from the extended washington group set to have more details on their functional limitation while controls are asked the same eight questions from the washington group questionnaire as part of the quality control after eligibility is confirmed the full interview is proposed to the person it includes a lifeevent interview on participants history of social participation employment resources sexual partnership and fertility using the lifegrid method 43 62 the lifegrid is made of two a3 sheets divided into several columns the vertical axis represents the time the first column gives time in years from birth to current year the second column gives the age from 0 to current age and the third column gives the time elapsed the other columns are used to report events according to their nature in addition the occurrence of important events is recorded as well as any information provided by the participants on the meaning of the events that occurred during hisher life the lifegrid helps to recall and structure the history of life events into chronological categories by crossreferencing the events the grid is continually shown to the study participants as biographical information is recorded by the interviewer the interview also includes closed questions on the participants characteristics activity limitations knowledge attitudes and practices on hiv and srh environmental factors social support and participation several questions probing exposure to physical andor sexual violence are asked at different moments of the interview these questions are intended only to screen for violence and not to investigate the nature or circumstances of these events however the qualitative component of this study will aim to give a better insight into the exposure to violence where needed pictograms and other communication tools are used to facilitate communication between study interviewers and respondents all interviewers received intensive training on study procedures interview methods as well as on disability and methods of communications with people with disabilities two interviewers are proficient in american and french sign languages and two have physical disability hiv testing each participant is offered voluntary hiv counselling and testing it is carried out at the participants home or at any other place where there is assurance of confidentiality if the participant prefers the counselling is led according to international guidelines communications strategies are adapted to each type of disability through the use of tools such as pictograms dolls drawings and wooden penis when relevant two rapid blood tests are used following national and international guidelines 63 64 hiv infection is initially screened using the sensitive rapid blood test parallel determine and further confirmed using the insti hiv1hiv2 an hiv elisa antibody laboratory test will be performed in case of discordant results between the two rapid tests and for 10 of all tests as part of the quality control all specimens are identified only through the anonymous study number to ensure confidentiality for participants who refused hiv testing a phone number is given for them to contact if they change their mind statistical analysis a weighted estimator will be used for prevalence and proportion estimates 36 65 cis will be adjusted for the sampling design using the bootstrap method and the rao and scott corrected pearson test will be used to compare proportions potential risk factors for hiv will be identified using multilevel regression three categories of variables will be considered individual characteristics environmental characteristics and lifecourse characteristics multistate models will be used to analyse sequences of events and life transitions experienced social sequences from the lifecourse grid will be analysed using optimal matching algorithms 66 first an overall analysis will be performed without accounting for the presence of a disability this will provide a number of typical life trajectories in the second step the association between specific life trajectories and the presence of specific impairments andor social participation restrictions will be assessed as well as the association between typical life trajectories and hiv vulnerability indicators univariate and multivariate logistic regression models will be used for these analyses exploratory work results and study adaptation before starting the crosssectional component a mapping of the various organisations for people with disabilities was completed using a snowball method until saturation of the information additionally a qualitative survey was implemented to assess the acceptability of the study procedures and determine possible barriers to reach people with disabilities using a purposive sampling method a total of 10 semistructured individual interviews and 3 semistructured focus groups were conducted focus groups were conducted separately with males and females interviews were carried out with people having visual hearing and physical impairments relatives of people with intellectual impairment and professionals working with people with disabilities all interviews were audio recorded and transcribed transcripts were manually coded and analysed using thematic content analysis all the interviewed persons with disabilities fulfilled the inclusion criteria of the handivih study the exploratory interviews revealed five main themes that need to be considered in the implementation of the study most of the key informants mentioned the frequent exposure of women with disabilities to physical and sexual violence this was accounted for in the study implementation through the identification of referral organisations for victims of violence and specific training of the interviewers on that topic all key informants insisted on the importance of developing a trusting relationship during the interview with the person with a disability the inclusion of people with disabilities in the interviewers team was a successful way to do that the lifeevent interview also contributed to such a relationship besides prior to launching the study sensitisation sessions have been conducted in each enumeration area through media reeves and traditional chiefs to increase the trust of families in the study some key informants highlighted the fact that interviewers might need to be accompanied by another familiar person with a disability to gain the trust of some people with disabilities a strategy that is used when necessary and more often with persons living on the street many key informants also stressed that people with intellectual disabilities may be hidden to the research team because of feelings of shame commonly found in their community to overcome this issue questions about the composition of the household are asked several times in different ways and at different periods of the enumeration and screening phases in addition interviewers have been trained and supported in developing interpersonal skills to get the trust of the first respondent of the household to finish key informants explained that in yaounde since there is only one institution that can accommodate people with disabilities most of them live in households they also hold the view that most of the people with disabilities begging in the street belong to a household and only few of them actually sleep on the street the interview tools for the different phases of the survey were fieldtested and adapted standardised reformulation of the washington group questions was prepared using the user and cognitive testing guidelines available from the website and from one of the coauthors substudies towards a better understanding of the disabled population throughout the spectrum the backbone crosssectional component might fail to include people with disabilities living on the streets to address this concern a substudy has been added that recruits beggars with disabilities through a purposive sampling strategy after consent is granted the same questionnaire and hiv counsellingtesting as for the crosssectional component participants are proposed to beggars with disabilities in addition information on their living conditions and on their social network is collected during the interview while most available studies recruit their study populations from dpos networks it has been pointed out that the characteristics of these populations may differ from those of the general population of people with disabilities who do not adhere to any groups or organisations in the second substudy members of the dpo mapped during the exploratory work are randomly recruited and offered to participate in the interviewing and to get an hiv testingcounselling after informed consent using the same statistical method as for the crosssectional components the characteristics of this subgroup will be compared with those of the participants in the main study to better understand to what extent data obtained from dpo members may reflect the situation of the overall population of people with disabilities for these two substudies no formal sample size calculation has been performed because of their exploratory nature however a sample size of at least 50 participants in each substudy was targeted in order to provide a power of 80 and to obtain results with a precision of at least 15 ethical issues the final protocol has been approved by the comité dethique pour la recherche en santé humaine in cameroon and comité consultatif de déontologie et dethique from the institut de recherche pour le développement special attention has been paid to giving adapted information to persons with intellectual disabilities and involving them in the consenting process emphasis was also given to ensure confidentiality and privacy during the interview and hiv testing since some questions explore sensitive topics that may cause emotional distress interviewers were trained to first provide psychological aid 67 and to refer people requesting assistance to available services in yaounde all participants diagnosed with hiv infection received information about antiretroviral treatment and places where they could receive care in addition the study nurse proposes to those who are disabled to escort them at their first medical visit in order to decrease possible barriers discussion to the best of our knowledge this study will be one of the most comprehensive surveys on hiv and srh to be conducted among people with disabilities in subsaharan africa it will use a rigorous methodology to provide quantitative data on the burden of hiv among people with disabilities as well as information on their life situation in the crosssectional component the study attempts to overcome several methodological difficulties in identifying persons with disabilities that deserve attention first a relatively complex sampling design has been chosen to overcome the problem of identifying people with disabilities in the absence of a sampling frame using a twophase cluster random sampling with screening of disability at phase one the rationale for this design is to use a first simple screening tool to reduce the population in which the more complex diagnosis tool is used compared to snowball sampling that has been used in most available surveys this sampling design decreases significantly the risk of selection bias available studies from subsaharan africa on the health of people with disabilities tend to rely on populations of people with disabilities identified from dpo or institutions rather than from the general population data collected so far in the handivih study confirm that the majority of people with disabilities recruited do not report connection to any known dpo which suggests that populations of people with disabilities identified from dpos may differ from the general population of people with disabilities a tradeoff had to be made between simplicity ease and speed of use of the screening tool and its sensitivity in order not to miss cases in this study it was decided to include two additional questions to the washington group short set to improve its sensitivity to detect intellectual or mental impairment because it was assumed that people with these impairments may be at an increased risk of sexual abuse and violence the main potential limitation of this twophase design is the inability of the screening tool to correctly partition the population into two groups defined by the disability status various tools have been used to identify people with disabilities in the surveys and comprehensive discussions of their limitations have already been published 13 26 34 68 in this study the two important features sought for the tool used to measure disability were its coherence with the icf disability model and its ability to provide valid and reliable data that could be compared with similar data from other countries currently the washington group questionnaire is increasingly being used recommended for use and the most validated questionnaire for screening disability in adults 69 although to the best of our knowledge it has not been used for hiv survey among persons with disabilities to date the wg questionnaire has been used in other surveys on health 70 71 and is likely to be included in future demographic health surveys nevertheless this tool is based on the selfreport of functional limitations and may not identify clinical impairments if the respondent does not consider hisher impairment as a limitation two recent studies conducted in cameroon and india have found that up to 46 of the people with disability identified through clinical impairment screening methods were missed by the washington group questionnaire 74 75 another important issue is the determination of a cutoff in the level of difficulties that will differentiate people who are potentially with disabilities from those without in this study using the experience from two other surveys 56 71 it was decided that anyone with a major difficulty in at least one domain or some difficulties in at least two domains would be considered eligible as people with disabilities to detect possible disability measurement errors done with the eight questions of the washington group questionnaire at the screening phase disability eligibility is confirmed with the washington group extended set before enrolment in the second phase of the study lastly it should be emphasised that the identification of functional limitations is only a first step to the identification of disability and needs to be complemented with additional questions on social participation and environment as well as impairment screening 27 33 an important feature of this research is the combination of different approaches to collect information on the study population the quantitative crosssectional survey constitutes the backbone of the project however since the population of people with disabilities is heterogeneous complex and understudied this quantitative component is completed with substudies having an emergent design this heuristic approach is expected to give a more flexible and comprehensive understanding of the studied population while maintaining scientific rigour and quality a first substudy was defined to get a better understanding of the situation of the people with disabilities begging who may not have been included in the crosssectional study the second substudy focusing on people with disabilities who are members of a dpo is expected to provide more insight into possible limitations of epidemiological results based only on membership of dpo these data are also expected to help to better adapt interventions to specific groups of people with disabilities as results accumulate other qualitative researches connected to the project may be defined another major challenge of this study is to get a better understanding of the mechanisms explaining the vulnerability of people with disabilities to hiv it should be emphasised that the crosssectional design of the study precludes any firm causal conclusion as could be done in a prospective cohort however the lifecourse approach used in the study may provide us with important information the strength of the lifecourse approach lies in its ability to provide a comprehensive insight into the context connecting sexual risk behaviour to other social factors and looking at events with an adequate time perspective 76 the life course perspective is particularly important in the context of people with disabilities who experience disadvantages that accumulate throughout the life 77 besides the lifegrid method for collecting biographical information has been shown to improve the recall and thereby the accuracy of collected data 44 retrospective data collection might not be as accurate as in prospective studies although it was shown to provide information with good validity and reliability for some types of events 78 79 80 moreover the subjective assessment of events and life circumstances during the lifeevent interview is important information that may contribute to a better understanding of the life situation of people with disabilities and its relation to hiv risk interestingly the lifeevent method gives more attention to the respondents perspective owing to this opportunity offered to respondents to account for their lives the lifeevent method creates an environment conducive for sharing intimacy which contributes to improving the quality and wealth of the data it also gives the possibility to combine individual and social data although possible the use of the lifegrid method with people with intellectual disabilities is challenging in our experience a third person close to the respondent has to help in answering to the environmental activities and resource modules nevertheless for most of this specific disabled population the training of the interviewers as well as the use of the communication tools has allowed the collection of intimate data without the help of a third person preventing the proxy bias in important topics such as sexuality and intimate relationships in conclusion this study aims at providing comprehensive information on the vulnerability of people with disabilities to hiv and in their srh to address the multiple challenge of providing comprehensive and valid data on the vulnerability of people with disabilities to hiv and srh adverse outcomes an innovative approach is used which needs to be shared and discussed with other stakeholders the key aspects of this approach are adoption of a disabilityinclusive approach as much as possible use of an exploratory phase to adapt processes and tools to the specificities of the target population use of a random populationbased sampling and of standardised icforiented questions to select people with disabilities in the study adaptation of the various tools to participants needs and adoption of a lifecourse approach to better understand hiv and srh vulnerability specifically related to disability the findings of this research are expected to bridge important gaps in the knowledge and to inform decisionmakers of the development of more accessible and appropriate hivsrhrelated interventions for people with disabilities they are also expected to stimulate additional research either to confirm these findings in other african settings or to broaden some aspects of the results author affiliations provenance and peer review not commissioned externally peer reviewed data sharing statement this article presents the study design and discusses the methodological aspects data being collected during the research are available to the first author

handiviha populationbased survey to understand the vulnerability of people with disabilities to hiv and other sexual and reproductive health problems in cameroon protocol and methodological considerations bmj open 20166e008934

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social inequalities are an important determinant of the global burden of disease within and between countries this is true for both high and lowand middleincome countries 29 disparities in healthrelated behaviors health outcomes and healthcare access may occur based on a range of individual characteristics such as gender age disability education income race occupation or urban vs rural residency 172131 for instance research conducted in high income countries suggests that those with a low socioeconomic status are less likely to engage in sufficient amounts of physical activity 26 similarly rates of cigarette smoking are three times greater among individuals with lower incomes compared to those with higher incomes within the united states 5 disparities may also occur due to structural and social causes such as divides in education or housing which may put certain populations at risk of not seeking or receiving appropriate care 31 accordingly disparities may also exist between geographical regions for instance the highest rates of dietrelated deaths have been observed in lowand middleincome countries while lowest rates were observed in highincome countries 1 reducing social inequality would have a massive impact on population health preventing countless premature deaths and increasing global quality of life accordingly reducing social inequalities is at the core of the united nations sustainability goals eg goal 6 and goal 10 digital health that is the use of digital technology in health promotion and healthcare and related areas has been proposed as an important vehicle to reduce disparities in health promotion and healthcare stakeholders assume that given the high and rising penetration by using technology access to high quality care may be improved at low cost 28 however social inequality is often associated with lower use of digital technology resulting in a digital health divide 12 for example older adults are less likely to use the internet 20 and smartphones 23 there is also a digital divide between countries with a larger share of people in the global north having access to the internet than in the global south patterns of social inequality regarding internet access however are similar between countries for instance people with lower incomes are less likely to have access to the internet in both regions 11 given that the use of digital health technology often requires access to the internet andor a computer or smartphone these access disparities challenge the assumption that digital health technology is making health promotion and healthcare more equitable this notion of a digital divide is furthermore supported by recent reviews on digital health technology use and effectiveness 16 for instance young people with a high level of education and higher income are more likely to use digital health technology 19 furthermore high ses populations benefit from digital interventions for physical activity while low ses groups do not 30 thus there is the risk that digital health technologies will not only reenact but also widen health disparities but research on testing whether this occurs and how it may be prevented is sparse western et al 30 only identified 19 randomizedcontrolled trials that specifically examined effectiveness for improving physical activity behavior based on ses furthermore the range of social inequality indicators studied is narrow szinay et al 27 synthesized the literature on a potential digital divide in the uptake of engagement with and efficacy of exclusively mobile interventions for weightrelated behaviors and found that out of the 16 publications included the majority focused on age gender education and ethnicityrace other inequality indicators included in the progressplus framework 21 such as income occupation urban vs rural residency or sexual orientation have not received similar levels of attention to date finally digital health research is conducted almost exclusively in western educated industrialized rich and democratic countries with the majority of studies stemming from north america europe and australia and new zealand 2730 there is thus a need for a systematic international and interdisciplinary study of the impact of social inequality indicators in digital health as well as the underlying mechanisms of this digital divide across the globe to reduce health disparities exchange between communities from different continents eg at conferences is rare due to costs and burden of international travel inperson exchange has been further complicated by the covid19 pandemic in addition different research traditions emphasize different social inequality indicators for example while studying disparities based on race is common in the united states the topic is usually not addressed in germany for historic reasons to advance the study of a digital divide in health promotion both within and between countries international collaboration is vital for this reason we conducted an international expert workshop that was held in kulmbach germany from 20 to 23 june 2023 eighteen researchers represented eight countries through their current residency and contributed perspectives from an additional five due to their countries of origin their research backgrounds were in psychology behavioral science public health and health promotion nutritional science law addiction science physical activity promotion and health economics through a series of presentations and group discussions workshop participants synthesized the current state of research discussed current issues in the field and formed an international network on the study of the digital divide in health promotion in the following we present the results of these discussions focusing on the main challenges in the field of digital health promotion and healthcare regarding social inequality to stimulate further research in this area and ultimately improve health for all first we present issues related to interventioninduced inequalities in this section issues are clustered following the digital rainbow model 12 this model is based on the whitehead and dahlgren 31 framework which organizes social determinants of health in five hierarchical levels ranging in descending order from general socioeconomic cultural and environmental conditions to stable individuallevel factors such as age and gender we use this model to highlight the different levels on which the digital divide may operate afterwards we present issues related to researchinduced inequalities where we reflect on the contribution of digital health research to the digital divide and how these may be overcome through changes in research practices interventioninduced inequalities socioeconomic cultural and environmental conditions these general conditions may influence population health through providing opportunities and removing barriers eg through legislation we know from nondigital interventions that interventions operating at higher levels of the system are more likely to impact health at scale 6 thus systemslevel approaches may also be required to address the digital divide for instance digital literacy can be increased through schoolbased interventions exposing students to digital technology and teaching them how to use it sensibly to achieve their goals such as searching for trustworthy healthrelated information and changing health behaviors however these approaches require the readiness of the political system to support these endeavors eg through providing adequate funding and making the relevant training mandatory for teachers not all political systems might be ready to tackle these inequalities 12 furthermore regulatory standards for digital health tools are needed to ensure that they are fit for purpose in some countries such as germany regulatory frameworks exist that state how digital health tools need to be evaluated in order for them to become recognized treatment options including the opportunity for costs to be covered by health insurances 25 in this way high quality digital health tools can be offered to patients independently of their ses to date however evaluation criteria do not take into account whether these trials included marginalized groups or had diverse samples it is thus to be expected that efficacy is only assessed for certain subgroups of the population which may benefit more from digital interventions 2430 similarly global initiatives such as the global digital health partnership 1 do not include diversity in their assessment to counteract this trend stricter evaluation criteria regarding inclusivity and diversity of samples are needed which again could be implemented through legislation living and working conditions living and working conditions also influence digital health inequalities for instance certain populations do not have access to digital technology and are thus considered digitally poor especially in global south countries such as nigeria internet access is often limited due to restricted availability and affordability through pay as you go service plans socioeconomically deprived populations may thus not be able to afford internet access or may only use it sparsely to keep costs low as a consequence not all settings and contexts are suitable for digital health interventions or the specific modality needs to be reconsidered this fit needs to be considered when digital tools are suggested or implemented as a public health measure social and community networks social and community networks may act as important guides to digital resources for instance individuals interested in using digital health technology may ask the advice of healthcare professionals regarding whether and which tool to use 13 several barriers such as low acceptance lack of competencies lack of awareness of digital health tools and the potential benefits or preconceived ideas and stereotypes of whom these tools are suited for among providers may influence whether and to whom digital health tools are recommended and so discourage the use of digital health tools among the intended users 7 healthcare professionals 1 healt hit gov topic globaldigit alhealthpartn ershi p text the 20glo bal 20dig ital 20hea lth 20par tners hip 20is 20a 20col labor ation 20of 2030and 20adv ance 20mut ually 20ben efici al 20pro jects including the clinical workforce thus should be involved in the development of digital health tools to ensure that they fit their requirements in addition campaigns are needed to promote awareness provide training on how to use digital health tools to complement care and tackle stereotypes about digital health tool users or privacy concerns to boost uptake moreover conflicts related to cultural moral and religious backgrounds among users can hinder the acceptance of digital health solutions especially in countries with various cultural influences and resulting differences in individualistic versus collectivistic tendencies 7 such as malaysia this may impact both engagement with a tool with tools not fitting ones cultural norms and expectations being abandoned 13 as well as interactions between healthcare professionals and patients when discussing the use of digital health tools culturally sensitive digital health tools are thus needed which again highlights the importance of expanding digital health development and testing beyond weird countries individual and lifestyle factors also individual and lifestyle factors play an important role in engaging in healthy and unhealthy behaviors in the context of digital interventions however little is known to date about mechanisms underlying the uptake of engagement with and effectiveness of digital health tools by different individual factors understanding these mechanisms be it motivation familiarity and technology skill and literacy developed in another domain such as work attitudes social norms or other personal factors would allow the transfer of knowledge from one digital tool to another gaining this knowledge requires a common understanding of social inequality indicators and standardized measurement which is especially difficult for ses given the variability of median income and education levels across countries 30 developing an understanding of the personal influences of digital health access and benefits also requires a more concerted effort to engage those disadvantaged in research studies something our scientific fields have collectively struggled to achieve researchinduced inequalities study planning design and analysis throughout the research process from study conception through recruitment to study reporting researchers often make decisions unconsciously that can impact the applicability of the study to marginalized groups and thus limit generalizability of the findings first and foremost researchers need to be made aware of the potential impact of their decisions and provided with solutions for how to improve their studies to not increase health disparities this principle applies both to tackling social inequalities in general and to digital health inequalities specifically in line with contemporary changes to research practices in the behavioral sciences changes need to be introduced to existing templates for study registration to include a wider range of potential inequality indicators similarly to aid transparency around addressing inequalities existing reporting guidelines such as consort or strobe should be extended to include social inequality indicators in baseline assessments and for potential differences to be explicitly checked when analyzing the data eg through sensitivity analyses 8 since many journals require reporting checklists to be included upon submission and preregistration of studies is becoming more common it is likely that these structural changes will lead to a relatively quick change in research practices 14 finally researchers should involve key stakeholders including patients clinicians community members and potential endusers of digital health interventions in the study planning process as early as possible eg through communitybased participatory research or patient and public involvement 4 to address research questions that are relevant and important to them and to design study materials in accordance with their needs and expectations recruitment when recruiting participants for any study it is important to take into account who is using which channels and thus who would be most likely to engage with study advertisements this is especially important when using digital recruitment methods different recruitment modalities reach different population subgroups 22 and research should be conducted with an understanding of the recruitment strategies and modalities that are more likely to reach certain population groups in addition recruitment benchmarks of specific population groups should be established so that researchers can periodically compare actual recruitment proportions to the established benchmarks and know when they may need to pivot to new recruitment strategiesmodalities decisions about how and where to recruit can then be made deliberately to reach the targeted group or to achieve desired sample diversity similarly inequalities may occur in all stages of the research process this also includes enrollment and engagement and not only intervention effectiveness all stages of the research process thus need to be critically examined regarding potential harmful side effects that may widen inequalities local vs global scope the digital health divide is a global issue research on this topic thus should not be limited to individual countries furthermore the issue is interdisciplinary in nature as highlighted by the socioecological models used to describe the contributing factors 12 as well as the fact that contributions of several disciplines including computer science or engineering as well as psychology sociology and other behavioral sciences are needed to successfully develop digital health interventions finally intersectoral collaboration that is between research clinical practice and industry is urgently needed to ensure that the developed tools are fit for purpose widely implemented and tested appropriately regulated and maintained in line with the technology infrastructure of all 2 for this to be achieved new funding structures need to be implemented that are available to larger international research consortia and that also appropriately address the needs of interdisciplinary and intersectoral collaboration furthermore international collaborations allow for studies to be conducted in the participants local language to ensure that english language skills are no barrier to participation yet these projects are rare and typically require funding by multinational organizations this issue may be overcome through big team science such as many labs projects which typically involve hundreds of researchers from various countries who pool their resources to collect data using the same measures and potentially also conduct experiments or interventions using the same materials in this vein effects may be compared between countries and cultures to see whether effects are indeed generalizable data collection methods furthermore improvements are required regarding research methods used since these methods might impact the willingness of individuals to take part in a study for example the completion of lengthy questionnaires requires the availability of time and ability to understand the questions and response options which may be limited in populations with low literacy importantly research also suggests that response scales are interpreted differently depending on study participants cultural background 9 it is thus advised that researchers think critically about the research methods used and that these measures are appropriately adapted to the target group for example by making materials culturally appropriate or adjusting sampling and data collection methods to preferences and use habits amongst others this could be achieved by involving participant representatives early in the research process through cocreation similarly inequalities may be exacerbated by the time commitment required to take part in a study especially if study participation requires visits to a study center which are usually located in the center of larger towns or cities accordingly rural populations or those living in more affordable but less central housing may experience difficulties in reaching these centers this difference may be exacerbated for low ses populations who might not own a car or cannot afford parking in city centers while these issues are relevant to any study digital tools might provide a solution to the issue remote assessments may bridge this gap and increase reach 18 finally study participation should be appropriately incentivized this may be especially important when aiming to recruit disadvantaged populations who may need to choose between taking part in a study and using the time to generate income 3 access to research results finally research results should be made openly accessible and summarized to facilitate knowledge exchange among researchers for instance living reviews ie databases that are updated at regular intervals or even automatically can provide an uptodate overview of findings similar databases containing developed and tested digital interventions including information on whether they worked for whom and under which conditions would accelerate research and prevent research waste 15 by making these results open access the existing digital divide in academic publishing due to high costs of journal subscriptions would be simultaneously tackled which would allow researchers from lowand middleincome countries to participate more equally in academic collaborations publishing in open access journals however is expensive especially researchers in lowand middleincome countries may not be able to afford the publishing fees fee waiversor diamond open access models that rely on sponsorships by organizations rather than payments by individual research teamsare thus essential to promote knowledge exchange in addition authors might want to consider selfarchiving manuscripts in repositories such as osf or other preprint servers these services are usually available free of charge international collaborations would also be beneficial to overcoming language barriers since not all study reports are published in english by involving an international research team publications in a wider range of languages could be reviewed and results could be made accessible to a wider audience through translations emerging artificial intelligence technologies could be used to help with translations furthermore through science communication activities researchers may translate their findings to key stakeholders or lay people thereby acting not only as a translator between audiences but also removing barriers related to health literacy conclusions without careful consideration of the points discussed in this article the introduction of digital tools in health promotion and healthcare risks widening rather than reducing existing health inequalities the digital divide is fueled by a range of interventioninduced inequalities relating to the way digital interventions are currently tested and distributed and researchinduced inequalities relating to the way digital health interventions are developed and evaluated changes in both areas are urgently needed to address the digital health divide this applies to a wide range of scientific disciplines that are typically involved in digital health intervention development and testing as well as industry and the public sector ultimately to improve practices resulting in or widening the digital health divide changes in political and research systems are urgently needed and the research community has to actively advocate for improving health for all authors contributions lmk rk ek and mjw generated the overall research idea and acquired the funding for the workshop all authors contributed to generating the ideas presented in this piece lmk wrote the main manuscript text all authors reviewed the manuscript funding the workshop was supported by the university of bayreuth centre of international excellence alexander von humboldt open access funding provided by university of vienna competing interests the authors declare no competing interests

social inequalities are an important contributor to the global burden of disease within and between countries using digital technology in health promotion and healthcare is seen by some as a potential lever to reduce these inequalities however research suggests that digital technology risks reenacting or evening widening disparities most research on this digital health divide focuses on a small number of social inequality indicators and stems from western educated industrialized rich and democratic weird countries there is a need for systematic international and interdisciplinary contextualized research on the impact of social inequality indicators in digital health as well as the underlying mechanisms of this digital divide across the globe to reduce health disparities in june 2023 eighteen multidisciplinary researchers representing thirteen countries from six continents came together to discuss current issues in the field of digital health promotion and healthcare contributing to the digital divide ways that current practices in research contribute to the digital health divide were explored including intervention development testing and implementation based on the dialogue we provide suggestions for overcoming barriers and improving practices across disciplines countries and sectors the research community must actively advocate for systemlevel changes regarding policy and research to reduce the digital divide and so improve digital health for all

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introduction to understand cancer literacy among contemporary men who selfidentify themselves as a member of a latin ethnocultural group a brief review of latin history and culture is necessary historically the latin language was a powerful tool used by the church and kingdoms in what would become europe in their clerical administrative and political decisions however latin was not restricted to the territories of kingdoms it spread throughout the european continent and its colonies and resulted in the emergence of other modern languages such as french italian portuguese spanish and romanian which maintained latins influential roots and flourished with cultural nuances for centuries european cultures with their stories of spanish italian and portuguese navigators conquests and bravery in the americas were influential consolidating ideas of manhood and patriarchy in the american continents conquerors exchanged goods with native people including alcohol which historians have argued has played the role of the perfect colonizer and disseminated the catholic faith through latinbased languages and culture today scholars acknowledge that european colonialism remains influential in the relationships between men and social power the creation of social problems and how masculinity is performed for example among men living in latin american countries notable historical and cultural similarities exist regarding masculine identity in various ethnocultural groups despite the linguistic diversity and the global intersectionality of identifiers the roots of masculinity have been shared lived and reinforced throughout generations of men across all nations settled by europeans to date mens global mobility remains a steadily growing phenomenon with an influx of adult male migrants in highincome and middleincome countries including those men originating from the aforementioned countries historically influenced by latin languageculture in their decision to live abroad resettle and integrate into a new social context men bring various lifestyles to a host society including values beliefs and health practices some of which include risky behaviors such as alcohol consumption an important asset for playing mens role is any society is the personal sense of masculinity guiding mens multidimensional healthrelated attitudes and behaviors the influence of traditional masculinity on mens health has been extensively studied revealing both the complexity of masculinity and the damage caused by this social construct to mens health such as risk taking abuse of illicit substances and neglect of selfcare our work is guided by the understanding of gender and masculinity that emerged from influential latetwentieth century feminists and theorists in mens studies drawing on these works we understand masculinity as a social construct performed in specific ways by men born and raised in latin american societies these expressions of masculinity have their roots in societal and economic changes political instability and gendered socialization including acceptance of plural masculinity within traditional conceptions of masculinity alcohol is frequently seen as a key aspect a mans life however how alcohol is understood is influenced by cultural normalization social class and professional activity associated with danger risk and high stress sexual orientation as well as social context or situationdetermined differences such as peerpressure and social role affirmation it is difficult to determine the cultural significance of alcohol consumption in different regions of the world due to its longstanding use but from a social epidemiological perspective there are patterns shaped by socioeconomic status and health behaviors that are related to alcohol consumption for instance consumption is positively correlated with income education and type of jobs increasing alcohol consumption is a current global health issue affecting lowand middleincome countries despite its widespread use the harms of alcohol consumption have been well documented low levels of alcohol use have been significantly associated with an increased risk of cancer mortality in both men and women indeed a large cohort study concluded that there is no safe level of alcohol consumption in relation to cancer mortality epidemiological evidence suggests that cancer of the oropharynx larynx esophagus liver colon rectum and breast can be attributed to alcohol consumption worldwide 237 million men suffer from alcoholuse disorder and disorderrelated hazards are well analyzed alcoholic beverages are among the over 100 known human carcinogens recognized by both the international agency for research on cancer and the us national toxicology program the impacts of alcohol consumption are also shaped by demographic and social factors for instance racialethnic differences in alcoholrelated health consequences relate to genetic factors in the usa alcohol consumption is a socially and commercially accepted cultural practice and abstinence is often stigmatized individuals recovering from alcohol use disorder often have trouble disclosing their nondrinking status for fear of being stigmatized that is either being judged negatively for abstaining from use or being judged for having had an alcohol use disorder this stigma frequently negatively affects recovering alcoholics social status and chances of employment despite comprehensive research on the risks associated with alcoholic beverages the general publics knowledge on alcohol is not easy to define participants in one study who selfidentified as light to moderate drinkers responded that cancer is unavoidable and so it is futile to change their behavior they saw alcohol consumption as a normal and necessary part of life mens literacy of cancer risk should be seen as an aspect of their wider health literacy which can be understood as a socially constructed array of skills and competencies typically developed through the accumulation of family school social and cultural assets gathered over time through exposure to information about health attitudes toward health and health behaviors mens perceptions of the risk of cancer associated with alcohol consumption is shaped by their understanding of masculinity for instance the risks of alcohol consumption can conflict with the traditional portrayal of men as being strong authoritative in control and fighters traditional masculinity also commonly associates vulnerability with weakness and femininity and thus something to be avoided or denied mens cancerrisk literacy is also shaped by their exposure to popular discourses about alcohol consumption and cancer it can be understood as a social image created within a structure composed of the real the imaginary and the symbolic components of a given reality as proposed by durand to better understand the existing influences between masculinity alcohol consumption and mens understanding of associated cancer risks the following research questions guided this study how do men who selfreport affiliation to latin ethnocultural groups understand how this affiliation shapes their views of masculinity and alcohol consumption and how do respondents perceive alcohol use in relation to its associated risk for cancer among men conceptual framework the population health promotion model framed this research the phpm considers the impacts of social determinants of health it is recognized that sdh relate to places contexts and conditions which contribute to the health inequities experienced by individuals who are socially positioned in various ways for example as a citizen worker or student the phpm proposes five comprehensive health promotion actions strengthen community action create supportive environments develop personal skills build a healthy public and reorient health systems related interventions may unfold at the individual family and society levels the phpm supports understanding specific and multilevel sdh within the individual level the following factors are of interest for this study at the individual level it includes age sex working conditions meaning of masculinity health literacy and health practices the family level includes norms and practices and the society level includes representation of masculinity practice of social gatherings peer influence and alcoholrelated culture it should be noted that our survey did not include geographic location as a sdh due to the impossibility of analyzing respondents complex lifestyles and health habits in many international locations this study aimed to identify the perception of alcohol consumption through the lens of masculinity in respondents ethnocultural groups review similarities and particularities across respondents ethnocultural groups regarding alcohol knowledge and the risk of cancer and examine individuals values and beliefs about alcohol consumption and risks of cancer for men methodology ethical considerations this study was approved by the canadian university research ethics board protocol 2018119 respondents provided their consent based on the principles of explicit consent by proceeding to the web link provided in the research ads only those consenting to participate in the online questionnaire advanced to the questionnaire via the web link design a nonexperimental descriptive research design was used to gain information to clearly identify the phenomenon under study generate information about its characteristics describe coexisting problems and examine individual behaviors this design neither sought causality among variables nor did it attempt to manipulate the variables an online survey with a questionnaire was used because this method tends to have a better response rate than questionnaires sent by mail population men selfreporting affiliation to latin ethnocultural groups regardless of alcohol use the population size was unknown it is important to note that this research considered language as the main feature of cultural identity since there was selfidentification for each latin subgroup the questionnaires could also be responded to in languages spoken by other subgroups this study used a social media platform to distribute the ad to their brazilian acquaintances and other men and women living in north and south america italianspeaking respondents were recruited through the personal social media accounts of the second author and the first authors personal contacts in italy and canada and the fifth author a frenchspeaking man from quebec distributed the ad on his social networks even though the research team had no contacts in portugal usa peru and argentina recruitment ad was also spread to these countries instrumentation a team of content experts from the fields of anthropology oncology and hp created 8 questionnaire items in the english language the survey items were freely translated by bilingual individuals to french portuguese italian and spanish all translated questionnaires were reviewed by men living in brazil canada and mexico who were considered as natural experts due to their local cultural immersion their review focused on the use of plain language and observed the high semantic diversity within the five languages to facilitate respondents full understanding of each question the questionnaires internal consistency was not evaluated by external experts and its validity was not established which threatens construct validity and external validity three sociodemographic questions explored age ethnocultural identification and country of residence two openended questions explored alcohol consumption and cultural acceptance of mens alcohol consumption and asked for their thoughts on research evidence concerning the elevated risk of cancer three multiplechoice questions were also asked the first concerned barriers men might have to perceiving the risk of cancer associated with alcohol use the second focused on which jobs men believed were associated with heavy alcohol consumption the final question asked which conditions caused men to consume alcohol as a coping strategy no questions directly addressed matters of hp for men who consume alcohol and its influence on mens professional and socioaffective lives data collection and storage data was collected through the opinio survey platform hosted by the canadian university analysis sociodemographic data and responses to closeended questions were compiled as descriptive statistics descriptive statistics as a measure of variability was chosen to describe summarize and synthesize data regarding a new unexplored aspect or characteristics of the new data set responses to the openended questions were analyzed using thematic analysis with the following modified procedures identification of emergent ideas after repeated readings grouped the ideas and reflected on them to identify themes and use of preestablished themes to respond to the research question the analysis was conducted using two preestablished themes alcohol consumption and its acceptance for men in respondents ethnocultural groups and thoughts about scientific evidence concerning the consumption of alcohol in high concentration and heightened risk of cancer results and discussion below the results of the survey are presented according to sample size the small sample size of each language group as well the sociocultural perceptions of masculinity alcohol consumption and risk of cancer in 8 of the 9 countries do not allow for analytical comparison therefore the evidence is mostly presented in its descriptive form some of the descriptive numerical results are corroborated by our qualitative findings specifically through examples provided by the respondents that may be understood as possible reallife connections with the three variables explored in the survey the results are presented according to the respondents language of choice and no information was collected about bilingualism or multilingualism the survey was completed by 176 men whose rate of participation per each language of choice was as follows portuguese english spanish french and italian researchers had no access to the raw data in the platform prior to the generation of the report produced by the platform itself it should be noted that of the 6197 male frenchspeakers who accessed the online informed consent form 4542 of them clicked no when asked to give their consent just six gave their consent and only four fully responded to the questionnaire no other language group showed the same significant loss of respondents table 1 summarizes data about respondents age country of residence and cultural selfidentity according to language of choice in responding to the survey with respect to age most respondents were in the youngest and oldest age ranges respondents informed nine countries of residence and five categories cultural selfidentity a question about perception of alcohol consumption in respondents country of residence with multiple possible responses drew 733 responses the three top statements were alcohol is a part of male students lives alcohol is a good way to feel accepted in social groups and alcohol is not repressed at social gatherings these results revealed the social context of alcohol consumption including the spirit of comradery other statements selected by respondents provide some clues regarding consumption habits alcohol is a useful way to handle stressful situations and it is not unusual to have a drink after getting home from work it is also important to note that a small percentage of respondents indicated that their families had engaged in the practice of encouraging boys to drink alcohol at gatherings at a young age which is indicative of cultural reinforcement of hegemonic masculinity by the normalization of alcohol use one spanishspeaker identified alcohol being used in baby bottles neither of the italian speakers knew about alcohol perception in their country of residence it is noteworthy that the statement i do not drink alcohol was chosen by 40 respondents sociodemographics absolute and relative frequency per language of choice age french 3 english italian and portuguese 0 french 2 spanish 1 other argentinian 12 english french italian and portuguese 0 spanish 12 total n 173 note not all questions were responded to by respondents source authors 9 the table 1 indicates that most of the respondents were young brazilian men who selfidentified as brazilian for their cultural group the success of recruitment and high participation rate of brazilians may reflect their openmindedness to discuss healthrelated matters as well as this groups interest in volunteering for research as a personal interest while in table 2 the results reveal the common socialization process of young men in a context of comradery freedom and interaction occurring mostly among the students where alcohol is part of the social context for relaxation enjoyment and wellbeing from a list of multiple statements respondents choices summed up 521 statements offering their perceptions about which jobs might lead men to consume more alcohol the three top choices were construction manufacturing and police officersfirefighters law professionals were identified in our sample as being the least likely to consume alcohol due to their job source authors results in table 3 reinforce stereotype of professions requiring common attributes of hegemonic masculinity such as physical strength and endurance courage and emotional control to which the alcohol consumption may be perceived by men as a support tool regarding the situational causes of alcohol consumption respondents selected 777 statements the most cited situational causes were stress unemployment or unstable job financial trouble divorce or separation personal healthrelated situational causes for alcohol consumption were identified as mental illness sickness or disability and chronic pain emotional pain due to the death of a loved one was also chosen as a situational cause for alcohol consumption source authors table 4 invites consideration of underpinning ideas about an increase in alcohol consumption related to situations where men are expected to remain in control of themselves and the surrounding context and circumstances low emotional control and having a job and financial stability are contrary conditions to what is socially expected for a man to keep respondents confirmed their perceptions about social expectations as related to masculine roles and social status two openended questions allowed men to voice their opinions about use of alcohol its social acceptance and the risk of cancer similarities and particularities exist among the mens five selfidentified ethnocultural groups both questions seemed to pique the mens interest and some of the respondents positioned their accounts in the context of their country of residence for the question exploring alcohol consumption and its acceptance for men in respondents ethnocultural groups there were 172 responses portuguese english spanish french and italian more detailed information regarding common drinking habits was provided by 11 respondents in english these respondents emphasized that men are exposed to alcohol consumption from a young age cultural differences between italy and canada were cited twice among 16 narrative responses for instance the frequency of alcohol drinking was 12xweek 710xsetting at every meal the three responses in french indicated that alcohol was culturally and socially accepted all 12 respondents in spanish agreed that it was very common for men of all social classes in their culture to use alcohol and the age of onset varied slightly by country in a narrative response one man claimed that 80 of men in the dominican republic drink alcohol regarding their thoughts about scientific evidence regarding the association between consuming alcohol in high concentrations and heightened risk of cancer 160 responses were gathered portuguese english spanish french and italian of the responses in english seven or 44 of the total responses believed the scientific evidence three were not concerned by the evidence and stated that they would not change their behaviors and six claimed they were unaware of the alcoholcancer correlation but were interested in the topic seven responses in spanish indicated they were aware of the correlation and three others were unaware of any risk one response in spanish revealed disbelief in any existing correlation while another respondent believed that alcohol was a necessity but should be regulated yet another individual stated that the correlation was new information to him two spanishspeaking men stated that they were not affected by the scientific evidence other accounts are presented in display 1 which provides many examples of mens thoughts beliefs and reflections about masculinity genderedbehavior alcohol use and the risk of cancer expressing the lived masculine norms in their home countries it seems that there is some awareness about masculinity as an influence on mens health status as stated by a brazilian participant who shared his reflection unfortunately male socialization in different societies is often based on the demonstration of strength power and domination which leads to displays of violence and sometimes selfdestructive behavior the results of our study suggest alcohol consumption in the participating countries is quite common and available in many social settings the study did not describe the influence of alcohol consumption on cancer literacy which is rooted in intergenerational practice and understood through the lens of masculinity nor the consequent interference on cancer prevention the study attempted to reveal multiple dimensions of mens relationship with alcohol and the influence of common perceptions of masculinity on alcohol use our evidence may indicate some reflection by men is required regarding alcohol consumption in relation to jobs traditionally held by men that require manual skills resistance to physical and emotional risk physical endurance and even preparedness for lifethreatening situations our results suggest alcohol consumption is viewed by many men as a social activity carried out in the context of interpersonal relationships social gatherings with family friends and peers alcohol is also expected to be part of mens attempts to endure unpleasant emotions related to professional personal and affective losses in fact mens perception of masculinity may impact how well they respond to contingent requirements for endurance resilience and coping our evidence indicates that cultural norms around alcohol consumption as a coping strategy may prevent men from developing a more accurate understanding of the risks of alcohol as they view consumption as a socially accepted form of selfcare moreover in a context in which alcohol consumption is normalized some mens disinterest in selfprotective behaviors and their compromised cancerrelated health literacy led to an increased risk for cancer this risky situation was documented by teese et al who demonstrated how the norms of hegemonic masculinity influence alcohol use and the consumption of illicit substances among adult men due to widespread social approval binge drinking is associated with mens lack of concern for risk to their physical wellbeing which is a key dimension of hegemonic masculinity the large number of narratives in our sample provided by respondents in portuguese allowed for an indepth qualitative intragroup analysis of this data analysis uncovered an expression of fearless alcohol consumption among most respondents and they provided minimal spontaneous comments about public preventive programs and policies the small size of other language subsamples did not allow qualitative intragroup indepth analysis or an intergroup analysis assembling all subsamples therefore alcohol consumption as an unhealthy expression of masculinity and exposure to the risk of cancer could not be analyzed and compared by language and country of residence overall our results suggest that some respondents have limited knowledge of the scientific evidence linking alcohol consumption in high concentration and the heightened risk of cancer revealing compromised health and scientific literacy on this issue throughout all subsamples the respondents made few suggestions about dissemination of scientific information about alcohol and risk for cancer using a mass education approach as a possible intervention to promote both forms of literacy for that cancer prevention strategies should consider evidencebased interventions and public policies to reduce exposure and encourage the adoption of a healthier lifestyle modifying the level of alcohol consumption by young adults rather than only focusing on heavy drinkers would be more effective in reducing the harms of alcohol including the risk of cancer discussion in this study exploration of alcohol consumption with an internationally diverse sample of men with a latin cultural background assumed that men would share common rationale in their decision to use this substance our evidence indicated that stressful situations may lead men to consume alcohol as a way of alleviating their concerns as well as stimulating their body and mind this possibility has been targeted by health awareness interventions for men while very few respondents they were completely unaware of the correlation between alcohol consumption and the risk of cancer there is room for improvement in raising awareness through mass hp considering the gaps in some respondents knowledge some misconceptions expressed by participants and unhealthy practices described by other respondents it is clear that many of these respondents could benefit from moments of reflection regarding their alcohol consumption more should be done motivate men to share information about risky behaviors adopt a healthier lifestyle and share their new insights with their peers thereby spreading awareness of the risks associated with alcohol consumption future health promotion actions could mirror the work done in some european countries in which mens health promotion has been inspired by the idea that men can act as agents of change and positively influence their peers the importance of understanding how alcohol consumption differs among ethnocultural groups is widely acknowledged our study documented some trends in alcohol consumption within ethnocultural groups in several countries thus contributing to the international scientific literature about effective health promotion regarding mens consumption of alcohol our evidence corroborates other studies suggesting that attitudes concerning alcohol consumption can affect the health status of men in our sample men living in france portugal and italy highlighted how alcohol is seen differently in these cultures having a particular focus on experience and gastronomy in portugal and france individuals consume four times more wine per capita than in the us our evidence about men living in brazil is compatible with macinko et als study which focused on patterns of alcohol consumption and related behaviors many men in their study reported that they started consuming alcohol around the age of 18 and consumed approximately five drinks at social events over half of the respondents indicated they had engaged in binge drinking with 42 reporting having binge drinking more than four times in the previous month rezende et al and van de luitgaarden et al studied several latin american countries including ones from which our sample drew and found that the risk of cancer is higher with heavy drinking than with moderate drinking in these countries our sample of residents in usa led us to acknowledge local trend in the overall consumption corroborating a us study by delker et al who documented high alcohol consumption among white hispanic and black individuals but found that weekly prevalence is slightly higher among hispanics than among whites and blacks the u s dept of health and human services stated that differences in ethnicity affect the early initiation of alcohol consumption and for hispanic americans the level of acculturation is a significant factor in determining whether a person will drink moreover hispanic immigrants who experience cultural stressors reported positive attitudes towards alcohol a worrisome trend in nonwestern countries mainly in nigeria is consumption of alcohol by underage men in reaction to the stigma of not drinking with abstinence commonly being viewed as a deviation of from heterosexual masculinity another stigma faced by men relates to mental health and coping mechanisms especially for those living in rural areas where access to mental health services can be less available or socially acceptable consequently alcohol consumption can be easily perceived to alleviate emotional health issues as identified by our evidence limitations a possible methodological limitation in this study concerns our recruitment strategies despite having followed rigorous methodological fieldwork procedures our decision to rely on existing social and professional networks may have constrained our sample the recruitment team only had one young adult mexican man and one male frenchcanadian professor while the other researchers involved in the recruitment were women belonging to different age groups for instance the second author is a young secondgeneration italian woman who contacted mainly young englishspeaking men in toronto and italianspeaking men in italy the first and fifth authors are brazilian women living in toronto with extensive social networks in brazil they targeted adult women to help recruit men within their social networks and reposted the ads in social media both authors directly recruited adult and senior men using their social media as well however it would be beneficial to have more diversity among the primary recruiters since this would help us reach a wider range of prospective respondents a larger and more diverse set of research respondents would support valid intergroup and intragroup comparisons the small sample size of respondents in french and italian language undermined these comparisons two other methodological limitations should be considered the lack of backtranslation of the five questionnaires to better grasp semantic differences and the impossibility of grasping the meaning of words in the same language spoken with semantic variation within and among several countries another methodological limitation relates to the impossibility of testing correlation variables due to the nature of the exploratory questions implications for practice andor policy and research evidence can influence policymakers and health promoters as they develop legislation and programming to limit unhealthy behavior related to alcohol consumption solid evidence is necessary to advance health literacy among individuals health professionals and health care organizations whose researchers can investigate which messages work best mass education campaigns can acknowledge the enjoyable aspects of drinking while also emphasizing associated cancer risks innovative campaigns should address the familial roots of drinking habits policymakers are invited to consider how to formulate international and crosscultural alcohol policies while researchers uncover the economic moral and emotional obstacles to promoting changes in consumption habits the global mens hp agenda should address the forms of masculinity embraced by boys youth and men and the intersections between gender and other markers of identity like sexuality and class a transparent and socially inclusive hp policy would support interagency collaboration to prevent and tackle discrimination and unsafe living conditions for male minority groups whose experiences of discrimination stress and social isolation sometimes lead them to use less healthy coping strategies moreover any global hp initiative for men in this matter should critically review the alcohol industrys conflicting interests and role as financial stakeholders in many social sectors it is particularly relevant for the world health organization development of alcoholrelated to critically consider stakeholders interest in any alcohol control policy to tackle such risks as recommended by rinaldi et al future qualitative research could provide important insights about mens lived experiences and perceived individual and collective representations of alcohol consumption the identification of testable correlated variables based on culture will elucidate the relationships between masculinities attitudes towards cancer and alcohol consumption research should advance knowledge in the field of hp by pointing out key gaps in the information men receive which if filled would allow men to make informed decisions about alcohol and cancer prevention our results suggest hp on this issue should be guided by the following principles democratization of knowledge about alcohol and risk of cancer is necessary to improve mens health literacy and specifically cancer literary and mobilization of some aspects of traditional masculinity such as personal responsibility and the society commitment to mens wellbeing to ensure men act on this knowledge conclusion our results suggest that alcohol consumption is normalized to a certain extent among men of different ages and backgrounds living in various international contexts the dyad of masculine risktaking and the alcohol consumption was acknowledged by many men in our study alcohol consumption was described by respondents as a feature related to masculinity and the overall social acceptance of drinking was evidenced by its consumption at social gatherings and within family homes as a symbol of maturity independence and autonomy language alcohol consumption and its acceptance for men in respondents ethnocultural groups thoughts about scientific evidence on alcohol consumption in high concentrations and the heightened risk of cancer english in canada alcohol is acceptable for men…especially for someone of italian background like me alcohol is marketed all over society wherever you look and has become ingrained in social gatherings as you grow older… it is very common…and is encouraged by the culture casual drinks with friends or at dinner appear to be part of life theres even a joke about canadians having stronger beer than americans while stronger beer is a canadian country song… …alcohol is common pretty much everywhere when i was younger i often saw people around me consuming alcohol on a daily basis whether it be at a party sports event or family function unidentified country i believe that like smoking cigarettes drinking alcohol is very harmful for your body however i continue to drink alcohol socially as it is a good way to enjoy life in the moment…dont really think about the consequences for the future research is research facts are facts need to live your life and have fun everything has pros and cons dont get too caught up on this i think this is concerning this fact should definitely be more widespread i have little to no knowledge on that subject however if that were true it would not shock me that is scary but probably true as a result of cirrhosis french in canada i live in quebec from advanced adolescence say 18 years it is considered acceptable in moderation acceptability then is always present according to a consumption considered reasonable in the sense of not too abundant… moderation tastes much better unidentified country i do not know the state of the research on this some people in the world could tell us more i guess that here too it must be a question of the amount consumed italian unidentified country until you have reached a dangerous level for your safety and of others and remain within the limits of modesty one glass of wine for lunch half a glass of wine for dinner unidentified country i think thats true i agree portuguese in brazil …this is very common and acceptable and even worthy of encouragement the consumption of alcoholic beverages by men is extremely stimulated since childhood and although there is a law prohibiting the sale to minors under the age of 18 in practice alcoholic beverages are easily accessible to adolescents in portugal …it is almost a must or imposition of masculinity to drink alcohol between men unidentified country it is possible because the components of alcoholic beverages are most often unknown consumption type frequency the time of use and the path that the alcoholic beverage passes through the human body can generate various types of cancers there is scientific evidence that correlates the immoderate consumption of alcoholic beverages particularly distilled alcoholic beverages with the risk of cancer there is also some evidence to suggest that moderate consumption of nondistilled alcoholic beverages …can help prevent cancer i believe that the use of alcoholic beverages with this content routinely brings a series of associated disorders and consumption of other substances such as a highfat diet therefore only with this information provided i cannot draw conclusions unidentified country that at present consuming alcohol is like a basic need of the human being the sale and consumption of it is legal in all areas however its sale should be considered restricted by the damage it causes to our organism spanish if we base ourselves on what the study says they give us the understanding that there is a very great risk about the mismanagement of these liqueurs in our country although they know the statistics the consumption of alcohol remains the same the main stimulant before any activity source authors finally the display 1 presents the respondents original thoughts about transnational and transcultural views of alcohol consumption and shared common elements such elements reinforce our interpretative insights about the longlasting influence and presence of hegemonic masculinity as lived and rooted in a common history of colonization in latin mens culture

objective to understand the underlying cultural effects of masculinity on alcohol consumption and the associated risk for cancer method an exploratory online survey data was collected 20182019 from 176 men living in 9 countries who responded to an online survey in english french italian portuguese or spanish sociodemographic data and responses to closeended questions were compiled as descriptive statistics responses to the openended questions were analyzed using thematic analysis with the preestablished themes alcohol consumption and its acceptance for men in respondents ethnocultural groups and thoughts about scientific evidence concerning the consumption of alcohol in high concentration and heightened risk of cancer results most respondents were under 30 years of age 337 results across the linguistic subsamples indicate that among 10 statements alcohol consumption is part of most students life 188 it facilitates acceptance in social groups 169 and it is not repressed at social gatherings 166 construction 275 was the top among professions in which alcohol consumption is most common among situational factors related to alcohol consumption respondents chose stress 181 unemployment or unstable job 180 and financial trouble 179 perceptions of acceptance of alcohol consumption are influenced by traditional masculinityrelated values beliefs and behaviors and the acknowledged lack of cancer literacy were revealed as conditions promoting a risk for cancer conclusionalcohol consumption is normalized to a certain extent among men of different ages and backgrounds evidence informs policymakers and health promoters as they develop legislation and programming to limit unhealthy behavior related to alcohol consumption

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background the profile of the medical profession has changed significantly in recent decades with a growing proportion of women physicians today in many countries half of the students entering medical schools are women however women physicians are still often viewed with a certain scepticism and gender inequality in academic medicine continues to be the rule indeed they face enormous barriers throughout their career they receive lower salaries family practice 2020 325331 doi101093fampracmz091 advance access publication 14 january 2020 and less funding have more difficulty publishing their research and have slower career progression than their male counterparts the publication of scientific articles is crucial for all researchers at it plays a major role in the process of promotion and career advancement besides rigidity in career structures discrimination and gender differences in the amount of time spent on domestic responsibilities gender inequalities in publishing are probably among the main reasons why men still largely outnumber women in academic leadership positions the quantification of womens publication activity can be considered as an indicator of their successful integration into science a large number of studies examined the gender gap in science by assessing the representation of male and female authorships but to the best of our knowledge only limited data are available for general biomedical journals in this bibliometric study we examined the prevalence of female first authorship in a random selection of articles published in 2016 in 18 high impact general biomedical journals we also assessed how this proportion fluctuated across a number of author article and journal characteristics methods identification of studies and data collection this bibliometric study was part of a larger project whose aim was to analyze the bibliometric characteristics of a random selection of articles submitted to general biomedical journals we described in detail the procedure used to select articles in another article only the main points are summarized below in order to create a representative subset of articles we used simple randomization based on computergenerated random numbers to select 781 articles published in 2016 in the 9 highest impact factor journals of general internal medicine and the 9 highest impact factor journals of primary health care journals that did not provide the submission acceptance and publication dates of published articles were not included in our article in other words for each of the two categories of journals the first nine journals with the three dates were selected this restriction in the selection of journals is related to the objective of the primary study in addition commentaries editorials brief reports correspondence case reports and nonsystematic reviews were excluded the 2015 impact factor list of journals publishing in the field of general internal medicine and the 2015 impact factor list of journals publishing in the field of primary health care were obtained using the jcr a product of isi web of knowledge in jcr these two categories are referred to as medicine general internal and primary health care respectively we used these two jcr categories for the selection of journals in our study then we extracted from the selected articles a number of data grouped into three categories author characteristics gender number of publications and place of affiliation of the first author article characteristics submission and publication dates number of authors number of study participants and design journal characteristics discipline 2015 impact factor and number of articles published in 2016 first authors gender was determined by inspection if an authors gender was not clear from hisher name we visited institutional websites social media accounts andor internet search engines to find a summary of hisher biography or photographs in total we were able to determine first authors gender for 767 articles the other articles were not included in further analysis we categorized all numerical variables into three categories choosing cutoffs by dividing the sample into terciles and rounding off to the nearest whole number 10 or 100 the number of publications was classified as follows 5 515 and 15 the number of participants as 100 1001000 and 1000 the number of authors as 5 57 and 7 the journal impact factor as 16 1622 and 22 and the study design as systematic review experiment cohort study crosssectional study casecontrol study qualitative study and other design in addition first authors place of affiliation was grouped into continents sample size determination and statistical analyses we computed the required sample size for the primary study we summarized the numerical data using medians and interquartile intervals and the categorical data using frequency tables we computed the proportion of articles authored by male and female researchers and compared the two groups of articles using univariate and multivariate logistic regressions adjusted for intracluster correlations all available covariates were included in the multivariate model except continent and number of participants the statistical significance has been set to a bilateral pvalue of ≤005 the sample size was estimated with pass sample size software version 13 all other analyses were carried out with stata version 12 results we collected data for 767 original articles representing 49 of the key messages • many studies examined gender inequalities in research • however only a few data are available for general biomedical journals • we found that the female authorship proportion was 48 • the proportion was 63 for primary care and 33 for general internal medicine • the proportion was particularly low in articles from the nonwestern world • the proportion was also low in systematic reviews and trials articles published in 2016 by the 18 journals selected for the study impact factors ranged from 197 to 16 for general internal medicine journals and from 51 to 11 for primary health care journals overall the femalefirst authorship proportion was 48 but the figure was significantly higher for primary health care journals than for general internal medicine journals adjusted pvalue 002 tables 2 and3 compare articles authored by male and female researchers according to author paper and journal characteristics the prevalence of female first authorship was relatively low among researchers publishing more articles for studies from asia south america and africa for multiauthored studies and for systematic reviews and trials in multivariate analysis women published fewer articles versus 9 5 versus 15 publications or 16 95 ci 1124 were more often affiliated with institutions in the western world were more likely to publish qualitative studies and to publish in primary health care journals there was no statistically significant difference between the two groups in the number of authors number of participants and journal impact factor discussion main findings in this descriptive study of bibliometric data we explored the representation of women in general biomedical research and how it fluctuated across a number of author paper and journal characteristics we found that the overall prevalence of female authorship was 48 but that the proportion varied considerably from one journal category to another from one region to another and from one study design to another comparison with existing literature many studies examined the gender gap in science by assessing the representation of male and female authorships in various disciplines for example in gastroenterology in cancer research in dermatology in pharmacy and in paediatrics other authors explored gender disparities through an interdisciplinary bibliometric approach for example in a large study covering more than 5 million scientific papers published between 2008 and 2012 lariviere et al showed that women were responsible for less than onethird of authorship worldwide in another study bendels et al reported that 33 of the first authorships in articles published between 2008 and 2016 in 54 scientific journals from the categories life science multidisciplinary earth and environmental and chemistry were held by women however there is only limited data available for general biomedical journals filardo b multivariate analysis a univariate analysis in summary the femalefirst authorship proportion found in our study for primary health care journals compares favourably with the existing literature while for general internal medicine this figure is lower than the proportion found in many disciplines except gastroenterology our finding may be partially explained by a decrease of gender gap in time as showed by several authors the proportion of articles with a woman as the first author increased for example from 27 in 1994 to 37 in 2014 for six highimpact medical journals from 9 in 1992 to 29 in 2012 for gastroenterological journals from 12 in 1976 to 48 in 2006 for dermatological journals from 30 in 1989 to 52 in 2009 for pharmacological journals and from 40 in 2001 to 58 in 2016 for paediatric journals interestingly several authors also showed an uneven gender distribution across authorship places which is probably linked to women underrepresentation in leadership positions in these studies compared to men women were relatively overrepresented at first but underrepresented at last authorship place for example in gastroenterology the female first authorship proportion was 29 for first but only 15 for last authorship place in cancer research these proportions were respectively 35 and 22 in pharmacy 52 and 34 and in paediatrics 58 and 38 note that our study was not designed to examine the authorship position the finding that female researchers were more likely to publish in primary health care journals than their male counterparts was not really surprising and could be explained in two ways first a number of studies suggested that there were meaningful differences in the way female and male doctors practice medicine in a similar way gender differences could also occur in research and explain where researchers decide to submit their research for example in their large interdisciplinary bibliometric study lariviere et al found that some disciplines or specialities were dominated by women and others by men second the proportion of female residents and the proportion of women in academic medicine tend to be higher for primary health care than for internal medicine for example in the united states the proportion of female residents increased from 52 in 2005 to 55 in 2015 for primary health care while it was 42 and 43 respectively for internal medicine in addition the proportion of women in academic medicine and the proportion of chairs held by women in 2015 were 49 and 36 respectively for primary health care but only 37 and 15 for internal medicine we found that women used qualitative methods for their research three times more often than men several authors already showed that women were overrepresented and men were underrepresented in published qualitative studies the usual assumption is that qualitative studies involve a prolonged relationship and emotional ties with research participants and it is presumed that female researchers demonstrate better relational skills alternatively women can be particularly interested in certain research questions that are better addressed by qualitative methods finally the academic successes of a number of female researchers in qualitative research can provide other women with female role models by contrast we found that women were less prone to publish trials this may be due to the fact that women receive fewer and lower research grants and are therefore less likely to be the principal investigator andor first author of these costly studies we found significant regional differences in our study in particular we found small proportions of female authors in asia these regional differences were already mentioned by some authors and probably reflect various sociocultural and socioeconomic conditions in regions with still a strong sense of conservatism and patriarchy andor in developing regions gender equity may not be a top priority for policymakers and a number of academic medicine departments as a result in these regions female researchers may face serious difficulties in terms of financial resources and support in contrast many countries of the western world probably made considerable efforts to offer more favourable conditions to women researchers for improving their participation in scientific publishing sociocultural perspective the topic of gender inequality in academic medicine is complex and constantly evolving various interactions between gender leadership and countries sociocultural context can partly explain the persistence of factors hindering the development of female leadership in academic medicine sociocultural factors can have a significant influence on gender differences in workfamily balance preferences in general female researchers tend to spend more time at home and less time at work which may reflect personal decisions but also cultural norms and persistent stereotypes the balance women create between their careers aspirations and their family desires makes it more difficult for female researchers to allocate the necessary time for their academic work in addition although gender discrimination is probably not as widespread as it was decades ago some forms of sexism still occur in academic medicine and modify womens academic trajectories female candidates for academic positions for example tend to be considered less competent than male candidates these stereotypes may discourage many women from pursuing their academic careers in addition to combating the stereotypes described above different strategies could be implemented to reduce the gender gap in academic research it is crucial to provide female researchers with strong role models universities should also encourage networking for women to create peer support systems finally universities should promote flexible working hours develop revised academic curricula and work on alternative indicators to assess academic careers limitations first only articles published in general biomedical journals were included in our study and several high impact factor journals could not be included because they did not provide the submission and publication dates of published articles the criteria used to select eligible papers limit the generalizability of our results and conclusions we can draw about gender gap and publishing in high impact journals second data extraction was limited to a single year the evolution of female authorship over time could therefore not be analyzed third we only recorded the gender of the first authors however it would have been interesting to evaluate the differences in gender authorship in a more global way also considering coauthorship especially senior authorship fourth in this study we used binary gender identification however the concept of gender is becoming more and more complex and a wider variation of gender could have been considered finally this bibliometric study is limited by the absence of information concerning certain important sociodemographic characteristics such as authors age training and academic position conclusion this descriptive study of bibliometric data gives an updated examination of gender disparities among first authors of articles published in general biomedical journals we found mixed results female authorship proportions were particularly high for studies published by primary health care journals for studies coming from europe north america and oceania and for qualitative research although these findings are encouraging in terms of integration of women scholars the underrepresentation of women in articles published by general internal medicine journals in articles coming from some parts of the world and in systematic reviews and trials need to be addressed and correcting the persistent bias in research and publication a top priority in particular there is an urgent need to combat the stereotypes faced by women to put in place policies to improve womens perspectives in academic institutions and to implement flexible work arrangements

background many studies examined gender inequalities in research but only a few data are available for general biomedical journals we assessed the prevalence of female first authorship in general biomedical journals and examined its variations across a number of author article and journal characteristics methods this study was nested within a larger project designed to analyze the bibliometric characteristics of scientific articles we retrieved 767 randomly selected articles published in 2016 in high impact factor journals of primary healthcare n 9 and general internal medicine n 9 we extracted the following data author gender number of publications and affiliation of the first author paper number of authors number of participants and study design and journal characteristics journal discipline and 2015 impact factor we compared the proportion of articles authored by women and men using univariate and multivariate logistic regressions adjusted for intracluster correlations results the female authorship proportion was 48 63 for primary healthcare and 33 for general internal medicine pvalue 0001 in multivariate analysis women published fewer articles 5 versus 15 publications or 16 95 ci 1124 were more often affiliated with institutions in the western world or 22 95 ci 1239 were more likely to publish qualitative studies versus systematic reviews or experiments or 27 95 ci 1548 and to publish in primary healthcare journals or 17 95 ci 1127 conclusions the underrepresentation of women in articles published by general internal medicine journals in articles from the nonwestern world and in systematic reviews and trials should be addressed

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background in latin america the arboviruses zika 1 dengue and chikungunya are transmitted to people by infected aedes aegypti mosquitoes primarily human biters these proliferate in domestic water storage containers as well as rainfilled artificial containers 1 many latin american households typically store water in containers in and around the home due to the lack of reliable water supply a study on dengue among urban residents in colombia found that out of 1721 households surveyed 961 either reported storing water in containers or were observed to have water storage containers 2 in el salvador water services are limited 48 of the drinking water supply was rated as intermittent in a 2014 report sponsored by the world bank 3 a 2016 crosssectional study in the san salvador metropolitan area found that all 110 respondents used water storage containers in the home despite 982 of households surveyed having piped water 964 of all respondents indicated that continued use of water storage containers was due to inconsistent water supply 4 to date the primary measure to prevent arbovirus outbreaks is the reduction of adult mosquito vector densities this reduction may be even more critical in the case of an emerging arbovirus among a fully susceptible population there is evidence to suggest that water storage containers become persistent sources of ae aegypti adults maintaining production of ae aegypti pupae throughout the year because households use them yearround 5 in an entomological study of vector breeding in urban settings of five latin american countries large water storage containers in highly dengueendemic areas of colombia and ecuador were found to produce most of the ae aegypti mosquitoes and their infrequent cleaning was identified as a key determinant of mosquito propagation 6 for these reasons water storage containers are critical sites for mosquito source reduction interventions to be effective as a mosquito control measure cleaning must eliminate the mosquito eggs and larvae and be feasible for those doing the cleaning unlike other mosquitoes such as culex quinquefasciatus that lay eggs on the water surface ae aegypti lay eggs on the interior walls of waterfilled storage containersjust above the water line 7 it therefore follows that general house cleaning and elimination of water puddles will not control this mosquito cleaning of water storage containers may not eliminate all larvae and the cleaning techniques commonly used may lack the specificity needed to effectively remove ae aegypti eggs 8 this because a householders objective may be to eliminate visible dirt such as grime or algae rather than to target and destroy ae aegypti eggs on the walls of those containers as a result householders may become frustrated at the persistent presence of mosquito larvae even after cleaning the container and come to doubt the effectiveness of the cleaning practice to meet these challenges a study conducted in el progreso honduras by sherman et al 8 developed the untadita an ovicidal procedure based on existing practices and locally available products it involved dabbing a mixture of undiluted chlorine bleach and detergent at a ratio of 51 directly onto the walls of emptied water storage containers followed by a 10min waiting time for the ovicidal effect to occur the method should be performed weekly 8 to break the ae aegypti life cycle which requires seven to 14 days to emerge as an adult after an egg hatches 7 an evaluation of the untadita in a subsequent controlled trial in honduras was shown to markedly prevent the development of adult ae aegypti mosquitoes 9 after inception of the untadita in honduras other variations of the method have been developed in the dominican republic eg a simplified approach removed the detergent to reduce the number of rinses required and used bleach only while increasing the wait time to 15 min 1011 it is important to note that bleach should be dabbed undiluted diluting bleach with water pouring bleach into the water at the bottom of a container or pouring bleach drops directly into the water to purify it delivers the bleach at too low a concentration to destroy eggs or kill mosquito larvae 8 el salvador has a long history of dengue epidemics with the reported number of cases among the highest in the americas between 1980 and 2007 132881000 dengue fever cases and 2073000 dengue hemorrhagic fever cases were reported 12 in 2002 as part of the response to the repeated dengue outbreaks the ministry of public health and social assistance of el salvador and the united states agency for international development funded change project2 had recommended that the untadita become an integral part of el salvadors national dengue prevention strategy 13 based on locally conducted formative research 14 any one of three modalities was recommended according to the situation in each household a dabbing walls with undiluted detergent and bleach followed by scrubbing of the completely emptied water container b dabbing bleach alone on walls of the completely emptied water container and c dabbing bleach alone just above the water level without emptying the container as a temporary measure to use during periods of extreme water scarcity all three modalities required waiting 15 min after dabbing to give the bleach enough time for the ovicidal effect to occur weekly application of any of the three modalities was recommended to break the ae aegypti life cycle rather than wait longer for a completely emptied container 13 since 2002 either the untadita or the washing of containers with bleach had been included in the countrys various dengue prevention strategy documents 1516 since 2015 the approach has also been promoted for chikungunya and zika prevention efforts 1718 when zika transmission emerged in south and central america in 20152016 national governments and international agencies undertook immediate action to halt its transmission efforts primarily involved communication activities through mass media and community mobilization to promote uptake of preventive behaviors by individuals families and communities a suite of preventive behaviors with a high potential to prevent zika and negative pregnancy outcomes includes behaviors for preventing mosquito bites sexual transmission of zika and reducing ae aegypti larval habitats around the home and community 19 in 201516 el salvador experienced multiple cases of zika with 11413 suspected cases recorded through the end of 2016 20 fiftyone of these cases were confirmed including four with zikaassociated congenital syndrome another 376 suspected cases were reported through january 4 2018 21 due to the limitations in confirmation testing and the mild symptoms of the infection the actual number of zika infections may have been higher during this period those came shortly after an unprecedented chikungunya outbreak with over 135 000 suspected cases in 2014 22 and another 64000 suspected cases in 2015 23 while knowledge attitudes and practice surveys have been carried out in el salvador 24 25 26 27 28 only one such survey provides information on potential motivators and barriers to zika prevention in which perceived effectiveness and community norms may have been important motivators while difficulty of practice a barrier 28 qualitative information for a more indepth understanding of motivators and barriers to zika prevention behaviors in the country is lacking specifically how people perceive and implement the protection and cleaning of water storage containers in their daily lives including how mosquito eggs may be removed from water storage containers in urban and rural areas of el salvador is not well understood the present qualitative study aimed to provide rich formative data on perceptions of several zika prevention behaviors including the untadita technique we sought insights into five behavioral determinants 1 community norms of zika prevention 2 perspectives on relative effectiveness of different behaviors 3 feasibility to practice the behaviors including mens social support of zika prevention in the context of urban and rural el salvador 4 peoples skills for effective mosquito egg removal and 5 peoples intentions to perform the recommendations in the community context while we conducted a comprehensive qualitative exploration of multiple zika prevention behaviors in this paper we focus on behaviors related to cleaning water storage containers including the untadita and the factors that influence these behaviors methods behavioral psychology researchers reviewing theories of health behavior change have reached a consensus that positive social pressure significant anticipated benefits outweighing the disadvantages lack of environmental constraints the possession of necessary skills and a strong positive intention to perform the behavior are among the key factors influencing behavior and behavior change 29 identifying and addressing these determinants might maximize the effectiveness of communitybased ae aegypti control activities for zika and other arbovirus prevention we studied the freely elicited actions that people in the community took to prevent zika as a proxy for positive social pressure or norms the relative effectiveness of zika prevention recommendations as a proxy for their anticipated benefits their relative feasibility as well as seasonality and mens social support of zika prevention recommendations as proxies for their environmental constraints and whether people had the skills and intentions to perform the recommendations in the community context we employed a qualitative study design consisting of focus groups and indepth interviews in an urban and rural context of varying topography in el salvador in case there were differences in practices or their determinants focus group activities included threepile ratings a simulation exercise and individual voting idis included further probing on the studys themes the participants came from two locations ilobasco cabañas dept and guaymango ahuachapán dept ilobasco is a larger urban municipality located 48 km northeast of san salvador at a medium altitude of 750 m and guaymango is a smaller rural agricultural community located 96 km west of san salvador at a lower altitude of 337 m near the guatemalan border hitherto referred to as the urban and rural site respectively both of these locations had reported zika cases according to the ministry of health as well as usaids zika implementing partners conducting behavior change interventions such as community educational meetings talks in schools and antenatal care sessions community cleanup campaigns and home counseling visits our research team selected these communities with the support of save the children and usaidel salvador save the children staff with the support of the respective local health center selected and invited participants through convenience sampling from three target populations pregnant women 18 to 30 years of age nonpregnant women aged 18 to 30 with a stable partner and zero to one child or an expressed desire to have another child and men over 18 years of age with a pregnant partner at the time of the study all interviewers and facilitators had extensive training and experience in qualitative data collection were native or bilingual spanish speakers and were familiar with the central american context focus group and idi field guides are provided as additional files 1 2 3 4 before beginning the focus groups and idis we asked each participant individually to mention all the actions that people in their community took to prevent zika recording each freely elicited action on a form and probing to ensure complete elicitations and the researchers clear understanding of the actions described by the participant focus groups began with introductions and a series of group activities first participants engaged in a discussion of 18 images depicting zikarelated behaviors the behaviors shown in the images represented one of three categories personal protection vector control and facilitating behavioral recommendations 19 along with a few popular but ineffective vector control actions all images are represented in fig 1 the moderator introduced the images not as de facto methods to prevent zika but as a series of actions to discuss in the focus group in the context of zika prevention after discussing the behaviors participants assigned them to three piles of low medium or high perceived effectiveness among their community members next participants performed a second rating in which they assigned the same images to groupings of low medium or high feasibility to practice the behavior in the community context participants came to a consensus on the rating of each image and explained their reasons for disagreement for each rating after the rating activities we asked participants to individually write down or draw the materials and steps used in the community to clean the rectangular cement washbasin known in el salvador as a pila we invited a volunteer to simulate these steps using a large oblong plastic container in lieu of a pila upon request the research team provided cleaning supplies such as water detergent bleach brooms and brushes the simulation was followed by a discussion among all participants about how their own recorded procedures complemented or deviated from those demonstrated before the focus group concluded each participant voted for the three behaviors that they felt people in their community would be most willing to implement to prevent zika we conducted idis with expectant fathers who had not participated in the focus groups we utilized projective techniques with four of the zika behavioral recommendation images used during the focus groups to further explore the perceptions of these behaviors among men in their community the images selected represented the main types of zika preventive actions two of the images were emptying water from containers around the yard and cleaning water storage containers because women were overrepresented in the focus groups the idis with the men provided the opportunity to further explore gender roles and gain a deeper understanding of zika prevention behaviors from the perspective of expectant fathers from april 16 to 24 2018 we conducted 11 focus groups with 71 participants and 12 idis we conducted 6 idis and 6 focus groups per study site 2 focus groups with each target population with the exception of the rural site where we conducted 1 focus group only with the men the focus groups and idis were recorded on digital audio and then transcribed into text for thematic coding using qualitative analysis software the washbasin cleaning simulations were recorded on video and then separated into individual static images for each step using a crossplatform multimedia player the cleaning materials and steps written down by individual participants were typed ordered and sorted in spreadsheet software the individually elicited zika prevention actions were similarly typed and ordered based on the frequency with which they were mentioned the ratings chosen by each focus group on the feasibility and effectiveness of each behavior were averaged among all focus groups the final voting was consolidated among all focus group participants this quantification of qualitative data complemented the interpretation of the textual data on the determinants of zikaprevention actions however like with any qualitative data no populationlevel inferences are possible based on the quantitative measures we developed a codebook to guide thematic coding according to the zikarelated behavior and the determinants of its effectiveness or feasibility the codebook is provided in additional files 5 6 respective quotes were sorted by study population and zika prevention method and various sets were printed we held a fiveday data analysis workshop from june 11 to 15 2018 to analyze the printed quotes as a team including team members directly involved in the data collection as well as representatives of two partners working on the zika response in el salvador the united nations childrens fund and medical care development international workshop members worked in pairs reading all the coded text and documenting key findings regarding determinants of the prevention behaviors and selecting key quotes for each behavior and study population pairs then shared their analyses with the larger group for discussion and identified trends across the data after the workshop we used the written and photographic data generated by the washbasin cleaning simulations and ordered in excel to identify patterns in the various steps of cleaning and materials utilized we shared preliminary findings in a meeting with usaidimplementing partners in the zika response on june 19 2018 in san salvador to obtain feedback on their interpretation and discuss the implications for program design results sociodemographic characteristics of study participants the focus groups each with three to nine participants together with the 12 idis involved a total of 83 study participants participants were of mestizo descent most of the women were homemakers male partners of pregnant women included six agricultural workers three food vendors three students the rest were artisans a video and graphic designer and an owner of an internet café there were no substantial differences in participants characteristics between the two study sites table 1 summarizes participants demographics the range of elicited zika prevention behaviors in the community during the individual free elicitation exercise participants mentioned over 200 actions that people in their community took to avoid zika on average participants mentioned five preventive actions there were no substantial differences between the two study sites nor between men and women participants except for condom use only mentioned by the men we consolidated similar wordings of the same action into a single common wording table 2 shows the first 34 of a total of 43 actions ordered by descending frequency actions related to cleaning were among the most frequently mentioned cleaning of water storage containers was the most mentioned practice when grouping cleaning modalities cleaning without bleach cleaning with bleach and the untadita method moreover the frequency of mentions of bleach utilization either explicitly or as part of the untadita method indicated the importance of cleaning water storage containers and the importance of bleach in the container cleaning process strong community norms around this practice and the idea that bleach might be affecting ae aegypti larvae or eggs in some manner after water storage container cleaning the most commonly mentioned prevention action was the cleanup of containers that accumulate or hold water the third most commonly mentioned action was general cleaning and tidying the house in their unprompted explanations of general cleaning and tidying practices many of the latter participants associated ae aegypti with dark and dirty places where adult mosquitoes and other pests were found including in vegetation around the house some felt that if they lived in a clean house they no longer needed to adopt other zika prevention behaviors such as use of condoms during pregnancy and skin repellent use furthermore they recommended bleach for mopping the floor or pouring into water storage containers with an understanding that its odor would repel adult mosquitoes another key finding from this exercise was that participants mentioned less effective prevention methods more frequently than more effective methods the use of a mosquito net which is less effective for a largely daybiting mosquito was mentioned more frequently than water storage container cleaning methods similarly general hygiene water purification and the elimination of puddles were mentioned more frequently than use of mosquito repellent on the skin and use of condoms perceived effectiveness and feasibility of cleaning water storage containers figure 1 highlights the averaged ratings for effectiveness and feasibility of the 18 studied behaviors for preventing zika as a result of dialogue and consensus among the focus group participants there were no substantial differences between the two study sites nor between men and women participants except for condom use which women generally thought it was very difficult to practice during pregnancy while some men found it acceptable in light of zika measures used to clean water storage containers were rated as both highly effective and highly feasible participants explained that households already held existing practices of cleaning their water storage containers as part of general cleanliness participants perceived that communities readily had the necessary toolssuch as bleach detergent brushes and spongesto perform the action beyond the effort and time to clean the containers the perceived cost was minimal only some mentioned that if people did not have money for detergent or bleach they would have to clean with water only most participants mentioned that the use of bleach was commonplace among households but at the same time they revealed their misunderstandings regarding its strength we use bleach to kill larvae bacteria things but only in water we dont use to drink it is important to note that communities used two different words in spanish for bleach cloro and lejía the meaning of these two words varied among participants but a general difference that emerged was that cloro was a less concentrated bleach used solely for the purification of drinking water while lejía was a more concentrated form of bleach used for cleaning laundry floors grime from plates and washbasins many participants noted that lejía was readily available in local stores while cloro was generally dispensed by local health centers despite this perceived difference in the two products a review by the study team of bleach brands in local stores indicated that many commercial products contained both words on their labels turn containers that accumulate water overface down 9 clean or purify the water 7 make smoke to drive away mosquitoes 7 change the water in containers 6 eliminate water puddles 5 use a condom 5 have promoters inspect the home 4 use fish in the washbasin 4 fill tires with dirt 4 use repellent on the skin 4 recycle things that could become breeding places 3 maintain balance in the body 3 go in for a prenatal visit 3 use insecticide spray 3 practice abstinence 2 use contraceptives to prevent pregnancy during zika 2 receive vaccinations from the health promoters 1 use clothing with long sleeves during pregnancy 1 cover toilets 1 a ten participants from idis and 69 from focus groups a majority of participants agreed that cleaning the washbasin was a highly effective measure for reducing the risk from mosquitoes as long as everyone in the neighborhood did it if we dont all do the same thing in our homes this not only affects us but everyone else in the community my neighbor might clean his washbasin but if i dont do it and i expect him to do it in a way i am a threat to the health of my neighbors so that is why it is importantman rural site 19enpm1gusm many participants indicated that cleaning the washbasin became even more critical during prior dengue epidemics in the country some even mentioned that they learned to clean the pila at school it was during these epidemics that the untadita method was introduced according to participants memory however many participants erroneously thought that the untadita was effective for removing the larvae of the mosquito rather than removing the eggs the cleaning method varied depending on the amount of dirt and mildew in the washbasin the size of the washbasin and local custom for that reason the reported time required to effectively clean a washbasin varied greatly between 10 min to 2 h water storage containers other than the cement washbasin such as barrels and drums were less common in participants households when families did have them these were commonly located in the bathroom due to the more frequent use of the water stored in these containers participants stated that they were cleaned more frequently but not as thoroughly for example i wash the one in the bathroom the same way as a washbasin but i wash that one more often because the water runs out faster i dont wash it with bleach but just with the broom and thats it because the water is used up so fast that its not necessary pregnant woman urban site 16gfme1ilblm the effect of seasonality on frequency of water storage container cleaning because cleaning requires much water this behavior was performed less frequently during the salvadoran summer between november and april when water is less available during this dry period the frequency of cleaning the washbasin varied between every three to 15 days according to how quickly the water was consumed and when the local water distribution day occurred participants of either gender and study site mentioned that fig 1 perceived effectiveness and feasibility of 18 candidate zika prevention behaviors rated among 11 focus groups vertical and horizontal coordinates represent the averaged rating for each behavior during their winter when rain is more frequent it was common for cleaning to take place twice a week or when the water arrived at their home if water arrived too soon or offschedule it was easy to miss the opportunity to clean the washbasin participants also reported that the water that arrived at households during the rainy season was cloudier washbasins barrels and drums were cleaned more frequently due to the perception that cloudy water was more prone to produce a green slime as well as contain more larvae brought in directly by the rainwater gender roles and water storage container cleaning both women and men participants in either study site discussed how cleaning the washbasin and the water barrels was considered to be the responsibility of the homemaker who typically was a woman one man from the rural site said that in his community mens prevailing mentality was that the broom is for the women and that a man caught doing a womans chores would be ridiculed or bullied pregnant women in a focus group said participant 1 we are the ones who do the housework so there are men who say ah i am not a woman participant 2 that is why i obtained you they say … laughs by all pregnant women urban site 17gfme1ibmr3 although some men said that they did clean the washbasins many women reported that men do not do the job well because they do it too quickly all participants said that it was common for women to clean washbasins until late in their pregnancy whereupon the responsibility shifted to an adolescent a motherinlaw or in rare cases their male partner some male participants felt that the use of bleach could be dangerous because it could make the washbasin floor slippery for a pregnant woman a few female participants stated that the physical position pregnant women take while cleaning a washbasin might hurt the babys spinal cord and a man from the urban site said that pregnant women should not be exposed to bleach because breathing its fumes could damage the babys lungs during the idis male partners of pregnant women described gender roles in some detail some said that the men could not clean the water storage containers because they worked long hours outside the home and came home tired it is worse when ones wife is pregnant because the man feels that more responsibilities are coming and strives to work even more therefore he has even less free time this causes the pregnant wifes housework to also increase because during the time that the husband is not at home the housework falls on her man rural site 19enpm1guba other men participants said that conserving water was extremely important and container cleaning required a lot of water thus the ideal moment for this task was when the water arrived at their home only at that moment could the household afford to empty the container and use running water to clean it rather than spend its stored water on cleaning but men tended to not be at home at that time so women were expected to do that task however several men said that they help with cleaning the water storage containers when they are at home resting from work during their partners pregnancy and beyond because as men they always worry for the health of both the mother and the baby and this is the best way to eliminate the mosquito if you just drain the water and do not scrub with a brush they will not die mind you men who stated that they cleaned the washbasin attributed their behavior to their upbringing since a young age cleaning became a custom for them despite working long hours outside the home because their families did not associate the action with the shame related to traditional gender roles however the majority of men did not report such experiences during childhood many men and women acknowledged that most men are brought up with an exaggerated sense of manliness or machismo as the norm finally male participants mentioned that unlike organized community cleanups in which men publicly took collective action with their peers washbasin cleaning occurred privately in the home this did not generate the same enthusiasm because it was perceived as a part of regular household chores carried out by the women assessing skills to reduce ae aegypti eggs visàvis the process of cleaning the washbasin the flowchart in fig 2 shows the washbasin cleaning modalities as described by the participants in writing and performed in the simulations there were no substantial differences in the findings between the two study sites nor between men and women participants who provided comparable detail community members used a range of approaches to clean their washbasins nine participants reported a prescrub without bleach or detergent if the washbasin was very dirty and all reported use of bleach before the washbasin was scrubbed however over half of the participants stated that bleach was diluted in the water at the bottom of the washbasin to dissolve a green slime that often formed there and on the walls the purpose of wall scrubbing was to remove the green slime and dislodge the mosquito eggs the waterbleach dilution at the bottom was believed to kill any dislodged eggs that fell into it as well as any larvae that were in the water before the scrubbing process started twentyeight participants referred to dabbing undiluted bleach with or without detergent as recommended by the untadita method men appeared more aware of the untadita and indicated they learned the technique through mass media a few years prior however only seven of the 28 participants acknowledged the crucial step of allowing the bleach dab to stand mentioning five to 10 min or long enough for the bleach to dry the rest did not report giving the bleach dab sufficient time to kill any eggs four participants reported waiting a variable amount of time after scrubbing with the intention of allowing any dislodged eggs or larvae found in the water to be killed by the bleach dilution fifteen participants dabbed or poured undiluted bleach on to the walls after first having used bleach to scrub the walls in a prior step this second application of bleach was intended to kill mosquito eggs or larvae purify the water upon falling in the washbasin and leverage the strong odor of bleach to repel mosquitoes a little bit of bleach like this poured from a small packet along the walls when the washbasin is empty so the mosquito doesnt leave its eggs pregnant woman urban site 17gfme1ibmr3 finally 11 participants completed the washbasin cleaning process by adding a few drops of bleach to the water after filling the washbasin in order to keep their water protected community intentions to practice the zika prevention behaviors there were no substantial differences between the two study sites nor between men and women participants in voting on the top three actions which their communities would be most willing to practice shown in table 3 the removal of containers from the yard and picking up garbage around the house received more votes than the cleaning of the washbasin and applying bleach to the walls of tanksbarrels cleaning water storage containers such as barrels also received a higher number of votes because that type of cleaning was considered quicker and less burdensome this voting indicates that positive intentions around general cleaning were stronger among study participants than the specific ovicidal cleaning to control ae aegypti discussion we explored key determinants of a series of preventive behaviors for zika and by extension other aedestransmissible viruses such as dengue and chikungunya in an urban and a rural community in el salvador our study fig 2 washbasin cleaning process across 11 focus groups data available from 61 of 71 focus group participants four participants could not write and six others left early sample size was adequate to achieve thematic saturation 30 and therefore attain information power commensurate with our study aim 31 our multimethod study design enabled extensive triangulation of the data we specifically addressed the determinants for water container cleaning because of its central role in controlling ae aegypti populations in the home and the significant focus on this preventive action by communitybased arbovirus control programs cleaningrelated tasks such as discarding of disposable containers around the home keeping the house tidy covering and cleaning water storage containers and using bleach in the process scored high on many explored determinants such as positive norms perceived effectiveness feasibility and positive intentions by both women and men as fundamental to ones wellbeing at the same time we found inadequate skills when it came to effective ae aegypti control important environmental constraints such as seasonal water scarcity limiting the frequency of cleaning containers and genderlimiting social support for frequent and thorough cleaning of the containers within the household the association of adult ae aegypti habitats with those of other pests found in dirty and dark places and with overgrown vegetation near the house indicates that communities may be paying more attention to the adult stage of ae aegypti thus misdirecting their cleaning efforts away from destroying this mosquitos larval habitats the finding that living in a clean house renders other zika prevention behaviors such as use of condoms during pregnancy and skin repellent use unnecessary is of concern as is the proposition to mop the floor with bleach or pour bleach into water storage containers thinking that its odor would repel adult mosquitoes both of these interpretations are at worst ineffective and at best inadequate measures for ae aegypti control participants revealed the communitys extensive application of household bleach throughout the simulation of water storage container cleaning bleach was perceived as easily accessible for most community members and was regarded as highly effective by households some participants were aware of the term and practice of the untadita as a method for controlling ae aegypti pointing to a degree of programming continuity since the 2002 dengue prevention campaigns despite such attentiveness we documented a misdirected overuse of bleach during the cleaning process and inadequate skills to use bleach as an ovicide to start bleach was weakened by being mixed in water instructions were often interpreted as pouring a certain amount of bleach directly into the water in order to destroy the larvae or the eggs that fell in the water after being dislodged through scrubbing however bleach dilutions are ineffective against either 8 furthermore bleach was often poured onto the walls straight from the bag thus allowed to run straight down to the bottom or added directly to the water after the container was refilled after cleaning the latter was in accordance with guidance for water treatment issued by diarrheal disease prevention programs however for effective ae aegypti control bleach has to instead be purposefully dabbed on the area above the waterline where ae aegypti eggs are found many participants reported or demonstrated a second application of bleach on the walls and the water following scrubbing this was an unnecessary repetition instead of applying the bleach correctly the first time lastly few participants reported enough time for the bleach to act on the eggs these results indicate that communities could spend a shorter amount of time cleaning with less bleach and be more effective both in cleaning containers and in controlling ae aegypti by destroying mosquito eggs furthermore given that cleaning washbasins took place every two to 3 days in most cases communities were cleaning their water storage containers with more effort than required the cleaning behaviors that participants described also reflected information heard during previous waterborne illness and dengue prevention campaigns campaigns including those during the zika outbreak emphasized that washbasins should be cleaned which can be done by a limpieza or a lavado meaning a cleaning or a washing respectively this was in agreement with findings from another qualitative study conducted in guatemala 32 as a result participants used these terms interchangeably to describe the process of sanitizing their water containers and not specifically for ae aegypti control this lack of specificity in the terms used by zika prevention campaigns might have led community members to fill knowledge gaps with their prior understandings and as a result dilute the effectiveness of cleaning water storage containers for mosquito control potentially creating a false sense of security regarding zika prevention lastly our study showed that women bear the primary responsibility for water storage container cleaning in the household consistent with their overall power and authority in the domestic domain 33 their responsibility for cleaning of these containers was reinforced by three factors scarcity and intermittent supply of water forcing households to limit cleaning only when water arrives at the household 11 which usually occurs when men are out working gender norms that assign cleaning of washbasins to women 3435 and womens assessment of mens cleaning performance as suboptimal however we discovered that as a woman approaches late pregnancy other family members including male partners may assume the role of cleaning despite mens long working hours outside the home many men reported a high willingness to provide substantial social support with cleaning during pregnancy as protectors of the family this was in agreement with two other qualitative studies conducted in guatemala and the dominican republic 3234 and it adds to the role that men can play beyond involvement in family planning or preventing the sexual transmission of zika during an outbreak 36 our study has two limitations first it only represented the opinions of participants from two departments in el salvador an urban area and a rural area due to financial time and security constraints we did not include participants from additional departments however both sites were impacted by the zika outbreak like other urban and rural salvadoran communities the second limitation was that the study investigated the perceptions and key factors regarding community actions and not the actual behaviors of the participants however the simulations and projective techniques used in the study were close proxies that enabled participants to openly share their perspectives without disclosing their personal conduct our findings translate to several programmatic recommendations households need clarity regarding the specificity of methods to reduce ae aegypti infestation cleaning out places where adult mosquitoes often hide such as dark or dirty corners in the home or in the underbrush outside would not eliminate mosquitoes at their source the focus should be on the eggs and larvae instead 37 instead of simply informing communities to clean their water storage containers interventions should emphasize and actually demonstrate the places where ae aegypti lays its eggs on the vertical walls of water containers not in the water 32 and should recommend dabbing saturating with bleach or spreading undiluted bleach onto those walls instead of using scattering or pouring coordination between public and private sectors is required to achieve the clarity needed implementing organizations should leverage the existing norm of cleaning because it is already a habit among most households however we recommend that stakeholders reframe the untadita to distinguish it from existing understandings of general hygiene and water purification one approach could be to brand the untadita as a treatment specifically to remove the ae aegypti eggs not the larvae to apply after people clean their washbasins 13 this tactic would separate the untadita from general cleaning while still allowing it to be linked to the current habit of washbasin cleaning this would be similar to a behavioral economics approach such as piggybacking 38 for example success has been shown in inducing individuals to floss more when it is coupled with teeth brushing 39 furthermore health communication activities should emphasize that the ae aegypti mosquito differs from other pests that are considered dirty and a result of poor hygiene interventions should make it clear that while actions of general cleanliness and hygiene are excellent for overall health they are ineffective for preventing arbovirusrelated illnesses companies that supply bleach to consumers are important actors within the private sector and could play a larger role in ae aegypti control efforts although not reported in the results our team took photos of common packaging of local bleach brands found in supermarkets and convenience stores in el salvador a minority of the national brands made references to mosquito prevention with little or no explanation only one label out of five noted that bleach could be used for the untadita method however it did not provide instructions on how to correctly perform the technique such minimal information may lead consumers to make misguided assumptions about how bleach works to prevent mosquito infestation furthermore one large multinational bleach supplier that operated in el salvador posted recommendations on their corporate responsibility web page that differ greatly from the untadita the data suggests that supplemental cleaning with bleach or treating water in containers that cant be emptied may reduce the attractiveness of these containers as breeding sites this supplemental step is now included in our public education materials harmonizing the messaging on bleach packaging with respected health authorities such as ministries of health could serve as an excellent touchpoint to reinforce the proper use of bleach for reducing ae aegypti at the household level at the very least efforts to harmonize such messaging would help reduce the inconsistencies that we observed about bleach use for zika prevention in this study the infrequent cleaning of water storage containers during the dry season when the water supply is extremely scarce in some communities represents another unresolved problem partial application of the untadita in the container above the water level without emptying the water out has been considered as a temporary solution in past campaigns 13 this option should be reexamined by health authorities and implementing organizations there is potential to sustain the reported high feasibility of such behaviors in households even during pregnancy families would do well to discuss how washbasins will be effectively and consistently cleaned to remove ae aegypti eggs at least throughout pregnancy implementing organizations should encourage such discussions with men detection of pregnancy especially among couples expecting a first child may be enough of a disruption of the status quo for a new behavior to be adopted 40 finally our data indicate that health communication activities should more effectively draw a distinction between preventive behaviors targeting ae aegypti versus the anopheline vectors of malaria the use of mosquito nets was rated high in norms effectiveness and feasibility as well as community intentions for future practice for the prevention of zika there is a role for nets to play when people nap during the daytime especially pregnant women and to prevent aedes mosquitoes from becoming infected with an arbovirus from viremic individuals while lying in bed and transmitting it to the virusfree in addition there is some evidence to suggest that nets lower the risk of dengue or the number of dengueinfected mosquitoes or the aedes infestation indices in some instances 41 42 43 44 but not in others 4345 that said the protective role of nets is much larger and easier to measure against anopheles than aedes because anopheles bite primarily at night in contrast the majority of ae aegypti biting activity is during the day 7 communities likely do not distinguish between the behavior of these two vectors and concurrent malaria prevention campaigns correctly promote the use of mosquito nets indeed el salvador is the first central american country on the way to achieving official malariafree certification by the world health organization 46 as a result communities may have developed a false sense of security by focusing their efforts on this less effective prevention method when it comes to arboviruses conclusions behavior change programs for the prevention of zika and other arboviruses need to improve community members mosquito egg destruction skills rather than perpetuate the promotion of nonspecific cleaning in and around the home as an effective measure egg elimination must be clearly identified as the objective of water storage container maintenance and programs should highlight the effective techniques to achieve this goal in addition programs must build the skills of family members who support pregnant women to maintain the frequency of effective egg destruction in all water storage containers of the home our findings can help zika and other arbovirus disease prevention programs sharpen their behavioral focus and improve their health communication efforts in el salvador and similar settings in the lac region supplementary information supplementary information accompanies this paper at 1186s12889020093705 authors contributions el and sm conceived of the study design participated in the collection analysis and interpretation of the data and were major contributors in writing the manuscript mr led the data collection and participated in the collection analysis and interpretation of the data er drafted parts of the manuscript tg and abs conceived of the study design gch conceived of the study design participated in the analysis and interpretation of the data and was a major contributor in writing the manuscript all authors read and approved the final manuscript funding the study was made possible by the support of the american people through the united states agency for international development under the breakthrough action cooperative agreements aidoaaa1700017 breakthrough action is based at the johns hopkins center for communication programs beyond advising on the selection of study sites the funder did not have any role in the design of the study the collection analysis and interpretation of the data nor in writing the manuscript the contents of this article are the sole responsibility of the authors and do not necessarily reflect the views of breakthrough action usaid the united states government or johns hopkins university competing interests the authors declare that they have no competing interests

background in el salvador aedes aegypti mosquitoes transmitting zika and other arboviruses use water storage containers as important oviposition sites promotion of water storage container cleaning is a key element of prevention programs we explored community perceptions surrounding cleaning practices among pregnant women male partners of pregnant women and women likely to become pregnant methods researchers conducted 11 focus groups and 12 indepth interviews which included individual elicitations of zika prevention measures practiced in the community focus group participants rated 18 images depicting zikarelated behaviors according to effectiveness and feasibility in the community context discussed influencing determinants voted on community intentions to perform prevention behaviors and performed washbasin cleaning simulations indepth interviews with male partners of pregnant women used projective techniques with images to explore their perceptions on a subset of zika prevention behaviors results general cleaning of the home to ensure a healthy environment was a strong community norm in this context participants gave water storage container cleaning a high rating for both its effectiveness and feasibility participants were convinced that they cleaned their water storage containers effectively against zika but their actual skills were inadequate to destroy aedes aegypti eggs a further constraint was the schedule of water availability even during pregnancy male partners rarely cleaned water storage containers because water became available in homes when they were at work furthermore prevailing gender norms did not foster male participation in domestic cleaning activities despite these factors many men were willing to provide substantial support with cleaning when their partners were pregnant in order to protect their family

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introduction despite the increasing prevalence of dental fluorosis in both developed 1 and developing countries 2 the association between dental fluorosis and fluoride intake by young children is a controversial subject with no strong evidence of the association 3 4 5 among the biological factors f intake from drinking water and dentifrices are important risk factors for f intake 6 and dental fluorosis 78 socioeconomic factors have also been suggested as potential risk factors for dental fluorosis 910 and f intake level by children 11 it has been reported that children with a higher socioeconomic status use a greater amount of dentifrice when tooth brushing and spend more time tooth brushing 12 moreover the brand of the dentifrice seems to be associated with the amount of dentifrice placed on the tooth brush amount of f ingested and time spent brushing 12 however the study 12 only compared ses to brushing habits but there are no data on whether socioeconomic factors influence the choice of a particular type of dentifrice or whether ses is associated with greater f intake by children from tooth brushing with fluoridated dentifrices the aim of the present paper was to determine whether socioeconomic factors and tooth brushing habits are associated with the purchase of a specific type of dentifrice and daily f intake by tooth brushing with a fluoridated dentifrice experimental section ethical considerations this crosssectional study received approval from the human research ethics committee of federal university of minas gerais under protocol number 27807 subjects the sample was selected by convenience and comprised all children enrolled at eight kindergartens in the city of montes claros brazil four private and four public kindergartens were selected in order to achieve a balance with regard to socioeconomic status the kindergartens were randomly drawn from a list compiled by the municipal department of education of montes claros at the time of data collection montes claros had 84 kindergartens all children enrolled at these kindergartens within the age range at risk for the development of dental fluorosis and whose parents agreed to participate were included eleven children were excluded for the following reasons nine children used nonfluoridated dentifrice and the parents of two children did not complete the questionnaire the final sample was comprised of 197 children aged from nine to 48 months pilot study before conducting the main study a pilot study was conducted with 10 children from a kindergarten not included in the main sample to test the collection method the parents and the children accepted the protocol well and the parents understood the questionnaire questionnaire parents were previously contacted to attend a meeting at the kindergarten to which they were to bring the tooth brush and dentifrice the child used at home the parents were informed as to the objectives of study those who agreed to participate signed a statement of informed consent and were instructed to respond to a structured questionnaire on their childrens current tooth brushing habits the questionnaire was selfadministered and was administered at the kindergarten by a single investigator with the aid of two dental students the parents were told that there were no wrong or right answers and they should consider their childs current oral habits the questionnaire was structured as follows questions on the childs current tooth brushing habits if the child used the same dentifrice as their parents or not frequency of tooth brushing age at which the child began tooth brushing and who applied the paste to the tooth brush if the child used the same dentifrice as the parents the product was considered a family dentifrice if the child used a different dentifrice from that of the parents the implication was that the parents bought a special dentifrice for the child or for their several children a childrens dentifrice this information was reported by parents and was checked with the brand of dentifrice that the parents took to the kindergarten questions related to the sociodemographic characteristics gender of the child type of kindergarten socioeconomic status of the family and parental educational level the ses was evaluated by the abepe 13 which is a commonly used questionnaire in brazil for classifying ses and is based on items possessed by the family such as the number of radios televisions household appliances cars etc ses was classified as high medium or low parents provided information on the years of schooling that the head of the family possessed this variable was dichotomised as 0 to 10 years of schooling and more than 10 years of schooling fluoride intake from tooth brushing with fluoridated dentifrices on the same day the parents and their children were asked to perform tooth brushing one at a time each parentchild pair was led to the bathroom of the kindergarten and instructed to perform tooth brushing with the tooth brush and dentifrice brought from home and to tooth brush in the same way that they usually do at home the parent andor child were free to disperse the dentifrice on the tooth brush in their usual manner the weight of the paste was obtained by weighing the tooth brush on a digital scale before and after applying the dentifrice the tooth brushing procedure was observed by the investigator that recorded notes on a structured form the child performed the tooth brushing in hisher normal way with or without the aid of hisher caregiver no formal instructions were given regarding brushing technique if the child requested to rinse hisher mouth the investigator provided deionised water for rinsing and a plastic cup for collecting the expectorate the deionised water was prepared at the biochemistry laboratory of the sanitation company of the state of minas gerais the investigator was aided by two dental students who maintained sufficient distance while observing so as not to disturb the normal routine of the procedure when the child rinsed herhis mouth andor spat the suspension was collected in a plastic cup some children rinsed and spat whereas others did not rinse and still others rinsed and swallowed the water distilled deionised water was used to wash the tooth brush vigorously and was also collected in the same plastic cup the suspension called the brushing residue was homogenised and the volume was measured from this material a 15ml sample was stored at 4 °c until the determination of the fluoride concentration habits directly observed by the investigator during the tooth brushing were noted on a structured form type of dentifrice type of tooth brush amount of paste placed on tooth brush whether the child spat the paste out rinsed the mouth and who brushed the childs teeth these directly observed variables were used in data analysis instead of data from the questionnaire in order to minimize information bias 14 after the tooth brushing session the children were weighed on a digital scale and the dentifrice was collected for subsequent lab analysis each child received a kit containing a childrens tooth brush and a fluoridated dentifrice to replace the one supplied by the parents the children parents and teachers had not been instructed regarding tooth brushing in order not to alter the habitual technique on a later date a meeting was held at the kindergarten to give formal instructions to the parents and teachers regarding recommended oral health care laboratorial analysis analysis was performed at the biochemistry laboratory of the piracicaba school of dentistry state university of campinas brazil the analyst was blinded to the type of dentifrice used by the children the difference principle was used for the determination of the amount of f ingested during brushing the amount of f recovered was subtracted from the amount initially used the daily dose of f to which the child was exposed was determined by multiplying the average amount of f ingested with the frequency of tooth brushing reported by parents on the questionnaire divided by the weight of the child the daily f dose was determined considering total soluble fluoride which is the biologically available fluoride that can be absorbed by the body the f concentration was determined in the brushing residues in duplicate total fluoride and tsf were determined totalling 1576 laboratorial analyses each brushing residue was mixed in the plastic cup from which 20 ml was extracted and 025 ml of the suspension duplicates were transferred to assay pipettes to determine tf the remaining suspension was centrifuged and duplicates of 025 ml of the supernatant were transferred to assay pipettes for the tsf analysis after hydrolysis of the ionisable fluoride in 025 ml hcl 2 m for 1 h at 45 °c the sample was neutralised with 05 ml naoh 1 m and buffered with 10 ml of tisab ii the analysis was carried out using a fluoride electrode coupled to an ion analyser previously calibrated with standards containing 0125 to 20 ppm f under the same conditions as the samples statistical analysis the data were analysed using the statistical package for social sciences descriptive analysis of the variables was carried out to characterise the sample daily f dose was tested for normality using the kolmogorovsmirnov test and levenes test for homogeneity of variance as the data had nonnormal distribution and variance not homogeneous the nonparametric mannwhitney test for two independent samples was used to compare means of daily f dose between children who used a childrens dentifrice and those that used a family dentifrice the percentage of f intake during tooth brushing was also compared between the childrens and family dentifrices three dependent variables were defined type of dentifrice amount of dentifrice applied during tooth brushing and daily f dose the type of dentifrice was defined as follows childrens dentifrices all with special flavour and special characteristics containing silica and sodium fluoride with tf declared on package varying from 500 to 1100 ppm f or dentifrices with calcium carbonate and sodium monofluorophosphate and tf declared on package varying from 800 to 1200 ppm f 15 dentifrices for adults all were mint flavoured with caco 3 and mfp tf declared on package varying from 1000 to 1500 ppm f or with silica and naf and tf declared on package varying from 1100 to 1450 ppm f 15 the amount of dentifrice was dichotomised as ½ the length of the bristles ½ the length of the bristles and entire length of the bristles the f dose was dichotomised as 005 mg of fkgday and ≥005 mg of fkgday this cutoff point was defined based on the lower threshold limit described by burt 16 the threshold limit varies between 005007 mg fkg bodyday 16 but only 30 children surpassed the limit of 007 mg fkg bodyday and 55 children ingested a dose ≤005 mg fkgday the limit of 005 mg fkgday was used because of the bigger sample below this limit univariate analyses were performed to test associations between the dependent and independent variables significance was set to 5 ses and parental educational level were also tested for significant associations with the other variables only the independent variables with p 025 were selected for the regression analysis model using the forward stepwise procedure two regression models were constructedone with the type of dentifrice and other with the daily f dose the variables that remained in the logistic regression model with p 005 were considered risk predictors the model was also tested for interactions between the predictor variables for those variables that had more than two categorical options dummy variables were created to be considered interaction α was set at 5 because the variable amount of dentifrice used during tooth brushing had more than two categorical options it was tested in multivariable logistic regression the variables that were entered in this model were those with p 025 results one hundred and four children usually used a childrens dentifrice at home and took this type of dentifrice to the kindergarten ninetythree children usually used a family dentifrice at home and took this type of dentifrice to the kindergarten table 1 displays the socioeconomic and tooth brushing variables according to type of dentifrice used at home the use of a childrens dentifrice was statistically associated with studying at a private kindergarten parents who had more than 10 years of study high and medium ses use of different dentifrices between child and family an adult brushing the childs teeth and use of a childrens tooth brush contrarily the use of family dentifrice was associated to studying in a public kindergarten parents who had 0 to 10 years of study low ses children that used the same dentifrice as the parents and use of tooth brush market for adults most parents reported a frequency of tooth brushing of twiceday followed by three or more timesday and one timeday no parent reported that their children brushed 1 timeday however there are five missing data due to incomplete answers to this item the total for this item was 192 answers considering the total of 197 65 children placed paste on ½ the length of the bristles 61 placed paste on ½ the length of the bristles and 71 placed pasted on the entire the length of the bristles dentifrice placed on the entire length of the bristles was significantly associated with low ses medium ses and parental education level of 0 to 10 years of schooling children who used a childrens dentifrice ingested an estimated daily f dose of 0046 and children who used a family dentifrice ingested a mean dose of 0040 this difference was not statistically significant although childrens dentifrices accounted with higher percentage of f intake during tooth brushing than family dentifrices this difference was nonsignificant the mean amount of paste used during tooth brushing did not differ between the use of a childrens and family dentifrice most children ingested a dose of 005 mg of fkgday and 55 children ingested a dose of ≥005 mg of fkgday the following variables were significantly associated with a higher f dose in univariate analysis parental educational level of less than 10 years of study higher frequency of tooth brushing and greater amount of dentifrice used during tooth brushing table 4 displays the results of the logistic regression analysis regarding predictive factors for the choice of a childrens dentifrice rather than a family dentifrice the following variables remained in model 1 and were statistically significant predictors of the use of a childrens dentifrice studying at a private kindergarten age that the child begun to tooth brush 2 years there was interaction between the variables use of the same dentifrice as parents and type of tooth brush used in model 2 there was interaction between the dummy variables frequency of tooth brushing twiceday and amount of dentifrice covering the entire length of bristles and frequency of tooth brushing 3 or more timesday and amount of dentifrice covering the entire length of bristles no variables were significantly associated with the amount of dentifrice used during tooth brushing in the multivariable logistic regression and the results were not represented in tables that means that this model did not find any significant predictor that might explain the use of higher amounts of dentifrice during tooth brushing 1 a variables entered on step 1 type of kindergarten parental educational level ses age that the child begun to tooth brush who tooth brushes the childs teeth the child rinsed during brushing child uses the same dentifrice as the parents type of tooth brush used type of kindergarten child uses the same dentifrice as the parents type of kindergarten parental educational level parental educational level child uses the same dentifrice as the parents parental educational level child uses the same dentifrice as the parents b variables entered on step 2 gender parental educational level ses age that the child begun to tooth brush who tooth brushes the childs teeth the child rinsed during brushing type of tooth brush used type of kindergarten child uses the same dentifrice as the parents type of kindergarten type of tooth brush used type of kindergarten parental educational level parental educational level child uses the same dentifrice as the parents parental educational level type of tooth brush used c variables entered on step 3 gender parental educational level ses who tooth brushes the childs teeth the child rinsed during brushing child uses the same dentifrice as the parents type of kindergarten type of tooth brush used type of kindergarten parental educational level parental educational level child uses the same dentifrice as the parents parental educational level type of tooth brush used ‡ variables with p 025 by chisquare test and fishers exact test incorporated in the model a variables entered on step 1 parental educational level frequency of tooth brushing frequency of tooth brushing amount of dentifrice used amount of dentifrice used parental educational level frequency of tooth brushing parental educational level amount of dentifrice used frequency of tooth brushing amount of dentifrice used discussion although not all social demographic variables remained in the final logistic model there was a tendency of children from lower socioeconomic status to use a childrens dentifrice in brazil studying at a private kindergarten is more common among children with a higher ses families that are more apt to buy childrens products appear to have higher ses and also have greater access to oral health care and information 17 moreover when parents buy a different dentifrice for their children it is generally a childrens dentifrice other studies have demonstrated that when the child uses the same dentifrice as the family it is usually a family dentifrice 18 19 20 these findings underscore the social tendency toward the choice of a childrens dentifrice which is usually more expensive than family dentifrices the most used dentifrices in the present study were the childrens dentifrice tandy ® and the family dentifrice sorriso ® 15 the former costs about us 159 and the latter costs about us 097 furthermore the interaction in model 1 shows that the effect of the dentifrice used by the child being the same as the family or not over the type of dentifrice depends if the child uses an adults or infant tooth brush moreover the study found that children 2 years are more prompt to use marketchildren dentifrice there is a notion disseminated by the population that infant products must be used by toddlers and maybe the expensive cost of these products makes parents to change for products market for adults as the child grows although this variable did not remain in the final logistic model the univariate analysis revealed that a lower parental education level was associated with greater f intake similar results are reported in a colombian study in which children with a lower ses were exposed to significantly higher f dose than those with a high ses 11 dentists should reinforce instructions to families regarding proper oral health practices especially the use of a small amount of dentifrice during tooth brushing a greater amount of dentifrice during tooth brushing by children can increase the risk of exposure to higher f doses and it has been previously confirmed by other studies 20 21 22 as tooth brushing frequency is used to calculate the daily f dose higher frequencies of tooth brushing are expected to increase the risk of f intake the dummy variable amount of dentifrice covering the entire length of bristles presented interaction with the dummy variables frequency of tooth brushing twiceday and 3 or more timesday that means that there is a synergistic effect between the amount of the dentifrice used and the frequency of tooth brushing over the dose of f intake however it is not prudent to recommend reducing the frequency of tooth brushing because it could reduce caries prevention the major concern should be instructing parents to use small amounts of dentifrice during tooth brushing moreover studies report that children with a lower ses use greater amounts of dentifrice when tooth brushing 1112 in the present study the univariate analysis revealed that children with a lower ses and whose parents had a lower education level were significantly more likely to apply greater amounts of dentifrice on the tooth brush one may therefore speculate that children from lowincome families are at greater risk of exposure to higher f doses however the strength of this association should be evaluated further the amount of dentifrice was more important than the type of dentifrice for the increased risk of f intake studies suggest that children who use a childrens dentifrice apply a greater amount of paste 2023 which may increase the risk of exposure to higher f doses 122024 however no significant association was found in the present study between the type of dentifrice and f intake in univariate analysis or in the comparison of mean f intake the mean weight of the paste used during tooth brushing was similar with both dentifrices this confirms previously published data that children are exposed to high doses of f by tooth brushing with fluoridated dentifrices 1820 regardless of the type of dentifrice some children may even exceed this value 11 however the authors cited 11 considered total fluoride unlike the present analysis which considered total soluble fluoride tsf was considered to predict the f intake dose due to its bioavailability in the body tf can be inactivated into insoluble fluoride which decreases the amount of f absorbed especially in formulas with calcium carbonate and mfp 15 that occurs due the reaction of ion f with the calcium from the abrasive forming insoluble caf 2 15 however even considering tsf it is worrisome that by tooth brushing with the fluoridated dentifrice approximately 28 of the children in the present study exceeded the threshold limit 1625 furthermore the children ingested 44 to 54 of the tsf in the dentifrices which underscores the need to decrease the amount of paste during tooth brushing although only 28 of children were exposed to a dose ≥005 mg of fkgday this value may increase if f intake from water and diet is considered some dentifrices had high concentration of f and they would contribute to a higher dose of f intake however at least 1000 ppm of soluble f is considered necessary for a dentifrice to have anticaries effect 26 but the current brazilian legislation only sets the maximum f concentration at 1500 ppm f without mentioning the need of soluble anticaries active f 2 furthermore this value is related to the declared on the package even if the dentifrice has 1500 ppm tf declared on package the actual tsf may be lower as proved by lab analysis of dentifrices with mfp and caco 3 with 1500 ppm f 15 the present study has some limitations that should be considered the questionnaire was answered on the same day as the tooth brushing which could have influenced the parents parents reports may lead to information bias 1427 the frequency of tooth brushing which was necessary for the calculation of the daily f dose was derived from the questionnaire and could be overestimated by parents the questionnaire was not validated and it was not possible to readminister the questionnaire to check the reliability of the results due the scholar calendar of the kindergartens however the sample was large enough to guarantee comparability of data there was only one observation of the tooth brushing since the parents and the children knew they were being observed they may have acted differently in front of the investigator than they normally do at home maybe some parents would tend to demonstrate a more careful behaviour and could have dispersed more or less dentifrice on the tooth brush or could have helped the child during tooth brushing although urinary excretion may be a cheaper and easier way to evaluate f intake by children 6 the present study did not used f urinary excretion however this does not invalidate the study since the method of saliva recovered after brushing is well recognized in literature 182028 the present study confirms that using a smaller amount of dentifrice used during tooth brushing is more important than the specific type of dentifrice it is important to establish public polices with the aid of the national health authorities and manufacturers of fluoridated dentifrices to create educational campaigns that emphasise the use of small amounts of dentifrice and the importance of supervising children during tooth brushing moreover the results suggest that children from higher socioeconomic status are more likely to buy childrens dentifrice and that children from lower socioeconomic status may be at greater risk of higher doses of f intake however this association should be further investigated families with a lower socioeconomic status should be closely followed and oral hygiene orientation should be reinforced as their children may be a greater risk of exposure to higher f doses dentists should be particularly concerned with such families as they have less access to dental services and to oral health information they may not adopt healthy behaviours consequently due the lack of information this population may put great amounts of dentifrice on the tooth brush conclusions the present study found that socioeconomic factors influence the choice of the dentifrice as families with a higher socioeconomic status were more likely to buy a childrens dentifrice tooth brushing frequency and the amount of fluoridated dentifrice placed on the brush can strongly increase the risk of exposure to higher doses of f doses regardless of the type of dentifrice

it is questionable whether socioeconomic factors influence the choice of marketed childrens dentifrices and whether these products are associated with greater fluoride f intake in children the present crosssectional study involving 197 children mean age 4098 ± 662 months was carried out in montes claros brazil parents completed a questionnaire on socioeconomic status and the tooth brushing habits of their children the children brushed their teeth and saliva residues were collected for f analysis f intake from dentifrice was determined with an ionspecific electrode univariate analysis and logistic regression were used to test whether the type of dentifrice childrens or family and f dose 005 and ≥005 mg fkg of body weightday were associated with the independent variables p 005 no differences were found between childrens and family dentifrices regarding daily f intake 0046 and 0040 mg fkgday respectively p 0513 the following were strong predictors for the use of a childrens dentifrice studying at a private kindergarten or 689 p 0001 age that the child begun to tooth brush 2 years or 293 p 0041 and the interaction between the variables use of the open access same dentifrice as parents and type of tooth brush used or 2720 p 0001 the amount of dentifrice used and frequency of tooth brushing p ≤ 0004 had a statistically and synergistic effect over the daily f dose the present study found a social influence over the choice of dentifrice children with a high socioeconomic status tend to use a childrens dentifrice the amount of dentifrice used can strongly increase the risk of exposure to higher doses of f regardless of the type of dentifrice

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those with traditional gender role beliefs often assume parenting is a mothers domain these beliefs have been associated with maternal gatekeeping behaviors maternal gatekeeping is often defined as beliefs and behaviors that limit mens opportunities to participate in the home as an equally contributing parent these behaviors may have negative effects on parentchild relationships or may protect children from negative outcomes although the outcomes of maternal gatekeeping have been explored predictors of gatekeeping are less studied furthermore predictors typically focus on characteristics of the mother ignoring the possible ways fathers may contribute to gatekeeping processes two specific gatekeeping contexts that deserve more attention are a fathers mental health and his masculine norm adherence thus the focus of this study is to examine the relationship between father depression and maternal gatekeeping using masculine norm adherence as a moderator conceptual foundation the fatherhoodmasculinity model our analyses are guided by plecks fatherhoodmasculinity model which articulates that masculinity may moderate associations between a fathers characteristics and other parenting practices enacted by him or by the mother of his children using plecks model this paper explores how associations between a fathers depressive symptoms and a mothers gatekeeping practices may differ based on the extent to which a father adheres to masculine norms plecks conceptual model is consistent with some research findings that men who adhere strongly to masculine norms often express their depressive symptoms through increased aggression and selfmedication with alcohol and substance abuse men who do not endorse masculine norms may not be as inclined to express depression in such externalized ways per plecks model how much a father adheres to masculine norms will not only alter the expression of a fathers depression but also likely impact a mothers gatekeeping maternal gatekeeping maternal gatekeeping as stated previously consists of behaviors and beliefs that allow mothers to dictate fathers participation in the home and with their children research has shown that both maternal gateopening and gateclosing behaviors exist in many families a mother who is a gate opener is more likely to encourage the father to spend time with their children and allow him to participate in their daytoday lives a gate closer is more likely to cut the father off from his children by consistently criticizing his interactions and actively preventing him from spending time with their children not all mothers are strictly gate openers or gate closers it is possible for mothers to not gatekeep at all and it is also possible for a mother to be both a gate opener and a gate closer maternal gatekeeping behaviors can decrease a fathers selfefficacy involvement and engagement into adolescence however not all gatekeeping is bad recent research found that when fathers are harsh or violent in their parenting gatekeeping protects children from adverse outcomes this paper explores whether externalized father depression creates another context for gatekeeping depression and adherence to masculine norms research focused on mental health has found that some men manifest their symptoms of depression differently from women men who adhere to traditionally masculine norms tend to express more externalizing behaviors such as alcoholism or drug abuse often selfmedicating to manage their emotions in many cases these externalized symptoms are not diagnosed as depression but rather are seen as a different problem leaving many men undiagnosed and consequently untreated mothers may feel a need to protect their children when a father is expressing externalized behaviors that threaten the family because depression can have lasting negative effects on multiple family relationships and child development and adhering to masculine norms may exacerbate mens externalizing symptoms it is critical to examine depression and masculine norm adherence in tandem current study in this brief report associations are examined between paternal depression adherence to masculine norms and maternal gatekeeping it is hypothesized that paternal depression and masculine norm adherence will be positively associated with maternal gatekeeping it is further hypothesized that masculine norm adherence will amplify the association between father depression and maternal gatekeeping when men report high levels of masculinity method participants data in this study come from the survey of contemporary fatherhood a national quota sample of 2296 fathers stepfathers adoptive fathers and father figures potential respondents were part of a qualtrics optin online panel this study was approved by the institutional review board at brigham young university data quality checks were used in accordance with the best practices in online data collection guidelines set forth by the american association for public opinion research data cleaning resulted in a sample of 2214 fathers multiple demographic characteristics were used in the sampling scheme to reduce bias prior research has shown that online optin panels are relatively representative of individuals with regular access to the internet but there is concern that online panels may underrepresent marginalized groups according to the pew research center more than 80 of adult americans have regular access to the internet and racial gaps in internet usage have closed considerably since 2012 although gaps because of income education and rural versus urban communities persist thus consistent with other studies using quota sampling results from this study are not nationally representative nonresident fathers lowsocioeconomic status fathers and racialethnic minorities are underrepresented in the scf fathers ranged in age from 18 to 72 years nine percent were single 56 were in their first marriage 7 were divorced 13 were remarried 11 were cohabiting 4 were dating exclusively or engaged child ages ranged from 2 to 18 years and 58 were male the mean yearly gross household income was 58000 twenty percent of fathers had a high school diploma or less 37 had some college experience or an associates degree 28 had a bachelors degree and 15 were either working on or had completed a graduate degree participants were 73 white 10 african american 11 latinx and 6 were other races see petts shafer and essig for further detailed procedure and sampling information see table 1 for descriptive statistics measures maternal gatekeeping the maternal gatekeeping scale is commonly used for measuring gatekeeping it consists of nine statements asking the participant how much more involved mothers are or should be with their childrens lives the statements are rated on a 5point likerttype scale ranging from 1 to 5 statements were adjusted from the original measure for fathers to respond for example if my childs feelings are hurt the mother should comfort them not me and if a decision has to be made for my child the mother should make it not me depression the center for epidemiologic studies depression 20item scale was used to assess depression levels the cesd is a common scale used to help diagnose depression respondents rated their symptoms on a scale this document is copyrighted by the american psychological association or one of its allied publishers this article is intended solely for the personal use of the individual user and is not to be disseminated broadly of 1 to 4 per standard practice items were recoded to range from 0 to 3 and summed if we followed the usual practice of using a score of 16 as the clinical cutoff 35 of our sample would fall above that cutoff however many have noted that when the cesd is used in the general population it is likely to be more sensitive and less specific than a more detailed clinical assessment to remedy this a cutoff of 20 is now recommended to better balance the need for diagnostic sensitivity and specificity using the cutoff of 20 28 of our sample presents depressive symptoms that may warrant clinical assessment masculinity the conformity to masculine norms scale was used to assess masculinity the short form consisting of 22 items was used traditionally this short form is treated as a single factor and all items are combined to create an overall measure of how closely men adhere to stereotypically masculine norms participants indicate their level of agreement on a 4point likerttype scale ranging from 1 to 4 with higher scores indicating stronger adherence to masculine norms control variables the control variables used include father age focal child age focal child sex income education race number of children type of father employment family structure and residential region of the country on average fathers reported having two children overall 73 of fathers reported being a biological father 7 reported being a stepfather 3 reported being an adoptive father 1 reported being a foster father and 16 reported being more than one of these types of father participants reported the number of hours they worked per week and we categorized those into unemployed employed part time and employed full time family structure was developed using various aspects of the fathers relationship with the mother of his child as well as residency with the child in total 62 were married to the mother of their child 14 were cohabiting with the mother 4 were residing with another partner 12 were single and 8 were not residing with their children overall 19 of fathers reported living in the northeast 24 in the midwest 38 in the south and 19 in the west region of the united states these control variables were selected for theoretical purposes and to maintain consistency with other published papers in which scf data were used results preliminary analysis depression and maternal gatekeeping were significantly correlated r ϭ 27 p ͻ 001 suggesting that men who report higher levels of depression were more likely to report higher levels of maternal gatekeeping masculinity was significantly correlated with gatekeeping r ϭ 31 p ͻ 001 thus men who report higher levels of masculinity were also more likely to report higher levels of maternal gatekeeping the significant correlation between depression and masculinity r ϭ 21 p ͻ 001 suggests that men who report higher levels of masculinity were more likely to also report higher levels of depression multiple regression analyses using stata 15 two separate regression analyses were performed the first model tested the main effects of masculinity and depression on maternal gatekeeping while controlling for age income number of children education focal child age focal child sex type of father race employment status family structure and residential region of the country the regression model was a good fit for the data and explained over 19 of the variance in maternal gatekeeping depression as well as masculinity significantly predicted maternal gatekeeping fathers who reported higher levels of depression as well as fathers reporting higher levels of masculinity were more likely to report maternal gatekeeping behaviors of the control variables father age child age income having a daughter and being a single father were significantly associated with maternal gatekeeping this document is copyrighted by the american psychological association or one of its allied publishers this article is intended solely for the personal use of the individual user and is not to be disseminated broadly moderation to test the hypothesis that masculine norm adherence would amplify the association between father depression and maternal gatekeeping when men reported higher levels of masculinity a statistical interaction term was created between depression and masculinity and was added to the equation from the first regression analysis the regression model was a good fit for the data and it explained about 20 of the variance in maternal gatekeeping whereas controlling for all other variables in the model the interaction term between depression and masculinity was significant the simple slopes analysis shows significant standardized slopes for low moderate and high masculine norm adherence with maternal gatekeeping and depression in other words depressed fathers who highly endorse masculinity were significantly more likely to report maternal gatekeeping than depressed fathers who did not endorse masculinity at the same high levels after including the interaction term masculinity remained a significant predictor of maternal gatekeeping however depression did not including the interaction term in the model did not change the effects of the control variables on maternal gatekeeping discussion the purpose of this study was to examine associations between father depression adherence to masculine norms and maternal gatekeeping the hypothesis that depression would be positively associated with maternal gatekeeping was supported the fathers in this sample who reported higher levels of depression were also more likely to report maternal gatekeeping we note that the direction of the association between depression and gatekeeping is unclear in our crosssectional analyses thus it could be that mothers tend to gatekeep because the father has depression or it is possible that father depression is exacerbated by the mothers gatekeeping behaviors longitudinal research is needed to better understand the direction of change in these effects direct effects were also found between masculine norm adherence and maternal gatekeeping implying that fathers who adhere more closely to traditional masculine norms are more likely to also report maternal gatekeeping suggesting that more research linking masculinity to specific father characteristics and parenting behaviors could be valuable the second hypothesis was also supported masculinity acted as a significant moderator of the association between maternal gatekeeping and paternal depression thus the association between maternal gatekeeping and depression is strengthened when coupled with masculinity consistent with plecks fatherhoodmasculinity model adherence to masculine norms may moderate depression because mens depressive symptoms are more likely to be expressed in externalizing ways when men endorse masculine norms these externalizing behaviors may provide this article is intended solely for the personal use of the individual user and is not to be disseminated broadly a context whereby mothers enact gatekeeping behaviors to protect their children this research is a unique addition to the gatekeeping literature and includes a rare large national quota sample it also establishes that characteristics of the father particularly his depressive symptoms and masculine norm adherence are meaningful correlates of maternal gatekeeping gatekeeping has historically been considered a problematic behavior whereby mothers reduce a fathers access to their children our findings suggest another possibility that warrants future research whereas this paper did not assess fathers parenting behavior the findings point to the possibility that when a mothers gatekeeping is connected with the presence of potential fathering risk factors such as depression and masculine norm adherence gatekeeping may be a tool mothers use to protect their children for example compared with nondepressed fathers many depressed fathers are less present in their childs life discount how they influence their children and use negative and critical language toward their children as a result depressed fathers may treat their children less warmly monitor their children less vigilantly and be less emotionally available than nondepressed fathers furthermore men who endorse traditional gender attitudes are less likely to be engaged in their childrens lives than egalitarian fathers including having lower observed fatherchild relationship quality we encourage future researchers to directly test the possibility that mothers use gatekeeping as a protective tool by including fathers parenting behaviors in their future assessments of paternal depression masculinity and maternal gatekeeping implications for these findings are both clinical and practical first gatekeeping that restricts a fathers access to his children has historically been considered bad maternal behavior our findings suggest that gatekeeping may be more complex identifying maternal gatekeeping as simply good or bad outside the context of other paternal behaviors and attitudes may not paint a clear picture about maternal behaviors or intent again future research that explores the potentially complex nature of maternal gatekeeping is needed concerning clinical implications therapists should understand the role that masculinity plays in a fathers depression and how that could influence interactions with his partner andor children mothers should learn to recognize their own gatekeeping behaviors and seek to better understand the purpose underlying their behaviors this knowledge for both mothers and fathers may help them become better coparents as they navigate the potential individual and relationship risks associated with depression when coparenting improves both mothers and fathers are more likely to feel empowered in their parenting efforts a few limitations exist in this study one major limitation to this study is that all the reports were from the father shared method variance may bias these estimates also because the research is correlational it is difficult to determine whether the men made these reports because of their depressive state or whether their depression resulted in more maternal gatekeeping behaviors furthermore it is also possible that depressed fathers are more likely to perceive increases in maternal gatekeeping regardless of actual changes in a mothers behavior future research should focus on better understanding these associations another major limitation in this study is that these data are not nationally representative nonresident fathers lowsocioeconomic status fathers and racial ethnic minorities are underrepresented in the scf because the short form of masculinity was used the multidimensionality of masculine beliefs and adherence is lost also this particular sample has a high level of depressed fathers thus it is not generalizable in other words the pattern of associations documented here may only characterize samples of fathers in which depressive symptoms are overrepresented and may not hold in less depressed samples lastly this study focuses on only a few select variables future research could examine other associations between maternal characteristics paternal characteristics and maternal gatekeeping this is the first research study to connect father mental health and masculine norm adherence with maternal gatekeeping significant findings add to the current literature and theory on why maternal gatekeeping exists as well as potential effects of father depression on family processes this research shows that a fathers depression masculine norm adherence and maternal gatekeeping are linked it further demonstrates that masculine norm adherence magnifies the effects of paternal depression on maternal gatekeeping these findings are vital to include in future research and theory regarding maternal gatekeeping

maternal gatekeeping has been associated with reductions in father involvement and can have a negative impact on the family few researchers however have focused on how characteristics of the father contribute to gatekeeping consequently this brief report is focused on associations between father depression father adherence to masculine norms and father reports of maternal gatekeeping we further test whether a fathers adherence to traditional masculine norms interacts with the relationship between depression and father reports of maternal gatekeeping this study adds to the current literature on both maternal gatekeeping and father mental health participants in this study include 2214 fathers from the survey of contemporary fatherhood including 73 white 10 african american 11 hispanic latinx and 6 from other races it was found that fathers who reported higher levels of depression also reported higher levels of maternal gatekeeping masculinity moderated this association the link between depression and gatekeeping was amplified when men adhered to masculine norms those fathers who were highest in depression and highest in masculinity were also highest in their reports of maternal gatekeeping although gatekeeping has historically been considered a problematic behavior our findings suggest that when a mothers gatekeeping is correlated with potential fathering risk factors such as depression and masculine norm adherence gatekeeping may be a tool a mother uses to protect her children

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introduction universally social security has been accepted as an instrument for poverty prevention and alleviation the social security system itself is able to increase employee motivation and loyalty or loyalty to the company so that it will have a positive impact on work productivity and will then encourage increased efficiency for the company this happens because workers feel comfortable at work where they have received protection from the possibility of losing part or all of their income due to work accidents death including termination of employment so that it spurs workers to work more productively in indonesia at present the workforce social security program organized by the employment social security administration agency consists of work accident benefit death benefit old age benefit and pension benefit in the law of the republic of indonesia number 24 of 2011 concerning the social security organizing agency it is explained that bpjs for employment has an interest in being able to reach the coverage of membership and its service orientation to all workers in the formal and informal sectors this is a challenge for bpjs for employment to be able to ensure that all workers in indonesia understand know and participate in the social security program for workers as the organizer of the workers social security program bpjs for employment always tries to build a positive image and provide the best service to participants this aims to provide satisfaction for workers which then creates a positive impression that makes them believe and believe in their choices the workers trust and confidence will raise their awareness and desire to continue to be participants in bpjs ketenagakerjaan su et al said that customer satisfaction is the main factor in assessing service quality consumers assess the service performance that is received and felt directly on the product of a service the higher the perceived service quality the higher the level of customer satisfaction which in turn will have a positive impact on a persons behavior in responding to the service customer satisfaction and dissatisfaction is the customers response to the evaluation of the discrepancy that is felt between expectations before using the product and the actual performance of the product that is felt after using it this condition explains that customers can feel satisfied or dissatisfied after they feel the product or service purchased or received from a company customer satisfaction is the level of ones feelings after comparing perceived performance with expectations the expectation in question is the expectation of the quality of service received regarding the quality of services provided by bpjs for employment one of which can be noted is the amount of participant claims based on data obtained from the bpjs for employment regional office of east java it is known that the bpjs for employment sidoarjo branch office shows the number of claims reaching 2210 claims consisting of 396 claims for work accident insurance 22 claims for life insurance 1264 claims for old age security and 528 claims for retirement security in 2020 the number of claims at bpjs for employment at the sidoarjo branch office is the highest number of claims after surabaya for the east java regional office in surabaya bpjs for employment has 4 branch offices with more than 4000 claims the highest number of claims was for old age security service claims which reached 2800 claims on the other hand during the covid19 pandemic in 2020 to 2021 the indonesian economy experienced a slowdown such conditions had an impact on the number of workers who experienced termination of employment the ministry of manpower of the republic of indonesia noted that there were 4156 companies that had terminated their employment and a total of 72 thousand workers experienced termination of employment during the pandemic the high number of layoffs that occurred during the pandemic was also followed by services from bpjs for employment which many participants complained about the complaint referred to is the management of bpjs for employment funds to the service system that is not optimal as a result it is difficult for participants to obtain social security rights on the other hand service quality should be the advantage and competitiveness of bpjs for employment can be measured to obtain an objective assessment this is reinforced by the opinion of zeithaml et al which states that the gap between customer expectations regarding service and perceptions of the services provided can be measured by the service quality scale based on the results of observations that have been made through the provision of suggestion boxes placed at the sidoarjo branch office of the bpjs for employment it is known that there are several other complaints such as difficulties in communicating and requesting personal data requirements for claiming benefits that are also difficult to other factors such as toilet cleanliness room waiting and limited parking space bpjs for employments ability to provide quality services will be able to increase participant satisfaction this is reinforced by cappelli et al which states that by providing good service quality customer satisfaction and loyalty will increase recent research has found that satisfaction alone is not enough to guarantee longterm customer commitment to service providers other variables are needed that are able to strengthen participants commitment to using bpjs for employment services such as trust service quality is the result of the gap that occurs between expectations and service performance perceived by customers quality is a characteristic or attribute that can be quantified and can be measured quality depends on the person looking at it so the product that best satisfies a persons preferences is a product of high quality according to zia the service quality model consists of tangibles reliability responsiveness assurance and empathy that have a positive effect on customer satisfaction service quality itself is an important factor for the business being run by the company this is supported by research results from uzir et al which explains that service quality has the greatest influence on increasing customer satisfaction customer satisfaction especially in the service sector is dominantly determined by the quality of service that can be provided by service providers therefore if the quality of service shows a decrease in quality it can have an impact on reducing the level of customer satisfaction excellent service quality has a significant effect on the satisfaction and trust of participants who have limited time this is supported by santa et al which states that the fast response of services must be considered so that participants do not experience difficulties when making transactions or communications that can result in a loss of trust in using the service the hypothesis put forward is h1 service quality has a significant effect on satisfaction the existence of a sense of trust shows a sense of security and protection provided by service providers to customers trust in service marketing places more emphasis on individual attitudes that refer to customers beliefs about the ability or quality of a service they receive trust contains two different aspects namely credibility which refers to the belief that the other party has the expertise in carrying out their duties and the other partys sincerity that he has the sincerity to carry out what has been agreed upon the trust felt by customers explains that the reputation of the service is a positive reputation such conditions can create a better sense of satisfaction for customers with the services that have been provided this is also explained by uzir et al that trust becomes an important tool to support a good interaction process between service providers and customers trust is considered a fundamental principle in every business relationship because it can determine the reliability of both parties in business transactions trust can also reflect positive expectations from customers regarding the services provided by service providers if this trust can be supported by services that match customer expectations then there is a high tendency for customers to feel satisfied the next hypothesis put forward is h2 trust has a significant effect on satisfaction trust can describe the competence and reputation of a company that provides services in addition trust can also show the desire of the company to be involved in a transaction even though there are known risks according to rimawan et al customer perceptions regarding quality and service have an influence on satisfaction when customers evaluate a service in the research conducted by su et al explained that trust can be a partial mediator in the relationship between service quality and satisfaction research conducted by panigrahi et al also showed the same result that trust has a mediating effect in the study by uzir et al trust can be a mediator in the effect of service quality on satisfaction these results explain that the influence of service quality can be greater on satisfaction when there is trust that is built in the minds of customers therefore the next research hypothesis is h3 trust can mediate the effect of service quality on satisfaction method this research is a causalresearch with a quantitative approach causal research itself is research that aims to explain the causal relationships that occur between the variables studied the quantitative approach explains research using data in the form of numbers and statistical analysis the population of this study are formal and informal sector workers who live in sidoarjo the research sample was taken using purposive sampling with the criteria being formal and informal workers who are members of the social security provided by bpjs for employment the determination of the number of research samples is 5 to 10 times the number of indicators the number of indicators for the variables of service quality trust and satisfaction is 24 so the number of samples in this study is 24 x 5 namely 120 respondents data collection uses a questionnaire distributed in the form of google form measuring the questionnaire using a likert scale 1 states strongly disagree to 5 which states strongly agree analysis of research data using sem pls analysis results and discussion respondent characteristic descriptive analysis this study uses respondents who are formal and informal sector workers who have participated in the bpjs for employment sidoarjo branch office the number of respondents who became the research sample was 120 people descriptive analysis related to the characteristics of the respondents is shown in table 1 the results in table 1 show that formal and informal workers participating in the bpjs for employment program are dominated by female workers the results of the analysis also explained that most of the formal and informal workers who had participated in the bpjs for employment program who were willing to be the research sample were aged 31 to 50 years with an educational background dominated by bachelors degree graduates variable descriptive analysis the results of the descriptive analysis regarding the research variables consisting of service quality trust and satisfaction can be explained as follows service quality has a mean value of 381 with the tangible aspect showing the highest mean with a value of 398 and is included in the good category the mean value explains that the tangibles aspect is the aspect that is considered the best by informal and formal sector workers who have participated in the bpjs for employment program the aspect that shows the lowest mean value in service quality is shown in the assurance aspect with a value of 361 but is still included in the good category the mean value explains that the assurance aspect is an aspect that is also considered good by workers who have participated in the social security program trust shows a mean value of 383 which explains that most of the informal and formal sector workers who participate have high trust in bpjs for employment the highest mean value is found in statement z1 with a mean value of 387 which is included in the high category this mean value explains that most of the informal and formal sector workers who participate have high trust in the services provided by bpjs for employment the statement with the lowest mean value is found in statement z3 with a mean value of 38 which is included in the high category this mean value explains that there are informal and formal sector workers who become participants who are not sure of the ability of the bpjs for employment to help the needs of participants satisfaction shows a mean value of 40 which explains that most companies participating in the bpjs for employment are very satisfied in addition informal and formal sector workers also have very high hopes to help provide solutions to the companys employment social security problems sem pls analysis in the sem analysis using pls the following shows the results of the validity and reliability tests that have been carried out the loading factor value shown in table 4 for each research variable indicator is greater than 07 which explains that all indicators used in this study meet valid criteria table 5 shows that the ave value is shown to be greater than 05 which confirms that each indicator has good convergent validity the composite reliability value shown is greater than 07 and the cronbach alpha value shown is greater than 06 these results explain that the variables studied have a high level of internal consistency reliability figure 2 smart pls outer model figure 2 shows the magnitude of the influence of service quality and trust on satisfaction and the mediating role of service quality on satisfaction in more detail the results of the sem analysis are shown in table 6 tabel 6 hypothesis test result hypothesis beta t statistic pvalue decision h1 service quality → satisfaction 0388 2267 0026 supported h2 trust → satisfaction 0301 2589 0011 supported h3 service quality → trust → satisfaction 0127 2162 0033 supported source result of analysis using smartpls 22 table 6 shows that the three hypotheses proposed in this study are acceptable these results explain that service quality has a positive effect on satisfaction because it shows a pvalue of 0026 which is lower than the critical value of 005 with a beta value of 0388 the next result shows that trust has a positive effect on satisfaction because it shows a pvalue of 0011 which is lower than the critical value of 005 with a beta value of 0301 the results of the hypothesis test also show that trust has a mediating role in the effect of service quality on satisfaction as indicated by a pvalue of 0033 which is lower than the critical value of 005 with a beta value of 0127 the results of the study explain that service quality has a positive influence on participant satisfaction in the bpjs for employment sidoarjo branch office these results explain that the better quality of service from the bpjs for employment will be able to increase the satisfaction of workers who are participants in the social security program the results of the research conducted are in line with the results of research conducted by zia which also explains that service quality has a positive effect on customer satisfaction according to uzir et al service providers such as bpjs for employment need to have a good understanding of the services provided so that the quality of services provided can be maintained and getting better the results of the study also show that the aspects that are most felt are in good condition by informal and formal workers who are participants in the bpjs for employment program these results explain that the condition of the physical aspect of the employment bpjs in providing services which includes office space equipment used the appearance of the bpjs for employment staff is a prominent aspect of the bpjs for health in being able to provide better services aspects of tangibles that have better quality than the expectations of participating companies will tend to provide a higher level of satisfaction as revealed by tjiptono that customer satisfaction will get better when the services provided are able to exceed the quality expected by customers on the other hand there are aspects that are felt by bpjs for employment participating companies to be less than optimal in supporting reduced service delivery namely the assurance aspect according to tjiptono the assurance aspect is manifested in the form of the level of knowledge ability courtesy and trustworthy nature of the actor or service provider the results of the descriptive analysis in this study indicate that there are still participating companies who feel that the staff of bpjs for health do not yet have sufficient knowledge and ability to provide services related to employment social security needs therefore it is important for bpjs for employment to be able to strive for every staff and employee to have an even and good ability and knowledge so that they can provide better employment social security services to every company participating in the bpjs for employment program the results of the next study explained that trust has a positive effect on participant satisfaction in the bpjs for employment sidoarjo branch office these results explain that the higher the level of trust shown by program participants can support the satisfaction of participants in the bpjs employment program for the better the results of the research conducted are in line with the results of research from anayasánchez et al which explains that the better satisfaction felt by customers is one of the reasons for the higher level of trust felt by customers for the perceived reputation of the service chong added that this trust itself arises when the service perceived by the customer is in accordance with customer expectations so that customer satisfaction can be better and provide benefits for service providers based on the results of the descriptive analysis it is known that most of the participants in the social security program have high trust in every staff of the bpjs for employment sidoarjo branch office in providing services this explains that staff have more value in the eyes of participants related to their ability to provide services trust itself is a fundamental aspect of every business relationship because trust shows the reliability of both parties in conducting business transactions the business transaction in question is that the service provider can provide services that are in accordance with what has been previously promised to customers so that customers can believe that customers are getting the same service as promised the results of the study also explain that service quality has a positive influence on satisfaction through trust the results of this study prove that trust has a mediating role in the relationship between service quality and satisfaction from participating companies in the bpjs for employment program the results of this study explain that improving the quality of service that is getting better from bpjs employment staff and employees will be able to increase company confidence in the services provided and then lead to higher satisfaction with employment social security services provided by bpjs for employment the results of this study support the results of research from stathopoulou balabanis which explains that trust has a mediating role in the effect of service quality on customer satisfaction furthermore stathopoulou balabanis explained that the better the quality of the service provided the higher the customers trust which in turn will lead to satisfaction the results of the same study were also described by panigrahi et al that services mediated by trust will cause customers to become more satisfied and loyal the results of this study alone prove that the mediating role that trust has in shaping the satisfaction of the companies participating in the bpjs for health program is partial mediation the partial mediation role explains that without trust service quality has a positive and significant direct effect this condition is different from the results of research from su et al which shows the full mediation role of trust in the effect of service quality on satisfaction this condition shows that basically improving the quality of service can directly affect the satisfaction of the companies participating in the bpjs for employment conclusion based on the description of the research results and discussion that has been explained the conclusion that can be conveyed is that service quality and trust have a positive effect on the satisfaction of the companies participating in the bpjs for employment sidoarjo branch office the results of the study also explain that trust can mediate the effect of service quality on participant satisfaction in the bpjs for employment sidoarjo branch office while conducting the research there were also obstacles that could be explained that this study only used a sample size of 120 while the number of formal and informal workers who had become members of the social security bpjs for employment sidoarjo branch office was larger so this study did not fully describe the actual conditions that occurred in the field regarding the satisfaction of the companies participating in the bpjs for employment sidoarjo branch office for bpjs for employment sidoarjo branch office can provide regular training programs for every staff who provides employment social security services to companies the training program is intended to increase the skills and knowledge of each staff regarding the employment social security products and services provided by bpjs for employment the training program itself can be carried out in collaboration with professionals such as training to improve public speaking skills for formal and informal sector workers who have become participants in the social security program from bpjs for employment they can provide input in the form of criticism and suggestions regarding each employment social security service provided by bpjs for employment the aim is to provide positive input which can then be considered by bpjs for employment to evaluate the employment social security services that have been provided

this study aims to analyze the effect of service quality and trust on the satisfaction of workers who have participated in the bpjs for employment sidoarjo branch office as well as analyze the mediating role of trust in the effect of service quality on satisfaction this research is a causal research with a quantitative approach collecting research data using a questionnaire distributed to formal and informal workers who have become members of the bpjs for employment sidoarjo branch office social security sampling using purposive sampling data analysis technique using pls sem analysis the results of the study explain that service quality and trust have a positive effect on participant satisfaction at the bpjs for employment sidoarjo branch office the results of the study also explain that trust can mediate the effect of service quality on participant satisfaction at the bpjs for employment sidoarjo branch office these results explain that the better the quality of service from the bpjs for employment and the better the level of trust from workers who are program participants will be able to increase the satisfaction of workers who are participants in the social security program in addition improving the quality of services that are getting better from bpjs for employment staff will be able to increase company confidence in the services provided and then lead to higher satisfaction with employment social security services provided by bpjs for employment

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introduction social network analysis is widely used to quantify relationships between people traditionally social networks are mapped using survey data by simply asking respondents to identify their friends these data are then used to define the edges between nodes in the network this approach is time consuming relies on subjective data collection and is sensitive to the precise framing of the questions new technologies have the potential to collect vast amounts of objective data at low cost and enable ecological momentary assessment ie monitoring and assessment in realtime and realworld conditions 2 badges with embedded sensors have been used to record objective data on facetoface interaction and proximity networks 34 similarly sensorenabled smartphones can be used to map social networks by assessing physical proximity using either bluetooth 5 location data 6 or by combining different data modalities 7 8 9 10 11 while most studies have handed out specially programmed smartphones to study participants we developed a smartphone application that participants can install on their own phone 12 using peoples own smartphones may help scale up this technology for largescale and population applications in research studies or selfmonitoring the use of sensor technology to efficiently map dynamic social interactions has been well established however the large variety of different methods available also raises the need to crossvalidate findings across technologies types of devices and social settings it has been shown that proximity data can be used to accurately infer friendships between participants 5 however several factors may affect both the networks that are derived from sensor data as well as the friendship reports obtained using surveys for example it has been shown that the size and characteristics of social networks vary considerably depending on the formulation of the questions use as name generators 14 15 16 similarly when defining networks based on the frequency of email exchange different choices of the threshold correspond to dramatically different network structures 17 similarly missing data in survey collection 18 or passive smartphone data collection 12 can significantly impact on the resulting networks missing data is expected when sensor data is collected from smartphones in real life where changes in data connectivity are frequent and participants turn off their device to preserve battery 7 we developed an application for ios and android to passively collect bluetooth data and map social networks of proximity here we assess the validity of social networks that are estimated based on bluetooth data acquired using peoples own smartphones we crossvalidated these against networks obtained using sociometric badges and selfreported survey data the study aims to identify potential strengths and limitations of the technology that can inform larger studies on the role of social networks in mental health the ability to accurately map social networks of proximity on a range of different smartphone typesacross both android and ios operating systemswould enable using these technologies at scale materials and methods procedure the installed app included a short survey at the beginning of the study and then passively collected bluetooth data for a fourweek period see below for more details participants were also asked to wear a sociometric badge during office hours when present at the institute sociometric badges are wearable electronic badges that automatically measure the amount of facetoface interaction conversational time physical proximity to other people and physical activity levels to capture individual and collective patterns of behaviour 19 to test the smartphone app we investigated the scanning statistics and compared the social network estimated from proximity data against the social network estimated using the sociometric badges in addition we compared both proximitybased networks with the social network obtained using a name generator included in the survey data acquisition native applications were developed for the android and ios operating systems based on the results of our initial feasibility study 12 for the ios application we used the bluetoothmanager private api as the public corebluetooth api only contains functions for interacting with lowenergy devices and it is currently not feasible to use bluetooth low energy to map social networks in ios 20 both android and ios versions of the application asked the user to give consent prior to the commencement of bluetooth data collection the application was configured to perform a bluetooth discovery scan every five minutes during the study period bluetooth is a shortrange communication protocol designed to allow a wireless connection between nearby devices a key feature of a bluetooth device is the ability to scan for other nearby devices when a bluetooth device conducts a discovery scan other bluetooth devices within a range of 510 m respond with their userdefined name the device type and a unique 12hexadecimaldigit hardware media access control address a devices mac address is fixed and can be used to differentiate one device from another when a participants mac address is discovered by a periodic bluetooth scan performed by another participant it indicates that the two smartphones are within 510 m of each other as the bluetooth mac address of a device is potentially personally identifiable information these data were cryptographically hashed on the handset to ensure the privacy of participants hashing generates a consistent signature for each data item that cannot be reversed to reveal the original data value in order to recreate the network and to distinguish participants from nonparticipants devices would need to report their own mac address since ios devices were not able to retrieve their own mac address a helper system was designed using ble on ios devices the ble service broadcast the device name and a writable characteristic for the mac address if the ios device was in range of an android device the android device would find the associated mac address from the periodic bluetooth scan and send it back to the ios device at the end of the study all devices were able to report their own mac address ensuring a complete network of participants could be constructed the app was configured to collect data only during standard office hours for each participant the period over which the app was active was retrospectively calculated based on the period over which bluetooth discovery scans were initiated the device was discovered by other participants or the apps internal telemetry was recorded participants were also asked to fill out a short survey on the smartphone app at the start of the study the survey included basic demographic questions as well as the opportunity to generate the names of up to five colleagues with whom they spend the most time to perform their job requirements these data were used to construct their selfreported social network in addition to the smartphone app sociometric badges were used to record proximity networks also using bluetooth 19 the badges contain a 24ghz wireless transceiver and a class 20 bluetooth module for the detection of other badges in close proximity the badges can also be configured to record additional sensor data eg line of sight proximity using infrared emitters and detectors audio recordings of speech or accelerometer data the badge was considered active on the period over which bluetooth audio or acceleromoter data were available although only the bluetooth data were stored for analysis connectivity analysis although the app also detects other bluetooth devices we only analysed the connectivity between participants we estimate the connectivity between participants based on the bluetooth scanning statistics of their smartphones from these statistics we define the connection strengths between participants and thus the weights of the network the average connection strength between device i and j can then be represented as r ij ¼ n ij ðtþ þ n ji ðtþ n i ðtþ þ n j ðtþ eq 1 where n ij is the number of scans where device i detected device j and n i the number of times device i scanned on time interval t by normalising the number of times one of the devices detected the other by the number of times each device scanned the connection strength r ij is bound on the interval 01 where 1 indicates that both devices always detected each other when they scanned and 0 indicates that the devices never detected each other if both devices did not scan during the interval of interest r ij is set to zero statistical analysis we first compared the proximity data obtained using the smartphone app and the sociometric badges a contingency table was created by comparing the time points at which the app or the badges detected a dyad to this end we pooled the data across all dyads the contingency table quantifies the likelihood that when a dyad is detected by the app it is also detected by the badges and vice versa we then estimated the association between these two binary variables using the odds ratio and the phi coefficient statistical significance was assessed using the chisquared test after directly comparing the proximity data obtained using the app and badges we then compared the social networks that we constructed from these data the undirected weights of the network were estimated by quantifying the percentages of time of the study period a dyad was detected ie the devices of both participants were in close proximity we used the mantel test to quantify the association between the weighted adjacency matrices obtained using the app and badges the mantel test quantifies the correlation between matrices and uses permutation test to quantify statistical significance 21 we used spearman correlation and opensource code to quantify statistical significance 22 and used bootstrapping to quantify the 95 confidence interval of the correlation coefficient 23 we then used the mantel test to quantify the correlation between the adjacency matrices from the app and badges with the adjacency matrix obtained from the survey data the survey data generated directed binary networks which we first converted to an undirected network by collapsing directed edges between two nodes into a single undirected edge we then extracted a binary backbone network from the weighted networks obtained using the app and badges 24 this filtering method provides a statistical method to extract the relevant connection backbone in complex multiscale networks by preserving edges that are statistically significant we used the r package disparityfilter to extract the backbone network 25 alpha was set such that the binary network has the same density as the network obtained from the survey data the binary undirected networks were then compared again using the mantel test results 21 participants agreed to join the study 9 participants used android handsets and 12 participants used iphones we first examined the amount of time the app and the badges were active during office hours on average the app was active for 791 ± 222 of office hours twelve of the 21 smartphone apps were active for more the 90 of the time the badges were active for an average of 370 ± 184 of office hours the percentage of active time of the badges were active are generally lower than for the app possibly because participants were only asked to wear the badges when they were at the office while the app would be active regardless of the location of the participants the scanning behaviour differed considerably between smartphones smartphones running android scanned more often than smartphones running ios as proximity is an undirected measure we can combine the data from smartphones a and b to estimate the edge between a and b of all 210 edges 919 of the edges were on average scanned at least once each hour and 543 of the edges at least once every 15 minutes scanning rates of less than once every 15 minutes were mainly observed for connections between two ios devices the sociometric badges do not provide basic scanning statistics and we hence cannot determine how often the badges performed bluetooth scans to compare the smartphone app with the sociometric badges we first compared the time points at which the app or the badges detected a dyad by pooling across all dyads we constructed a contingency table of all time points at which a dyad was sampled by the app and then determine whether the badges detected the dyad at the same time point table 1 gives the contingency table across all office hours of the 4week study period the marginal odds show that physical proximity is sparse and that the app more often detected a dyad than the badges although the marginal odds differed considerable there was a significant association between the time points at which the app and badges detected a dyad the contingency table shows that the app more often detected a dyad when the badge did not than the other way around we then restricted the analysis to time intervals when both devices of a dyad were active on average the app on two smartphones was simultaneously active for 637 ± 260 of the study time and pairs of sociometric badges were simultaneously active for 171 ± 117 if we restrict the time interval to periods at which the app or badges of both participants were active the marginal odds increased considerably the association between both measures also increased the app still more often detected a dyad when the badge did not than the other way around we also compared the association separately for connections between android users between ios users and between android and ios users we then quantified the connection strength between participants by calculating the percentage of time participants were in close proximity by estimating the connection strength between all pairs of participants the weighted adjacency matrix was obtained we first estimated the adjacency matrix for the whole study duration the adjacency matrices again show that the app more often detected other devices than the sociometric badges the smartphone app detected some dyads for 45 of office hours where the maximum connectivity for the badges was only 8 of the study time although they visually look quite different the adjacency matrices of the app and badges were significantly correlated we then estimated the adjacency matrix only during time intervals when both devices of a dyad were active as expected only considering the time interval when both are active increased the percentage of time two devices detected each other the correlation between the connectivity matrix of the app and badges remained largely the same we then compared the social networks of proximity with the networks derived from the survey data the proximity networks are weighted undirected networks whereas the survey data provide binary directed networks to facilitate comparison we converted the survey data into an undirected network and extracted a binary backbone network from the proximity data with the same network density the three networks were all significantly correlated although the correlation coefficient differed between pairs of networks counting the number of edges that matched between the networks the network obtained using the app had fewer matching edges with networks from survey data than the network obtained using the sociometric badges fig 4 shows the adjacency matrix and the topological representation of the three networks finally we used resampling to test for potential biases resulting from unequal scanning rates of the app weighted adjacency matrices were constructed by using a fixed number of random samples for each participant and correlated to the adjacency matrices constructed using the badge and survey data fig 5a shows the correlations coefficients for networks estimated with 10 to 500 random samples as only the app data is resampled the correlation between networks estimated using the badge and survey data remained fairly constant around 06 in contrast the correlation between the networks estimated using the app and badge a the weighted adjacency matrix of the app network was constructed using a fixed number of random samples for each participant to investigate potential biases resulting from unequal scanning rates the number of required samples was varied from 10 to 500 samples the mantel test was again used to estimate the correlation with the networks constructed using badge and survey data colour patches show the 99 confidence interval estimated by resampling the network 1000 times b the size of the network that was compared decreased with increasing number of required samples as participants with insufficient number of scans were excluded to facilitate comparison the incoming and outgoing edges of from the survey data were combined to obtain an undirected network in addition the binary backbone was extracted from the weighted adjacency matrix of the smartphone app and the sociometric badges a adjacency matrices for the survey data smartphone app and sociometric badges b topological representation of the corresponding networks node size represents its degree layout was rendered using the kamadakawai algorithm increased from 015 when only 10 samples were used to 051 when 500 samples were used the correlation between the app and the survey fluctuated between 02 and 04 as only participants were included for which the app recorded the minimum number of required samples the size of the networks decreased with increasing number of required samples as a result the networks also become increasingly sparse at 500 samples the survey network only contained 3 edges discussion we aimed to validate sensor technology to map social networks by comparing the proximity networks that were measured using a smartphone app and sociometric badges the app and the badges both collected bluetooth data and a name generator was used to map participants selfreported social network the app performed more frequent bluetooth scans on android devices than on ios devices the sociometric badges did not report basic scanning statistics but based on missing data points we determined that the badges were active for 37 of the study duration compared to 79 for the app a contingency table revealed that the app was more like to detect a dyad than the badges marginal odds 292 for the app and 019 for the badges the weighted adjacency matrices obtained using the smartphone app and sociometric badges were significantly correlated we then extracted the binary backbone networks from the weighted adjacency matrices to compare them with the selfreported networks the binary network obtained using the badges was more strongly associated with the selfreported network than the binary network obtained using the app although the association between social networks was statistically very robust the proximity networks obtained using the smartphone app and the sociometric badges differed considerably the association increased when the network was only estimated between participants whose app recorded at least 500 bluetooth samples in this study we only analysed bluetooth connectivity between devices from participants to enable the comparison between the smartphone app and the sociometric badges it is interesting to note the different scanning statistics obtained using the badges and the app although both are based on bluetooth technology badges were only worn while in the workplace whereas the app collected data during office hours regardless of location nevertheless even when examining the data for the periods where both the badge and app were actively collecting data the smartphone app provided a denser network than the badges as the sociometric badges detected a dyad less often but revealed a stronger association with the selfreported networks these findings may indicate that the bluetooth range of the sociometric badges is smaller that is close proximity between participants may be a better proxy for actual social interactions and formal and informal interactions can be distinguished based on interpersonal distance 26 as the bluetooth range may be greater than the separation between rooms it is also possible that dyads were detected between participants in neighbouring rooms and may therefore not just reflect facetoface interactions between participants 1927 as such detected interactions at larger distances could be considered false positives as they do not reflect true social interactions although the sociometric badges and most smartphones have class 2 bluetooth with a range of about 10 m differences in the bluetooth radio hardware and software stacks used on different devices may result in different sensitivities and detection patterns 28 the received signal strength indication of bluetooth can be used to estimate distance between smart devices 2930 however rssi is only available in the ios corebluetooth api used for bluetooth low energy and not in bluetoothmanager api used in the current study it is currently not feasible to use ble to map social networks due to the inability of ios devices to detect another ios device when both are in a locked state 20 differences in network structure may also be partly due to participant behaviour for example when someone carries their phone with them but leaves the badge behind in their office or vice versa the battery of the sociometric badges need to be regularly charged and badges need to be turned on when entering the office participants may forget to do this as they are less used to wearing and using the sociometric badges which would result in missing data the sociometric badges do not explicitly report missing bluetooth data but we considered the badges to be active on the period over which bluetooth audio or accelerometer data were available this showed that the badges were only active for 37 of office hours suggesting that participants regularly forgot to turn on or charge the sociometric badges although the app was active most of the time the scanning rates different considerable across devices and was much lower on iphones than smartphones running android the lower scanning rates on iphones result from restrictions imposed by ios on the background execution of apps restricting the scope for passive data collection applications compared with android devices reduced scanning rates may affect the reliability of the estimated social network in particular between devices that both have a reduced scanning rates in a previous study we showed that variations in scanning behaviour may introduce a bias in the estimation of social networks 12 although the scanning rates on ios have improved compared to the previous study this needs to increase further to improve the accuracy of the social network that can be mapped indeed when we only used devices that recorded at least 500 bluetooth samples the correlation with the networks estimated using the badges increased to 051 the current study has a small sample size which reduces the precision of the correlation coefficients that are estimated due to the limited sample size we cannot systematically test how the app performs on different types of smartphones and when running different versions of the operating system future studies involving larger samples can address individual variability and estimate the effect of user behaviour using subgroup analyses for example to investigate potential gender differences in the estimation of proximity networks in the current study we quantified the connection strength between participants as the percentage of time one of the devices is detected by another device this simple metric may not be the best predictor of social connectivity and further feature engineering may assist in extracting the most important network features for example by quantifying the duration or the frequency of contacts the smartphone app and the sociometric badges collect dynamic connectivity data and the temporal patterns of social interactions provides valuable information about human social activity 1131 indeed by using the temporal and spatial patterns of physical proximity data it is possible to accurately infer 95 of the selfreported friendships 5 several computational approaches have already been identified to improve the accuracy of information about social activities that can be derived from passively collected proximity data for example computational models have been used to identify both missing and spurious interactions and reconstruct a network that yields more accurate estimates of the true network properties than those provided by the observations themselves 3233 in addition probabilistic models can be used to discover interaction types from largescale network data and infer the latent meaning of each interaction based on the set of observed interactions over slices of time 34 these analytic tools may allow inference of the selfreported social connections more accurately from the proximity data than we collected in this study however selfreported social connections cannot be considered the gold standard as this approach is subjective and depends on the type of name generators that are used 14 15 16 future research is hence needed to determine the relationship between different methods of mapping social networks conclusion the current findings show significant correlations between the social networks estimated using a smartphone app sociometric badges and selfreported data crossvalidating these technologies to estimate proximity networks despite statistical robust correlations large differences in networks were observed these differences are most likely due to missing data differences in range and participants not always carrying the devices with them sociometric badges were active for less than 40 of office hours suggesting that participants often forgot to turn on or recharge their badges in contrast the smartphone app was active most of the time but revealed a high rate of missing data in particular on ios although background execution of apps is challenging on ios this is a technical problem that can likely be resolved through software engineering estimating proximity or restricting the range at which devices detect each other may enable more accurate information about social interactions but the sociometric badges and the smartphone app do not have this functionality ble would allow to estimate the distance between devices but this is currently not feasible on ios user behaviour is more difficult to control and some missing or spurious data is unavoidable as participants will not always carry the device with them or forget to charge them recording over longer intervals and the use of computational models may enable the detection of these behaviours a smartphone app is more convenient and less intrusive than devices build for research purposes there are currently 23 billion smartphone users worldwide and is continuing to increase 35 this study demonstrates that it is feasible to collect bluetooth data on participants own smartphones rather than distributing devices to participants for the duration of the study this has important implications on the ability to use this technology at scale which is for example needed to reliably identify social markers of mental health 3637 data cannot be made publicly available for ethical reasons as public availability would compromise participant privacy to obtain access to the data researchers who meet the criteria for access to confidential data can contact the

social network analysis is a prominent approach to investigate interpersonal relationships most studies use selfreport data to quantify the connections between participants and construct social networks in recent years smartphones have been used as an alternative to map networks by assessing the proximity between participants based on bluetooth and gps data while most studies have handed out specially programmed smartphones to study participants we developed an application for ios and android to collect bluetooth data from participants own smartphones in this study we compared the networks estimated with the smartphone app to those obtained from sociometric badges and selfreport data participants n 21 installed the app on their phone and wore a sociometric badge during office hours proximity data was collected for 4 weeks a contingency table revealed a significant association between proximity data ϕ 017 p 00001 but the marginal odds were higher for the app 86 than for the badges 13 indicating that dyads were more often detected by the app we then compared the networks that were estimated using the proximity and selfreport data all three networks were significantly correlated although the correlation with selfreported data was lower for the app ρ 025 than for badges ρ 067 the scanning rates of the app varied considerably between devices and was lower on ios than on android the association between the app and the badges increased when the network was estimated between participants whose app recorded more regularly these findings suggest that the accuracy of proximity networks can be further improved by reducing missing data and restricting the interpersonal distance at which interactions are detected

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introduction cesarean delivery on maternal request is defined as a primary cesarean section in the absence of any maternal or fetal indications 1 over the last few decades the cesarean section rates have increased all over the world from 121 in 2000 to 211 in 2015 to 60 in 2020 globally 2 3 4 5 the highest rates are in korea china and brazil ranging between 36 to 50 67 in india the state of telangana had a 100 institutional delivery rate in 2021 and the highest caesarean section rate in india 8 every institute state country is struggling with rising cesarean section rates and looking for reasons for this increase a pregnant woman requesting a cesarean section even when she can have a safe vaginal birth often perplexes obstetricians cdmr is a significant contributor in increasing the cesarean delivery rates 910 in 2015 the who concluded that there was no evidence to support that cesarean section benefitted women or infants who did not require the doi procedure 11 the control of these rising cesarean section rates requires an indepth analysis of every reason and the indication for this major procedure the reasons for cesarean delivery on maternal request are specific and differ by social and cultural backgrounds 12 indian culture is unique and has very different social economic and cultural differences this study aimed to understand the magnitude and reasons why women chose a cdmr in southern india to develop a framework for efforts to reduce cdmr methods an observational descriptive interviewbased study was conducted at fernandez hospitals hyderabad telangana india for a study duration of 10 months ie from february 2019 to november 2019 the study protocol was approved by the institutional review board the study included women who had cdmr with no medical indication for cesarean section and excluded women with multifetal pregnancy or previous cesarean section we took a prior informed consent for the interview from eligible women after she had a cesarean section the principal investigator who was not involved in case management conducted facetoface semistructured interviews using a semi structured questionnaire that included closed ended and openended questions all interviews were done by the principal investigator after first 24 hours after the surgery when the woman was comfortable with good pain relief the interview included questions to find the main reason for cdmr and whether they made the decision for cdmr before or after onset of labour primary outcome was to understand the reasons for choosing a cdmr maternal and fetal characteristics that were collected from the medical records for these women who had cdmr maternal request cesarean included age bmi time of first visit gestational age at birth birth weight apgar score stillbirth or neonatal death the reasons for opting for cdmr collected from interviews were categorized by the principal investigator into three themes social norms emotional experiences and personal experience the theme social norms included subthemes like social influence from family and friends cultural influence like mahurath which is choosing an auspicious daytime for birth of the baby emotional experiences theme included four subthemes fear of vaginal birth fear of baby injury safety and risk perception the third theme was personal experience including previous stillbirths or miscarriages or other adverse outcomes the health care providers advice was also documented the sample size for this study was calculated based on a 4 to 5 prevalence of cs on request reported in the literature with 2 precision and alpha of 005 the minimum number of interviews that were required was estimated as 32 the study included 92 consecutive pregnant women who provided consent and participated in the interviews statistical analysis descriptive analysis was carried out by mean for quantitative variables frequency and proportion for categorical variables statistical analysis was carried out using coguide version 2 software 13 results there were 8464 deliveries including 3921 women who had a cesarean section over a 10 month study period from february to november 2019 at the study institute women with multifetal pregnancies and previous cesarean sections were excluded three hundred and fortyfive women had cdmr after exclusion cdmr accounted for 804 of all cesarean sections done in women with singleton pregnancies without history of cesarean section the interviews were conducted for 92 women the characteristics of these women and birth outcomes are mentioned in table 1 the main reason for choosing cdmr was categorized into one of the three themes social influence emotional experience and previous experience the theme social norms included subthemes like social influence ie influence from family and friends cultural influence like muharath which is choosing an auspicious time for birth of the baby in india and maternal choice only seven women chose one of the above reasons the most common reason was emotional experience by 82 women the emotional experience theme included four sub themes like fear of vaginal deliveries fear of baby injury which may be due to large baby or fear of meconium aspiration safety and risk perception worried about loss of control and avoidance of memory related to previous birth amongst these women sixty five said they opted for caesarean due perceived fear of vaginal birth vaginal examinations of trauma to the baby safety and risk perception of cs as safer was quoted by ten women as the reason the third theme is personal experience including previous still births or miscarriages and health care providers advice was selected as a reason by only three women two due to previous bad obstetric outcomes and one on healthcare providers suggestion as she had previous pregnancy loss twenty nine women had made up their decision before onset of labour majority of the women mentioned that it is their own decision to have a cesarean birth while remaining 23 suggested that got the initial suggestion of cesarean delivery from their family members mother motherinlaw and husband one woman explained that her maternity care provider gave an initial advice for cesarean delivery as the babys weight is towards higher side forty one women decided for cesarean delivery in the antenatal period 49 made their decision after onset of labour and two women had already made up a decision before pregnancy only nineteen women had attended childbirth classes which are offered to all women discussion the proportion of cdmr in our study is similar to other studies that have reported a magnitude of 44 to 14 for cdmr 14 15 16 the choice of these women to have caesarean section a surgical major procedure which was not needed by medical indications is new for the developing world and has reasons which are very specific to social and cultural backgrounds majority did not attend the childbirth classes reflecting that the decisions were already made not to try for vaginal birth childbirth classes are not mandatory to attend and are specifically aimed to promote natural birthing remove anxiety about labour and birth and give an opportunity to allay fears if any all women are offered and explained the benefits of attending the childbirth classes facilitating the attendance or making it mandatory appears to be one option to try and see the effect on the rising requests for caesareans childbirth education has been proven to be very effective in reducing the caesarean section rates for maternal request in some settings 1718 seven women cited ivf conception as a reason for requesting elective caesarean section which reflected a concept that cs is safer for baby when compared to vaginal birth our study showed that 43 women had a prelabour elective caesarean section which implies a decision made even before onset of labour the remaining 49 women made a decision after onset of labour induced labours seemed to be a major determinant for this request and is an area that must be explored further the induction process can be painful and longer and many women felt a loss of control over the process of birth the focus of counselling must include preparing the women for childbirth and most importantly avoiding inductions when possible only ten of these women had induction of labour for social cultural reasons specific date and time of birth and went on to request cdmr the interview findings were interesting as social reasons were not the major reason the decision of caesarean delivery was often shaped by pressure from their partners family and friends the social influence was sometimes linked with the negative experience of their own mothers and sisters with vaginal birth few of the responses given by the mothers were tabulated in table 3 the most important finding of this study was that fear was chosen as the most common reason for cdmr which is similar to many studies 19 20 21 22 this suggests a need to focus on this aspect very early in antenatal care pathways a mandatory module to discuss identify and clarify the benefits of vaginal birth and risks of caesarean section may help these young women to explore and make better choices with support the counselling provided by healthcare providers can also be a factor which makes the woman choose caesarean section fear of hurting the baby was chosen in the context of meconium staining of amniotic fluid and large for gestational age baby fear of vaginal examinations has been associated with history of sexual trauma and women with such fear may need professional help through all the interviews the common thread that seemed to be running was the concept that vaginal birth is less safe for the baby and fear of harm for the baby during the birthing process choosing a caesarean section was regarded as a better or safer choice the findings have a major role to play in antenatal care and help to focus conversations on perceived safety risks their fears and to help pregnant women with support groups promotion of vaginal birth as a safe better alternative should have a major emphasis in antenatal care the limitations of this study were the limited number of questions to explore various aspects of the decision making by pregnant women in greater depth we chose a minimum number of questions to avoid inducing a feeling of guilt regarding their choice in these women conclusion fear was the main reason for cdmr in our series these women and their families seem to have a misconception that vaginal birth is harmful to baby the study gives important information to introduce changes in antenatal care and follow up the impact on reduction of caesarean section rates funding no funding sources conflict of interest none declared ethical approval the study was approved by the institutional ethics committee

the increasing demand for caesarean delivery on maternal request cdmr is adding to the increasing caesarean rates worldwide pregnant women and families choose a cdmr for several reasons that include social economic and cultural contexts this study was done in a south indian state to explore the common local reasons for cdmr as a first step to reduce this trend methods prospective observational semi structured interviewbased study of women who had chosen cdmr women with multifetal pregnancy and with previous caesarean sections were excluded the primary outcomes were the reasons to choose a caesarean section over vaginal birth the reasons were collected and divided into three themes social and cultural emotional reasons and personal previous experiences results ninetytwo women gave consent to participate in the study and were interviewed the most common reason to choose a caesarean in the absence of any medical indication was fear of harm to the mother or baby trauma or vaginal examinations by 65 out of 92 women 7065 theme of social influence was quoted as the reason by seven 76 and previous personal experience with birth outcomes was cited by three women 32 the majority chose cdmr in the antenatal period even before they set into labour conclusions fear was the most common reason for choosing a cdmr representing a misconception that caesarean birth is a safer better alternative for the woman and her family there is a need for change in discussions around antenatal care options exploration of fears and support systems to make a betterinformed choice

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introduction fake news stories have had more than trivial effects in such vital areas or civic life as national and regional elections public health social cohesion and financial markets worldwide in brazil particularly fake news have become so central in the political scenery that a congressional committee was called to investigate a notorious fake news operation known as the office of hate allegedly led by president jair bolsonaros family and close associates this comes as a follow up on the 2018 elections when massive dispatches of fake news sponsored anonymously by rightwing wealthy brazilian entrepreneurs gave bolsonaros campaign a herculean boost the threat to democracy posed by fake news is of course not a brazilian privilege nevertheless fighting fake news has become a case of do or die for brazilian democracy for a few reasons while the number of social media users has stabilized in developed economies in brazil as in other socalled emergent economies the number of smartphone owners and social media users is still on the rise particularly among younger users this means the number of citizens expected to be exposed to fake news in the following years and elections is increasing and so is the size of the marcelo el khouri buzato problem also fake news sharing in brazil is a systematic method of ultraright digital populism used to create animosity and justify threats of a crackdown on civil society since one should not expect the brazilian state to use government intelligence and security services to contain the systematic spread of fake news researching and tackling the problem demands more creative strategies as well as other contemporary forms of systematic deception and disinformation through social media the practice of producing and distributing fake news stories dates back to circa 44 bc in rome when a smear campaign was launched against mark anthony through slogans etched onto coins current fnss form and methods however are qualitatively and quantitatively unique to begin with presentday fns come bundled in cyber warfare boosted by powerful computational technologies and spread instantly through networked computerized communications on social media a kind of massive media which allows consumers to also produce and distribute media content with no editorial supervision the business of social media in turn is a poorly regulated operation that applies data science and artificial intelligence techniques oriented by principles of neuromarketing and psychological profiling these techniques make the business of fake news incomparably more efficient than coins dispensed at random pamphlets dropped out of a piper cub or even orson welles radiophonic war of the worlds therefore a more sophisticated approach to research and restrain fns is needed by sophisticated more precisely i mean approaches based on three assumptions first that the systemic tools integration to fight fake news from a posthumanist perspective problem be conceived from a systemicecological perspective second that the human and nonhuman agencies involved by treated symmetrically allowing for a posthumanist view of humanplusnonhuman cognition and embodiment finally that an ontological stance be adopted which goes beyond interposing naïve realism to false assertions such ontological strategy is needed because along with internet rumours and hoaxes conspiracy theories fringe theories identity theft and other instances of posttruth ideology fns do not operate on hiding the truth but on making truthfulness or falsity irrelevant in other words the strategy must assume that like fake news factual news and facts themselves can not be discovered they have to be made consequently the ethical difference between factual and fake news goes beyond alleged neutrality or transparency it lies on the moral use of modes of veridiction these requirements considered this paper proposes an initial exploration of a framework for researching and fighting fake news based on key elements of three systemicecological accounts of meaningmaking cognition and existence jay lemkes ecosocial semiotics gregory batesons cybernetic explanations of mind and bruno latours research into modes of existence even though i will not explore the philosophy of posthumanism in depth it is fair to say this work has a posthumanist inspiration because it will construe fns as meaningmaking trajectories across material metaphysicalprobabilistic and biopsychosocial agents defined by their performances rather than by their ontological status as human or nonhuman marcelo el khouri buzato this is obviously too ambitious a proposal to be developed in depth in one single paper by one individual proponent therefore i am counting on the readers resilience of both a certain density in the argument and a certain superficiality in my appropriation of the concepts from the theories invoked my goal is simply to entice an exploratory dialogue among the theories from a particular perspective in the hope that it is found useful and pushed forward collectively fake news content form and context fake news stories represent but one of the various forms of blindness to evidence mistrust of authority and appeal to irrational arguments rooted in specific fears and anxieties of the usersreaders which are captured by social media data analytics to understand how fns work we must make a few important distinctions first we should distinguish between fake news and lies since those who lie are necessarily even if ironically honouring the truth while those who release fns mean to undermine the theoretical infrastructure that makes it possible to have a conversation about the truth as bufacchi puts it fns are not bufacchi explains hiding the truth but exploring gaps in the resources for collective interpretation that allow for a society to make sense of itself and act coherently factual news stories in turn should not be seen as immediate expressions of truths even though they are expected not to lie this is because factual news is always written from a certain angle in a certain language by journalists that work for certain news companies that have certain advertisers and certain adversaries or are loyal or disloyal to certain governments all of these elements of mediation act in the process of turning the thread of experience of material events into lines in textual accounts no matter how unbiased the process is meant to be the benefit of factual news for democracy is therefore not the same as that of science which seeks to produce the real by sustaining the stability of the inscriptions held together the benefit factual news provide is to bridge the very gaps in the collective meaningmaking infrastructure of democracy that fns fill with toxic waste in practice verisimilitude of content is not as important as likelihood of formal design in fns for while their content is geared towards impact their formal design is meant to signal reliability impact is important because it prompts an immediate urge in the reader to forward the piece before any rational considerations occur that is why fns usually elicit preexisting social tension caused by sectarianism racial cultural and gender hate as regards their linguistic content fns tend to pack the main claim into the title which is longer and uses more proper nouns and verb phrases than in official news the text body on the contrary is less informative and has plenty of action verbs it is also often incoherent with the headline and written in nonstandard style containing mistakes misprints and mistranslations the neglect of the text body contrasts sharply with the careful visual design not only of the piece but of the whole intertextual system of blogs posts videos and tweets built around and hyperlinked to the message a design that matches the visual style of reliable online news sources marcelo el khouri buzato not only visually but quantitatively fns producers try to create an impression of reliability urgency and acceptance they do so by deploying bot armies that substantially and constantly inflate the number of likes shares and comments on in the pieces intertextual system likewise fnss producers employ hashtagging and metatagging tactics to trojanhorse the piece into socialnetworks and fool recommendation and search algorithms to take them to a broader group of readers this strategy works out because such algorithms measure the relevance of contents as redundancy not importance let alone truthfulness falseness or moral imperatives for deontic morality is hardly computable regardless of how they gain initial momentum or make themselves credible and relevant for human and nonhuman interpreters fns spread more quickly in their early stages and as they move across social media they create a disinformation ecosystem fns are usually shortlived although they might return from time to time because at some point factchecking agencies official media or rationalcritical readers will blow the whistle however refutations fed back into the social media ecology are of little effectiveness for two reasons first the denial will hardly ever penetrate the circuits where the fake story gained initial momentum because the algorithms will not find enough redundancy of forwarding in those networks for the rebuttal pieces second shame and fear of losing social capital plus diminished selfassurance will make it difficult for a forwarder to take it back to sum it up the meaningmaking trajectory of fns is made of tradeoffs and transforms among content formal or quantitative systemic tools integration to fight fake news from a posthumanist perspective features and material activity performed by and between human and nonhuman cognitive and material activity next i will suggest implications of this description of fns systems we can derive from ecosocial semiotics second order cybernetics and modes of existence theory an ecosocial perspective of fns ecosocial semiotics integrates elements from urban studies semiotics and physics as an attempt to apply dynamical open systems theory to semiotics and semiotics to dynamical open systems the idea was to explain how meanings are made out of material interactions across timespace scales from synapses to vocalizations phonemes utterances texts genres registers discourses dialects and languages trajectories of meaningmaking in the theory are conceived by analogy with developmental trajectories of organisms and environments in biologyecology and through principles of ecosocial theory in epidemiology an approach for tracing diseases in communities to broader historical sociological economic and political factors both geographically and historically the threelevel model of ecosocial semiotics asserts that each level of organization in a complex system embodies information needed to construct the system the process starts with the initial emergence of any system that has enough autonomy or closure from what then counted as its environment for instance a subspecies of an animal species that marcelo el khouri buzato emerged on an island isolated from the continent by a geological event a dialect emerging in a prison system or a specific variety of hate speech emerging in dark web forums where a collective of resentful antisocial extremists spend most of their time together each new level is not simply added to the top or bottom of the system hierarchy though it emerges between higher levels and lower levels as a subspecies is bellow a species and above its individuals a dialect below a language and above single speech events a hatespeech digital militia above the level disorganized mobs occasionally shattering shop windows in violent street demonstrations and below the level of connected rightwing extremist think tanks and regimes in the case of fake news systems the level bellow is constituted of the exchanges of novelties expectations and opinions about current states of affairs that enable us to sustain the weak social ties we need to cooperate and compete in our extended communities exchanges that involve the use of our imagination and wishes as well as our need to gossip an evolutionary trait of the human species the level above that where fns thrive according to the ecosocial model must be comprised of more highly and broadly organized activity that captures the degrees of freedom available in the levels below and harnesses them to organize its own organicenvironmental processes i argue computerized social media plays that role lemke points out that the meaning made from or the response to a material interaction by an interpretive system is a function of not only the material properties of the reader the object but also of other phenomena in the environment and the history of the interpretive system itself that is the syntagmatic and paradigmatic contexts of the meaning making process these interpretations must be learned or trained by the same token the system of interpretation constituted through these learned or coded rules must persist and extend far enough to be able to use the lowerscale interactions of its multiple constituents the power of a fake news story depends therefore not only on the ingenuity of those who create it or the lack of wit of those who read it but on a network of heterogeneous agents and rules that work above the scale of the maker and the reader fns that get shared cross a gigantic cybernetic interpretive system in pretty much the same way a bad or distorted idea crosses a human mind therefore individual writers and readers alone are not accountable for the damage fns cause but the whole interpretive system that produces and sustains it which includes algorithms and robots who are delegates of other agencies together these elements constitute a set of integrated mental processes that we can call a mind marcelo el khouri buzato fake news systems and the cybernetic mind gegory bateson was a leading scholar of socalled secondorder cybernetics a version of cybernetics focused on sociocultural phenomena originally cybernetics was a branch of mathematics that dealt with problems of control and information in selfregulating mechanical systems even though some firstwave cyberneticians thought it directly applicable to improving society by tightening the chains of control among human beings bateson on the other hand made it a point that cyberneticians include themselves in the systems they observed taking responsibility for the social impact of the systems they devised and built cybernetic explanations start with the possibilities of some course of action to occur and then look for the restraints that rule out some of those possibilities making other courses of action predictable if we want to understand why a clearly implausible piece of fake is quickly and massively forwarded by readers in good faith we should think about what restrictors were at play in the circuit where such readers are chained we have seen that fns use succinct textual content that impacts readers emotionally but we must ask what restrictors make it likely for it to be believed and forwarded immediately and how they get to interfere in the meaningmaking trajectory in the reader as interpretive system in cybernetics the meaning of a message is information in the mathematical probabilistic sense so it is not about reference but about redundancy of signals that introduce predictability in other words making meaning in cybernetics is confirming the model of the systemic tools integration to fight fake news from a posthumanist perspective universe where messageplusreferent are supposed to exist that is as true to redundancy detected by piece of running software as it is for a human subject who finds redundancy between a fake story and her existing opinions and world views a case psychology qualifies as confirmation bias along with the design of the fake news message which is redundant with the look and feel of news coming from credible sources and the redundancy brought by the intertextual network of fake blogs tweets and videos that are linked to fns not to mention the fact that they often come from someone in the readers social network confirmation biases turn redundancy into reliability at no material cost but how do fns find readers with the confirmation biases needed for the piece to stay alive bateson explains that establishing a correspondence between message and referent is quite simple when the information fits a slot that it is supposed to fit according a the model however creating location demands a second order set of metadata which in turn is achieved by statistical induction from a larger more complex pattern or pattern of patterns this is also how social media algorithms help fnd fit the slot that readers confirmation biases suggest creating a more selfassuring world for them not only what the reader herself has accessed liked commented on and shared in the past but also the patterns of access liking commenting and sharing in her social network plus semanticthematic patterns that fit the piece of fake news in the users range of probable marcelo el khouri buzato interests provide the complex metadata that feeds back into the sender through the fake news piece in cybernetics any ongoing ensemble of events and objects which has the appropriate complexity of causal circuits and the appropriate energy relations will surely show mental characteristics but no part of such an internally interactive system can have unilateral control over the remainder or over any other part since all parts must adapt their own present actions to the effects of their own past actions for bateson consequently a mind is not immanent in a human self but in the circuits that contain it within cybernetic systems across scales a mind is immanent in the brain only if the brain is the system it is immanent in the brainplusbody if that is the system or immanent in the brainplusbodyplusenvironment system if we chose to conceive the system at that scale thus it is not that social media systems know what users think but users thoughts must constantly pass through the mental consequences of their past actions in the system in the various fake news circuits conceived as a system the mind that interprets a piece of fake news is the whole circuitry of logiccomputational semiotic and material and emotionally charged socially bonded humans if fns circulate long and far enough to cause damage it is because the social mediaplususers system as mind finds ways to exchange transforms of physical power cultural meaning and informational redundancy among its components every mind prosystemic tools integration to fight fake news from a posthumanist perspective cess however requires collateral energy available in the environment that is turned into labour by virtue of some constraint that separates noise from pattern in a fns system besides food and electricity energy boosts come from sudden energy charged body processes called basic emotions such as fear wrath and disgust which emerge below the line of consciousness and organize a quick instinctive material response to share it as fast and as far as possible the labour produced by negative emotions elicited by fns is captured by recommendation algorithms as metadata to determine the relevance of that piece of content for the user the meaning of relevance in this case can only be informational redundancy so the more frantically and repeatedly someone likes or forwards a certain kind of content the more relevant it becomes no matter the cultural meanings or matteroffactness in it recommendations and search relevance become biased reassurance of the users biases to sum up batesons account of the cybernetic mind allows us to question the notion that fns are simply interpersonal human misdeeds and to consider the systematic release and distribution of fns as a sort of intoxication of the social media mind it is toxic because on integrating cultural meanings material processes and informational patterns across people software and machines fns turn human emotions into irrational material action human self and social expression into illusory selfassurance and reprisal of poor past choices and attachment into relevance telling this troubled mind the truth is too rudimentary a treatment we need to investigate its modes of veridiction marcelo el khouri buzato the modes of existence in news stories modes of existence are the object of a collective research project led by bruno latour the project is an expansion of his actornetwork theory of the construction of scientific facts and technological artifacts aimed at reconciling the ontologies of science technology economy law religion economy and moral philosophy in order to overcome sectarianism revisionism and negationism in the interdisciplinary endeavours against world problems such as climate change modes of existence refer to consolidated regimes of veridiction in those fieldsinstitutions which were created paradoxically in quest of universality latour argues that real world is not a universal notion but one particular mode of existence that of science among others even though all modes claim universality they all must sustain themselves by passing through other modes thus producing ontological crossings the key to finding and describing the modes is mapping institutionaldisciplinary ontologies onto the immanence of language and its works therefore the beings produced by science such as equations xrays laws of nature etc can be considered on the same ontological 1 i will adopt the notation used by latour himself which goes like this each mode in itself is indicated as an abreviation in all caps inside square brakets mode crossings of one mode through another are indicated by the abreviation of the modes name in lower case with a dot indicating the crossing with the next abreviation the order of the elements in the combo makes a difference since the previous mode is interpreted through the next modes means of verediction and not viceversa latours investigation is open for as many modes as can be found by collective investigations of the projetcs collaborators but here i am limiting my analysis to the modes already encoded in latour much more than a silly bet on radical relativism the modes are a tool for researchers to describe how truth or falseness is produced in particular institutions disciplines and cultural practices ethnographically that is by tracing their particular kinds of action or operation in the practices of veridiction latours inquiry can help us fight fns i argue by helping us trace the articulation of the modes that make a piece of fake news pass as factual news and consequently facilitating the kind of interdisciplinary and crossinstitutional work needed to minimize the problem or at least deploy some better forms of damage control systemic tools integration it is impossible to outline all the fifteen plus modes that have been identified by latours team so far but a brief look at the basic ones should suffice here beginning with the three metamodes network preposition and doubleclick net is the ontological primitive that connects a series of heterogeneous undefined elements to produce a new being pre is a mode that defines one mode as the interpretive key to another and allows us to identify when one truth value is judged using instrumentation from another as in faith in science or scientific proof it is very popular because it saves labour and provides quick selfassurance however it is only reliable as long as the materialsemiotic work that produced the knowledge it claims to access still holds beyond these three metamodes there are three regular modes directly implicated in fns i argue fiction fic technology tec and reference ref fic is the mode that vibrates between forms and materials promoting a suspension of disbelief if properly placed by pre before other modes for instance when we enjoy a fairy tale or a horror movie technology sets up associations of agencies to redistribute resistances and overcome obstacles the beings of tec become delegates who perform actions on behalf of other beings faithfully establishing chains of control ref or reference is finally the mode of scientific knowledge which gives mediated access to the real by networking inscriptions calculations quotations graphs equations etc and observing which entities remain constant across transformations in the process unlike dc ref is firmly rooted in experience and trials of strength before we move on it is important to explain that as they pass through one another the modes produce crossings which inspired in latour´s metalanguage i will express using lowercase versions of the modes names with a dot in between them so for example the equations on the blackboard of a teen we can now begin to define a fake news story using the same method used with factual news by simply using pre to change the positions of reference fiction and politics so that instead of ref polfictec news we have fake news that is not enough though to understand how fns work for we know their believers need to be given a false interpretive key a job pre can not do because it can not tell the truth or lie but only define which mode should be the key to interpreting the next based on our discussion about the fake news system as a cybernetic mind we can easily identify dc as the culprit for it is informational redundancy and confirmation biases that make the reader use the wrong key and thus believe that fiction is reference or politics is journalism the trick used by fake news makers with the help of dc has a secondary ontological effect it turns readers from citizens into wetware beings of tec and creates a huge machine in order to overcome what fake news system leaders consider an obstacle rational openended factbased debate in the public sphere geared towards a sense of systemic tools integration to fight fake news from a posthumanist perspective weus rather than a sense of usthem not only is fake news an oxymoron then but fake news systems are machines aimed at making reality oxymoronic and politics a perpetual lie in latour´s definition research on modes of existence is an ongoing process and it does not focus journalism specifically but this brief outlook should suffice to argue that together with ecosocial semiotics and cybernetic explanations it usefully supports interdisciplinary collaboration towards combating fns in particular and posttruth in general the idea that fns are effective because they explore the ontological arrogance of specific institutionsdisciplines and use their modes of veridiction to fool one another should facilitate a sense of collective responsibility for the problem and make it harder for corporations legislators and users themselves to weasel out by blaming it on one another likewise the theory encourages disciplinesinstitutions to respect learn and borrow one anothers tools for producing and judging veridiction to stop fns just like fake news producers borrow and ensemble the modes for evil conclusion this paper proposed an initial assessment of the explanatory power of three systemicecologic theories brought together for research and intervention on fake news as a systemic problem a posthumanist perspective of social and cognitive agency was adopted so that not only the interdisciplinary nature of the problem be highlighted but also an alternative understanding of the agencies and accountabilities involved can be pursued as strict ontological assumptions about humans and nonhumans that hinder lateral thinking about the problem are kept at bay marcelo el khouri buzato there are no permanent conclusions to take from this work due to its exploratory and tentative nature but we can highlight at least one consequence derived from each of the approaches discussed from the ecosocial semiotics it is implied that despite the claim by social media companies that they are not content suppliers but only provide a platform for content distributed by users social media business models are clearly coresponsible for the emergence of fake news systems from the notion of social media as a cybernetic mind we can derive that each piece of fake news is a circuit of human and nonhuman agencies some of which are below and others beyond an individual human reader´s consciousness and therefore factchecking addresses but a very small part of the problem finally the way fake news stories manipulate modes of veridiction suggests that if post truth is not about lies but about making truthfulness or falseness irrelevant to conceive of fake news as simply the opposite of facts is a much less powerful strategy than it would be to investigate what modes of veridiction matter for those who believe and share them finally looking at human and nonhuman agencies symmetrically makes clear that fake news systems are turning fake news readers into devices for creating human divides

a theoreticalpractical framework is proposed for an understanding of fake news stories from an interdisciplinary ecological and posthumanist perspective key elements of three systemic approaches to meaning are integrated that allow for a symmetrical account of human and nonhuman agencies in fake news as a phenomenon the findings are descriptions of fake news as systemic materialsemiotic activity that emerges from algorithmic capture of human emotion and socialdiscursive degrees of freedom how preconsciousemotional triggers can be hacked by informational patterns in fake news pieces an ontological syntax of truthiness and falseness across institutional agencies in fakenews activity

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for the more than 82 of youth who grow up with one or more siblings their relationships with their parents are interpreted in the context of how their siblings get along with their parents this process labeled parental differential treatment has the potential to influence youth development grounded in social comparison theory research has linked pdt to higher rates of youth risky behavior and poorer sibling relationships such that pdt tends to have negative implications for youth who receive less favorable treatment than their siblings kowal implications of pdt for youth wellbeing social comparison processes have been invoked to explain links between pdt and youths individual and relational outcomes from this perspective siblings who receive favorable treatment form downward comparisons and as a result of their favored status they have enhanced selfconcepts and wellbeing siblings who perceive that they are less favored in contrast form upward comparisons relative to their favored sister or brother with correspondingly negative implications for their selfconcepts and wellbeing past work on pdt provides support for these social comparison tenets for example relative to lessfavored siblings youth who experience favored treatment exhibit better academic performance and mental health as well as lower levels of risky behavior and substance use siblings who perceive favored treatment also report more positive sibling relationship quality although work on pdt has established links with adolescent behavior and sibling relationships less is known about links between pdt and parentchild relationships given the implications of parentchild relationships for youth development it is critical that sibling scholars consider the ways in which pdt is linked to parentchild relationship qualities adolescents who perceive themselves as favored may develop better relationships with parents over time at least in part due to the links between favored status and youth positive selfconcepts in contrast less favored siblings may perceive their parents as unfair and experience greater emotional distance and tension in their parentchild relationship tenets of social comparison theory further suggest that effects of comparisons and as a result pdt may vary based on individuals personal characteristics recent work on social comparison and siblings suggest that birth order may play a particularly salient role for example litt stock gibbons found that younger siblings who engaged in more social comparison were more likely to use alcohol if their older sibling did jensen et al more specifically found that younger siblings engaged in more social comparison of their siblings than did older siblings and that pdt was linked to youth outcomes but only for younger siblings who engaged in more comparisons thus links between pdt and parentyouth relationships may be more salient for laterborn siblings parentyouth discrepancies in perceptions of family experiences past work suggests low to modest agreement between parent and youth reports of family patterns processes and parenting with correlations typically ranging between 04 and 41 although discrepancies raise concerns about reporter bias and measurement reliability from another perspective the level of disagreement between parents and youth may be substantively meaningful for example abar and colleagues found that youth reports of parental monitoring were more closely tied to their risky behavior than were the reports of parents the discrepancy between youth and parent reports however was uniquely predictive of youth adjustment larger discrepancies were linked to higher levels of risky behavior similar patterns have been found in relation to parent and youth reports of family conflict and adjustment discrepancies may also be important in regard to pdt when youth and parents disagree about the amount of pdt in the family it may cause tension in their relationships as a result parents and youth may feel less close to each other and may have more conflict essentially discrepancies may be a risk factor for parentyouth relationship quality beyond main effects discrepancies between youth and parent reports of pdt may have a cumulative impact on relationship outcomes youth who perceive themselves as less favored may be at risk for poorer parentyouth relationships and a discrepancy in the perception of pdt may elevate that risk alternatively greater discrepancies may diminish the main effects of pdt past research on social comparisons suggests that accurate comparisons are more closely linked to outcomes than inaccurate comparisons although parent reports of pdt are not necessarily more or less accurate than those provided by youth agreement between parent and child about pdt may provide confirmation for youth that their perceptions are accurate or at least shared thus when there is greater agreement between parents and youth about pdt links between youthreported pdt and wellbeing outcomes such as dyadic parentchild relationship quality may be stronger than when there are greater discrepancies again given some research showing that siblings lower in the birth hierarchy are more focused on sibling comparisons we tested whether these linkages were moderated by birth order present study in sum we examined the roles of pdt and discrepancies between parent and youth perceptions of pdt in parentadolescent relationship qualities by using a lagged longitudinal design and by grounding our work in a family systems perspective social comparison theory and past research on pdt and parentyouth discrepancies specifically we tested the hypothesis that youths perceptions of pdt would be linked to parents reports of parentyouth relationships in the following year such that parents would report more warmth and less conflict with youth who perceived themselves as more favored we used youths reports of perceived pdt because past work highlights that perceptions of pdt as reported by adolescents play a consistent role in development parent reports of parentchild relationships were used to avoid single reporter bias further we anticipated that these patterns would be more evident for secondborns than firstborns in addition we tested the hypothesis that larger discrepancies between youth and parent ratings of pdt would predict poorer parentchild relationships in the following year and again whether these patterns differed by birth order additionally we tested two hypotheses about the interaction between youths perceptions of pdt and parentyouth discrepancies in perceptions first from a cumulative risk perspective we tested whether the link between pdt and parentyouth relationship qualities was stronger when there were larger parentyouth discrepancies in pdt reports specifically that larger discrepancies would exacerbate the link between youths unfavored status and lesspositive parentchild relationship characteristics second from a social comparison accuracy perspective we tested if links between youths perceptions of pdt and parentyouth relationships were stronger when parentyouth discrepancies were smaller that is when there was greater parentyouth agreement again we tested whether these processes differed by birth order each hypothesis was tested separately for relationships with mothers and relationships with fathers method participants participants included firstborns secondborns mothers and fathers from 393 families living in a northeastern state in the united sates who were interviewed in their homes as a part of a larger longitudinal study to recruit the sample letters were sent home with fourth and fifth graders in 17 school districts because we did not have demographic information on the families to which letters were sent the true response rate of eligible families is unknown however more than 90 of families who responded and were eligible participated reports for the current study came from yearly interviews across three years in which participants were in adolescence the final sample included 381 families who participated in all three time points families who did not participate at all three time points did not differ on any dependent or independent variable except that firstborns in families who remained in the study were slightly younger at time 1 compared to those who did not participate at all time points 234 p 05 m 1664 sd 83 reflecting the demographics of the region us census bureau 2000 almost all families were white and working to middle class most parents had completed some college or posthigh school training and almost all were dualearners most parents were in their early 40s at time 1 firstborns averaged 1569 and secondborns averaged 1318 years of age the sample was approximately evenly divided by youth gender and sibling dyad gender constellation most of the families had only two children in families with only two children the firstborns and secondborns were slightly farther apart in age 283 p 01 m 265 years sd 89 than in families with three or more children the families did not differ on any other independent or dependent variable procedure separate home interviews were conducted with mothers fathers and each sibling by trained interviewers youth interviews averaged about one hour and parent interviews averaged about three hours combined after providing informed consentassent families received an honorarium of 100 to 200 depending on the year of the study the study was approved by the universitys irb measures parentyouth warmthat separate points in the interviews mothers and fathers reported on their warmth with their firstand secondborns using a 24item scale from the child report of parental behavior inventoryparent version parents rated items such as i am a person who understands my childs problems and worries on a 5point scale ranging from 1 to 5 overall parents reported high levels of warmth but mothers reported warmer relationships than did fathers 1123 p 001 mothers m 399 sd 49 fathers m 372 sd 53 α ranged from 92 to 94 mothers did not report being closer to firstborns or secondborns fathers however on average reported having a warmer relationship with secondborns 345 p 001 m 378 sd 45 than with firstborns parentyouth conflictat separate points in the interviews mothers and fathers each reported on the frequency of their conflicts with each child parents rated conflict in 12 domains including chores school work social life and behavior using a measure adapted from smetana using a 6point scale ranging from 1 to 6 overall parents reported low levels of conflict and mothers and fathers did not differ in their reported conflict with their adolescents mothers reported on average having more conflict with secondborns 418 p 001 m 227 sd 57 than with firstborns fathers also reported on average as having more conflict with secondborns 307 p 01 m 216 sd 49 than with firstborns perceptions of pdtperceptions of pdt were assessed with items adapted from daniels and plomin parents used a 5point scale to rate their differential affection and discipline toward their firstborns versus secondborns 1 2 3 4 5 youth used a similar 5point scale to rate their mothers and fathers affection and discipline toward themselves versus their target sibling 1 2 3 4 5 in these analyses greater affection and less discipline relative to a sibling were considered as favored treatment and reports were recoded so that 0 reflected equal treatment positive values reflected selffavored or firstbornfavored treatment and negative values reflected siblingfavored or secondbornfavored on average both mothers and fathers reported displaying slightly more affection and discipline toward secondborns and did not significantly differ from one another in their reports on average secondborns perceived themselves as being more favored in terms of affection from both mothers 252 p 05 m 06 sd 61 and fathers 248 p 05 m 11 sd 58 than did firstborns in regards to differential discipline firstborns perceived similar levels of treatment from mothers and fathers as compared to secondborns discrepancies in perceptions of pdtwe calculated discrepancies in perceptions of differential treatment by taking the absolute value of the difference between parent and youth reports for each domain and each parent although some researchers have suggested that difference scores are not the best method for examining discrepancies and interactions should be used instead others however have suggested that the difference score approach is acceptable in our analyses the difference score approach was preferable because of the hypothesized threeway interactions using the interaction approach to the discrepancy would have created a fourway interaction which would be unnecessarily difficult to interpret additionally the absolute value of the difference score was used so that we could test the accuracy hypothesis the resulting variables fell on a 4point scale where 0 reflected agreement and 4 reflected the maximum possible extent of disagreement on average firstborns and parents had small to moderate levels of discrepancies about the level of pdt similarly secondborns and parents had small to moderate levels of discrepancies regarding pdt discrepancies between parent and youth report did not differ between firstborns and secondborns results analytic strategy we tested our hypotheses using a threelevel multilevel residualized change model with lagged variables specifically time was clustered within siblings who were clustered within families separate models were tested for each dependent variable each model was tested in three steps in the first step we entered the lagged dependent variable to control for that parentadolescent relationship quality the year before this variable was centered on the crosstime average thus effects of the lagged dependent variables reflect differences from the dyads crosstime average conflict and warmth we also tested youth age sibling age spacing sibship size parent education level gender sibling gender constellation and birth order all continuous control variables were meancentered in this step we also entered youths ratings of differential affection and differential discipline and the absolute value of the difference between parent and youth perceptions of differential affection and discipline both youth perceptions of differential treatment and discrepancies in perceptions of differential treatment were lagged variables so that we could test whether time t1 effects predicted parentchild relationships at time t in the second step we entered six twoway interactions to examine the accuracy and cumulative risk and birth order hypotheses specifically pda x dda pdd x ddd birth order x dda birth order x ddd birth order x pda and birth order x pdd in the third step to test whether potential accuracy and cumulative risk effects varied by birth order we included two threeway interactions birth order x pda x dda and birth order x pdd x ddd mothers reports of warmth findings for motheryouth warmth are reported in table 1 among controls when mothers reported higher than typical levels of warmth at time t1 then they reported less warmth at time t youth age was negatively related to warmth and mothers reported less warmth toward sons and secondborns further main effects indicated as expected that youths report of being favored with relatively more maternal affection predicted more motherreported warmth the next year but larger discrepancies between mothers and youths pda reports predicted less maternal warmth the next year these two main effects however were qualified by an interaction between pda and dda consistent with the accuracy hypothesis tests of the simple slopes revealed that youth reports of being favored with more maternal affection predicted subsequent maternal warmth only when motheryouth discrepancies in reports were small turning to differential discipline no main effects were evident but an interaction between youths perception of pdd and birth order in combination with tests of the simple slopes revealed that secondborns reports of being favored with relatively less discipline predicted higher levels of motherreported warmth the next year but there was no such association for firstborns no significant threeway interactions emerged fathers reports of warmth findings for fatheryouth warmth are reported in table 2 when fathers reported higher than usual levels of warmth at time t1 they reported less warmth at time t and they reported less warmth toward older adolescents firstborns samegendered siblings and when there were more siblings in the family there was no main effect for differential affection or fatheryouth discrepancy in reports of differential affection an interaction between dda and birth order did emerge but testing of the simple slopes revealed that the association was not significant for firstborns nor secondborns with respect to fathers differential discipline a main effect for youths perception of pdd emerged but was moderated by birth order here tests of the simple slopes revealed a significant association only for secondborns secondborns reports of being favored with less discipline at time t1 predicted higher levels of fatherreported warmth at time t there were no significant threeway interactions mothers reports of conflict findings for motheryouth conflict are presented in table 3 among controls mothers reports of higher levels of conflict than usual at t1 predicted lower levels the next year and mothers reported less conflict with older youth and daughters additionally pda was a significant predictor such that youths reports of being favored by more maternal affection at time t1 predicted mothers reports of less conflict at time t the effect however was qualified by the interaction of pda with discrepancies in perceptions of differential affection testing of simple slopes revealed that consistent with the accuracy hypothesis the negative link between differential affection and motheryouth conflict was significant only when motheryouth differences were small an interaction between dda and birth order also emerged simple slopes showed that for firstborns larger discrepancies in their own versus their mothers reports of differential affection predicted more conflict on the next occasion but this link was not significant for secondborns for differential discipline there were no main effects of either perceptions of differential discipline or discrepancies in report there was a significant interaction between pdd and ddd but testing of the simple slopes revealed that neither association was significantly different from zero results also showed an interaction between pdd and birth order testing of the simple slopes revealed that as expected secondborns reports of receiving comparatively less discipline at time t1 predicted maternal reports of less conflict at time t in contrast firstborns reports of relatively less discipline predicted maternal reports of higher levels of conflict at time t there were no significant threeway interactions fathers reports of conflict among covariates fathers reports of higher than typical levels of conflict at time t1 predicted less conflict at time t and they reported less conflict with older adolescents secondborns and daughters there was no main effect of differential affection or discrepancies in differential affection on conflict with fathers there was an interaction of pda and birth order but simple slope followup tests revealed no significant effects for either firstborns or secondborns turning to differential discipline a main effect of youths reports of fathers differential discipline emerged and revealed that being favored with less discipline at time t1 predicted lower conflict at time t this effect however was qualified by an interaction with birth order and tests of the simple slopes showed that pattern was evident only for secondborns there were no significant threeway interactions exploratory analysis in each model the interaction of perception of differential discipline x birth order was significant because age and birth order could be confounded in our sample and the birth order effect could be due to secondborns being younger than firstborns we additionally tested if that twoway interaction varied by age in the model predicting conflict with mother the threeway interaction of perception of mothers differential discipline x birth order x age was significant the corresponding threeway interaction in the model predicting conflict with father was also significant in each case testing of the simple slopes revealed that the association became stronger over time for secondborns but was not significant for firstborns the interaction was not significant in models predicting warmth with either mother or father discussion siblings serve as important sources of social comparison regarding parental treatment and a growing body of research shows that pdt is linked to adolescent adjustment we built on this research to examine links between pdt and warmth and conflict in adolescents relationships with their mothers and fathers using a lagged longitudinal design borrowing from research that has examined parentyouth discrepancies in perceptions of their shared relationship experiences we also expanded on prior research to test whether parentyouth discrepancies in perceptions of pdt were linked to parentadolescent relationship qualities in addition testing social comparison accuracy and cumulative risk hypotheses we also explored whether parentyouth discrepancies in perceptions of pdt moderated the links between pdt and parentadolescent relationship qualities finally due to prior research having shown that social comparisons are more common for siblings lower in the birth order hierarchy we tested birth order as a potential moderator of these processes pdt and parentyouth relationships we anticipated that youth who perceived themselves as favored would develop better relationships with their mothers and fathers additionally we expected that these patterns would be stronger for secondborns in all four models when secondborns perceived themselves as favored in terms of receiving less discipline both mothers and fathers reported more positive relationships with them the following year importantly this effect was manifested over time was net of the effects of dyadic parentyouth relationship qualities in the previous year and was based on pdt reported by the youth and parentyouth relationships reported by the parents in only one instance was the association also significant for firstborns consistent with recent findings from other samples it is possible that laterborn siblings engage in more sibling comparison and thus are more reactive to pdt given that older siblings are more advanced in most domains and are granted more privileges and autonomy prior research shows that pdt is linked to higher levels of risky behavior and such behaviors may be both cause and consequence of poorerquality parentyouth relationships effects that vary by birth order however need to be interpreted cautiously parentyouth relationships and interactions vary by age and in analyses that only include firstborns and secondborns from the same families age and birth order may be confounded so that apparent birth order effects could be due to age and not ordinal position in the family we reduced the risk of this confound in our analysis by controlling for age and testing whether significant interactions with birth order further varied by age in cases where the interaction with age was significant patterns still supported the basic findings from twoway interactions with birth order specifically even at older ages pdt was more salient for secondborns to increase confidence in these patterns future studies will need to include firstborns and secondborns in a wider array of ages parentyouth discrepancies in perceptions of pdt we hypothesized that greater discrepancies in perceptions of pdt would be linked to poorer parentyouth relationships our findings provided only limited support for this hypothesis in only one instance was a greater discrepancy linked to poorer relationships with parents when mothers and firstborns had a greater discrepancy in perceptions of differential affection they had greater conflict the following year given that in our study pdt was more salient for secondborns it is possible that in some instances firstborns serve as a social referent for younger siblings and parents as a referent for firstborns discrepancy in reports also allowed us to test the social comparison accuracy hypothesis and the cumulative risk hypothesis in line with social comparison research we only found support for the accuracy hypothesis although support was limited specifically lower discrepancies in perceptions of differential affection from mothers accentuated the role of mothers differential affection when youth reported receiving comparatively more affection and their mother reports the same their relationships improved the following year this raises the question as to why differential affection and discrepancy in perception of differential affection mattered and not differential discipline and why the effects only emerged with mothers and not fathers differential affection may be more salient if youth are unable to justify differences in affection whereas with differential discipline youth may be able to justify the differences in treatment due to different ages or differing levels of behavior between the siblings in regards to mothers given that mothers spend much more time with their children than do fathers it is possible that youth are more aware of discrepancies in perceptions with their mothers than with their fathers limitations and conclusions in the face of its contributions this study was not without limitations first the sample included only two siblings per family the processes of interest and our focus on birth order call for future studies that incorporate measurement of the experiences of all siblings in a family findings also were limited in their generalizability by the samples homogeneity in family structure raceethnicity and socio economic status although others have found similar patterns in more ethnically and socially diverse samples it will be important to examine these processes in varying contexts lastly the study was limited by its focusing on differential affection and discipline as these related to parental warmth and conflict these domains of pdt are the most commonly studied and an important research direction will be to examine other domains of pdt such as parents investments of time and material resources in their children despite the limitations the findings of this study suggest that social comparisons within families regarding parental treatment may play a significant role in parentyouth relationships especially for laterborn siblings the findings of this study suggest that if parents want to improve their relationship with a laterborn youth that they need to help that child feel favored or at least not les favored this process need not come at the expense of the other children in the family but future work will need to be conducted to explore how parents can help each child feel favored and appreciated supplementary material refer to web version on pubmed central for supplementary material jensen and mchale page 18 note t1 signifies predictor variables measured in the year prior to the dependent variable controls that were not significant in any model were excluded from the tables sibling age spacing and parents education two threeway interactions birth order x pda x dda and birth order x pdd x ddd were tested in an additional step but were not significant and so they are omitted from this table author manuscript note t1 signifies predictor variables measured in the year prior to the dependent variable controls that were not significant in any model were excluded from the tables sibling age spacing and parents education two threeway interactions birth order x pda x dda and birth order x pdd x ddd were tested in an additional step but were not significant and so they are omitted from this table

a family systems perspective directs attention to the potentially different experiences and perspectives of family members this study examined parents differential treatment pdt of siblings discrepancies between parent and youth reports of pdt and their links with relationships between adolescents and their mothers and fathers across three years participants were first time 1 m age 1571 sd 107 and secondborn time 1 m age 1318 sd 129 siblings from 381 predominately white working and middle class families analyses revealed that siblings perceptions of being favored predicted less conflict with and greater warmth from both mothers and fathers primarily for secondborn adolescents larger discrepancies between maternal and youth reports of differential affection were linked to more maternal conflict and less warmth for firstborns these findings may suggest a hierarchy within families parents may serve as referents for firstborns and firstborns as referents for secondborns

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introduction the subject of crimes known as whitecollar crimes has been studied by scholars for over a hundred years as early as 1916 the danish marxist willem bonger made an apt distinction between crime in the streets and crime in the suites the american muckrakersa group of journalists tracking the pathologies of the political and social system at the turn of the 19th and 20th centuries also made a significant contribution to the understanding of the crime of whitecollars they led inter alia to the criminalization of numerous criminal acts under us federal food drug and cosmetic act of 1906 however edwin h sutherland was the first who systematically deal with this phenomenon and drew attention to crimes committed in the upper or whitecollar class composed of respectable or at least respected business and professional men these crimes he contrasted with crimes and criminals typical of the lower classes and resulted from poverty he defined the crimes of whitecollars as a crime committed by a person of high social status and respectability in the course of his occupation it should be noted that this concept remains not fully regulated and the discussion about the meaning of whitecollar crime continues to this day in this work the concept of whitecollar crime is understood as criminal acts committed by persons of high social and economic status having broad qualifications and knowledge in legal management and economic matters these people use their positions in the world of business and politics to commit crimes and these crimes generally have a financial motive whitecollar crime research has developed into the following four strands first look for empirical generalizations of who and why are involved in whitecollar crime and what organizations are most at risk secondly attention has been focused on modus operandi studies ie on the ways in which these crimes are committed third the focus was on analyzing the procedures for detecting and preventing these crimes the fourth marginalized approach is the study of social awareness focusing on the moral aspects of evaluating individual acts this type of research is rarely sponsored we already know quite a lot about the whitecollar crime thanks to this we can introduce appropriate and effective legal regulations and prevent this phenomenon the crime of whitecollars is closely related to gender only 7 of women were involved in financial scandals in 20012018 in multiethnic societies the racial factor plays an important role as much as 65 to 89 of whitecollar crimes are committed by whites moreover the perpetrators come from noncriminal backgrounds and families perpetrators in the fourth decade of life and older clearly dominate and moreover middlelevel management prevails a factor that significantly increases the risk is the absence of implementation of internal control mechanisms usually these are crimes that last a long time the statistics of losses and penalties caused by these crimes are also closely monitored and lists of criminal law regulations are created in addition to demographic characteristics the socioeconomic characteristics of whitecollar criminals are also studied this article examines the social perception of the phenomenon of whitecollar crime among poles the perception of whitecollar crimes in the public consciousness is of great importance citizens tend to focus almost all their attention on street crime a similar focus occurs in criminal justice moreover the public is more in favor of stricter crimes against street crimes than those that occur in apartment crimes corruption scandals usually increase public awareness but the durability of changes in social attitudes remains questionable to this should be added the fears of entities investigating whitecollar crimes against the sanctions of the organizations concerned by these crimes such events may potentially damage the image of these institutions for example in the first editions of the book by eh sutherland the whitecollar crime in which the case studies of 70 us corporations and 15 public institutions were made the names of these institutions were not disclosed the full uncensored version of the book was not published until more than thirty years had passed this is not a good phenomenon because whitecollar crimes cost society a higher cost than street crimes whitecollar crime is more widespread and there is less potential for deterrence through diffuse penalties and social sanctions in addition whitecollar criminals tend to receive significantly lower penalties compared to street criminals at the same time there is a higher recidivism rate whitecollars committing crimes are assessed more leniently in terms of morality their actions are more often rationalized and justified therefore the deterrent mechanism is not working materials and methods the empirical data analyzed in this study are collected thanks to the financing provided by the justice fund which is at the disposal of the minister of justice whitecollar crime and research is part of a larger project that started in 2020 this project is entitled creation of a universal and standardized methodology for measuring crimerelated phenomena researching these phenomena and spreading social awareness under the program for counteracting the causes of crime and financed by the victim assistance fund and postpenitentiary assistance the study was conducted in october 2021 on a sample of n 1004 adult poles the research was carried out using the technique of computer assisted telephone interviews which has a number of important positive methodological organizational and technical features this method guarantees higher data quality accuracy precision low error rate credibility validity cati research is commonly perceived in the subject literature and research practice as having the ability to generalize the results from a sample to a higher population than other available research methods and a higher percentage of people agreeing to participate in the study compared to other research methods is obtained the sample selection has statistical representativeness and was carried out using a method called random digit dialing this method is considered optimal and classic by researchers it is constantly modernized in research practice new phenomena such as the impact of the development of mobile telephony are taken into account this method will enable the random selection of the sampling frame and as a result obtain representativeness in terms of sociodemographic features crucial for research purposes the assessment of the respondents awareness was started with the question of where in their opinion whitecollar crimes are most frequently committed the respondents could indicate state institutions or profitoriented enterprises the respondents could indicate the answer on a fivepoint symmetrical scale with one neutral point 1 much more often in the private sector 2 rather in the private sector 3 more or less equally in the public and private sectors 4 rather in the public sector 5 definitely in the public sector 6 i dont know hard to say from among numerous criminal acts 15 groups were distinguished and the respondents were asked to rate them on the following fourpoint symmetrical scale without a neutral point 1 i strongly condemn 2 i rather condemn it 3 i rather accept it 4 i strongly accept i do not consider this act a crime additionally the respondents could choose the answer i dont know hard to say which was not read by the interviewer the respondents escape from the answer is significant it usually means complete ignorance of the item about which the question is asked or much less often the will to avoid the answer due to attitudes inconsistent with social expectations the following criminal acts were finally included in the model as in table 1 a comparative measurement was also undertaken it was measured to what extent the acts were negatively assessed in legal and moral terms two actions were presented to the subjects for evaluation their summary is presented in table 2 the comparative list of the two acts was preceded by the following introduction now i will read you pairs of crimes from each pair you will have to choose one that you consider to be a worse act statistical analysis was based on multidimensional modeling and descriptive and inductive statistics and categorical regression optimal scaling in order to measure the cumulative impact of variables the source of this method is correspondence analysis and multidimensional scalling the central concept of this method is nonlinear regression with categorical variables by optimally scaling categories in categorical data the purpose of using this method is to quantify the relationships between multiple independent variables and the one dependent variable the fundamental advantage of optimal scaling is the ability to discover interactions ie the combined effect of selected independent variables on the dependent variable it is a comprehensive data mining technique which the fundamental advantage is the ability to discover interactions results the subject of statistical analyzes were the following three complementary issues assessment of the location of whitecollar crimes evaluation of whitecollar crimes against other crimes moral attitudes towards particular manifestations of whitecollar crimes and examination of social and demographical factors determining positive attitudes towards whitecollar crimes collars whitecollar crimes in the public and private sectors perception of the frequency of occurrence the question posed on the prevalence of whitecollar crime in the public or private sector is presented in table 3 table 3 whitecollar crimes in the public and private sectors whitecollar crimes are more often committed in the private sector or the state sector valid percent 1 much more often in the private sector 32 2 rather in the private sector 59 3 more or less equally in the public and private sectors 465 4 rather in the public sector 168 5 definitely in the public sector 227 6 i dont know hard to say 49 total 1000 source own study poles believe that whitecollar crime occurs simultaneously in the public and private sectors or this crimes prevails in the state structures religiosity income and marital status are moderate predictors of differentiation in attitudes towards locating whitecollar crimes among representatives of the first and the second sectors income is a key factor in differentiating attitudes towards the place where whitecollar crimes occurs lowand middleincome individuals tend to see this crimes as being more concentrated in the public sector on the other hand people with high income tend to argue that whitecollar crimes are distributed equally in the public and private sectors persons who do not believe have doubts in matters of religious faith and believe but do not practice have significantly less trust in state institutions they believe that corruption affects these structures much more than profitoriented companies the other sociographic and psychographic variables turned out not significant moral assessments of whitecollar crimes in comparison with other criminal acts the tendency to condemn similar acts by the surveyed poles depending on their role or motives is presented in table 4 most poles treat criminal acts arbitrarilyaccording to them they are just as reprehensible regardless of who commits them or what the motives are however the following situations provoke a stronger moral condemnation abuse by a person of public trust abuse of an officials power for political purposes than for private purposes corruption by an public official rather than a teacher and corruption by an public official than a manager of a private enterprise the results confirm the clear and statistically significant requirement of higher moral standards towards representatives of public authorities than with other entities moral attitudes towards particular manifestations of whitecollar crimes attitudes towards individual whitecollar crimes were examined assuming that attitudes towards particular crimes may be varied numerous whitecollar crimes are almost unanimously condemned by the majority of poles it is also worth pointing out that the percentage of the lack of opinion is small and does not exceed the maximum standard error of estimation on the other hand the following whitecollar crimes are most socially accepted wash trade fictitious business activity insider trading tax fraud the level of acceptance of all investigated whitecollar crimes negatively correlates with the age of the respondent the lower the age the higher the acceptance of this type of crimes these dependencies although low are clear and statistically significant to a slightly lesser extent but clearly with the acceptance of whitecollar crimes positively correlate with sociodemographic features such as lower education marital status and a negative attitude towards religious faith men treat whitecollar crimes more liberally women unequivocally condemn whitecollar crimes more than men there is a slight positive correlation between the level of net income and the consent to whitecollar crimes other variables such as the place or size of the residence and political views are not correlated with the moral condemnation or condemnation of whitecollar crimes factors determining attitudes towards whitecollar crime regression model it was examined what social characteristics correlate with high acceptance of whitecollar crimes considering the combined influence of the explanatory variables allows for the creation of a uniform profile of people with identical attitudes and examining whether they are similar to each other in terms of other social characteristics it is important because it allows to determine which social groups may require corrective actions in the educational sphere or social campaigns in the previous subsection of the article the individual sociodemographic features were considered in isolation here from sixteen variables relating to the support or condemnation of whitecollar crimes one quantitative indicator of consent to the phenomenon of whitecollar crime was created for this purpose categorical regression was used to create a multivariate model fifteen sociodemographic variables were taken into account from which a model consisting of five characteristics was created age attitude towards religion selfperception of income political selfidentification gender selfidentification the model is presented in table 6 the most liberal approach to the crimes of whitecollar collars is represented by the social category of young people up to 35 years of age secular views moderately or very satisfied with their income identifying themselves with center options including centerright and centerleft most of them are men discussion and conclusions the effects of whitecollar crimes are not directly visible it is impossible to identify the victim personally indirect effects of actions may include financial destruction of the enterprises and thus contribute to the pauperization of people or investors working in it on the other hand the institutions of social trust may be compromised and the publics trust in it may decrease lowering the quality of democratic political culture effective prevention of whitecollar crimes requires both adequate legal implementation as well as a sufficient level of public awareness usually legal solutions are taken on an ad hoc basis which is not conducive to the coherence of the legal culture comprehensive and systematic reforms have been initiated in poland the ministry of justice in 2018 increased the scope of penalties for economic crimes under the justice and security program in september 2021 further reforms were initiateda wideranging draft amendment is being processed in the parliament aimed at tightening the penal regime the changes also apply to whitecollar crimes these were relevant changes in the context of some empirical materials indicate that the covid19 pandemic significantly increased the problems related to white collar crime the problem of social awareness is more complex and that is why it is the subject of this article public opinion reacts spontaneously to disclosed crimes of white collars however the durability of changes in social attitudes is shortlived moreover whitecollar crimes are more often rationalized and justified by society despite the relatively higher financial and social losses caused by this type of crime poles seem to be well socialized the vast majority of them condemn the whitecollar crimes independent international comparative research shows that there is nothing to worry about the global corruption index created annually by the global risk profile is included in one of the indexes called whitecollar crime indicates poland among the countries of low risk of whitecollar crime two disturbing phenomena were noted during the study firstly poles are more inclined to accept two groups of crimes than other crimes crimes related to the stock exchange or the activities of companies in the first case these are crimes about which the general public lacks awareness and knowledge moreover they are characterized by the fact that the victims of such actions ie those who suffered real losses cannot be identified personally with regard to the second group of crimes ie those relating to economic activity this applies to many poles personally the reasons for such attitudes are complex both psychological sociological economic and even historical second the endorsement of whitecollar crime is not evenly distributed throughout society but is focused on young people mostly men having secular views financially well off with broad centrist political views identification of a specific social group allows for awarenessraising educational and remedial activities this is particularly important in the context of research into effective prevention whitecollar crime it turns out that social condemnation and scattered sanctions are a more effective tool to deter criminals of this category than incarceration

the paper explains whether and to what extent the attitudes of poles towards various types of white collar crimes are varied the scope and type of social and demographic characteristics determining these attitudes are also examinedfindings most poles treat criminal acts arbitrarilyaccording to them they are just as reprehensible regardless of who commits them or what the motives are but statistically significant part of respondents require of higher moral standards towards representatives of public authorities than with other entities in the whitecollar crime context whitecollar crimes are almost unanimously condemned by the majority of poles 9 out of 10 respondents express condemnation the disturbing phenomenon of social consent to the following four types of white collar crime has been observed and explained wash trade fictitious business activity insider trading tax fraud partial consent and acceptance of whitecollar crimes are not evenly distributed throughout society but is focused on young people mostly men having secular views financially well off with broad centrist political views identification of a specific social group allows for awarenessraising educational and remedial activities practical implications identification of a specific social group which accepts the crime of white collars to a greater extent than other groups allows the indication of who can be used awarenessraising educational and remedial activities originalityvalue this is the first study on moral attitudes towards whitecollar crime undertaken since the introduction of extensive changes in criminal law which exacerbated the penalization of economic crimes including whitecollar crimes

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introduction there have been so many acts of terrorism connected to radical muslims that its why it is not surprising islam has a public relations problem pollsters historians and other experts say that the wests collective instincts toward islam have been shaped over decades by a patchwork of factors these include demographic trends psychology terrorism events foreign policy domestic politics media coverage and the internet therefore it is not surprising that muslims are the most negatively viewed faith community in some countries as the united states the internet and social networking applications have bypassed the traditional media filter and magnified the influence of fringe activists on public perceptions of islam online communication platforms have become a staple for terrorist organizations who are taking advantage of the fruits of globalization and modern technology especially the most advanced communication technologies to communicate seduce plan and coordinate their deadly campaigns with such terrorist groups as isis using social media campaigns extensively including online magazines recruiting videos featuring narration in americanaccented english and even video games muslims then started using social media to condemn isis fight islamophobia and most of all launch media campaigns denouncing those groups and denying exploiting islam in this outrageous form social networks are not only a central platform in the pr effort opposing isis but also an important tool that isis itself uses for both psychological terrorism and recruiting activists however as the media presence of isis grows so do the voices of young muslims around the world who transmit an unequivocal message both to the west and isis rejecting the organization and anyone who would join its ranks the current research will be divided into two parts the first part presents a review of previous and upcoming campaign hashtags as a theoretical framework and review of literature the second part tackles the major findings regarding analysis of social media platforms conclusion will follow theoretical framework and literature review activism via social media social media accounts are important in coordinating activism and the challenges of building and maintaining strong connections social media have enabled the explosion of dialogue and information sharing by both proponents and critics social media are rapidly evolving requiring a responsive and flexible approach when used for campaigning uniquely twitter for example offers a direct means of communication with hardtoreach targets such as celebrities creating access opportunities that were previously difficult to imagine another advantage of social media is that it is possible to track how information is being shared and then monitor audience reaction as tweetreach to track and analyze the effect of our social media advocacy the open accessibility of tweetreach and twitter means that it is possible to see who has engaged with information and their responses allowing campaign information and strategies to be amended and tailored in real time islam is a religion of mercy for the entire humanity it is imperative to present the true picture of islam and for this we have to employ all the advanced means of modern information technology and promote islam on social media uddin wondered whether hashtag activism is doing enough to stop bad speech about minority communities and affect social change social media accounts by members of minority communities are responding to racism and stereotyping in the media and getting results the online muslim community has demonstrated its ability to identify and counter harmful speech but it needs to take the next step and seek more constructive and productive solutions instead of taking to the streets muslims are rallying on twitter facebook and tumblr social media are helping western muslims for instance to embrace and reflect the culture of selfexpression to counter bad speech proislam hashtags related to counter terrorism campaigns the notinmyname movement is not the first time that muslims have spoken out against terrorist organizations though it may feel like it for some people the vatican has reported that the secretary general for the organization of islamic cooperation stated that isis has nothing to do with islam and its principles that call for justice kindness fairness freedom of faith and coexistence egypts highest religious authority has also denounced isis as a group that violates sharia and humanitarian law these messages were not accompanied with trendy hashtags so the wellmeaning declarations may have fallen on deaf ears results definitely suggested the existence of other campaign attempts aiming at the image restoration of islam although mostly lacking organizational and unified perspective over the years many individual and group attempts were spotted to modify the distorted image of islam either online or offline many online campaign hashtags launched via different organizations preceded aligned with or followed not in my name although mostly not that successful and gaining far less coverage some of these attempts were as early as 2010 exploring islam british foundation used social media via facebook and you tube to launch a campaign to improve the image of islam after an opinion poll found that more than half of british people associate the religion with extremism and terrorism inspired by muhammad aimed at promoting islam as a faith which contributed positively to british society posters of muslims with captions like i believe in rights for women so did muhammad featured at bus stops tube stations and on london cabs a website provided online support for the campaign by hosting straightforward information about islam muhammad and british muslims in 2012 in the us a month after an ultraconservative group plastered controversial defeat jihad ads on 10 cta buses and likened muslims to savages a local muslim group countered back with a campaign to reclaim islam and educate the country about the true meaning of the word jihad through cta bus and train ads and a social media campaign on twitter facebook and youtube participants were being asked to express what their jihad is with the hashtag myjihad the response to the twitter campaign has been mindblowing with tweets pouring in from australia england the middle east and south asia it also gained support on facebook from organizations such as americans against islamophobia the campaign was revived once more in september 2014 as chicagobased organization and public education campaign myjihad announced their condemnation of the extremist group isis or isil and encouraged all muslims globally to openly condemn this group and any similar groups the declaration comes after numerous muslim organizations in the us and around the world that include muslim clergy have come forward to publicly denounce the actions of the isis group following criminal acts of persecution and murder against christians in iraq as well as yazidis muslims and other innocent people in addition to the tragic beheading of american journalist james foley the initiator of this and several other campaigns believed the rationale behind the national initiative was not only to foster a more positive public perception of islam but a deeper faith among muslims in canada and inspired by notinmyname the ahmadiyya muslim community launched a similar social media campaign in october 2014 under the title stop the crisis with proposals of how to deal with the challenge of radicalization including education open dialogue and finding solutions for the isis crisis in 2014 the american take on hate campaign has been pushing back against bigotry by correcting the false light placed on arab and muslim americans those who monitor bigotry can barely keep up with islamophobia fueled by politicians and media pundits starting feb 8 through valentines day 2016 the group launched a social media campaign take on hate with love to showcase the contributions of arab and muslim americans in december 2015 the ahmadiyya muslim community of usa launched an unprecedented and comprehensive campaign to separate true islam from extremism the true islam and the extremists campaign educated americans and muslim americans on the peaceful antiextremist teachings of islam by clarifying 11 of the most common misconceptions extremists use to radicalize youth the community extended invitations to over 2100 muslim american imams and thought leaders to endorse the campaign to demonstrate true islam and advance this proven model to combat extremism the campaign was publicized through press conferences flyer distributions meetings with members of local state and federal government opinion editorials television and radio interviews interfaith dialogues public lectures university hosted debates and the public invitation to all americans and muslim americans to join through social media other campaigns followed the same path but were not fully documented literature contribution past research concentrated mainly on the evolving nature and effects of social media usage as a main launching pad of different activism campaign hashtags from reviewing past literature the researcher noticed that while abundant theoretical research tackled the matter of violent extremism via social media and methods to counter this sort of violent extremism known as cve no research actually analyzed the role of social media activism campaigns or campaign attempts to combat extremist and terrorist activities nevertheless lots of research tracks have been discovered that will be dealt with hereafter ameripour et al discussed the usage of social media in iran to launch conviviality campaigns and found out that internet conviviality cannot be treated as an independent variable with deterministic outcomes on society but as a technology that is shaped by ongoing economic and political forces furlow found out through analyzing three cause related marketing campaigns via facebook that they have effectively reached their target audience through social media özdemir analyzed the social media green campaign yemezler launched in turkey as an advocacy pr campaign and proved effectiveness and feasibility for ngos through an advocacy pr campaign on twitter in both us and canada brickner analyzed educators care health care campaigns via social media gained lots of attention pillai tackled the issue of healthcare campaigns via social media cameron et al tackled the effect of social media campaigns via facebook on organ donation livingston et al studied effects of a social media intervention campaign on the attitudes of young people towards mental health issues dowshen et al discussed the effect of social media on promoting getting tested for stds among american adolescents jawad et al revised a social media campaign on water pipe smoking hazards dunlop et al studied utilizing social media campaigns in promoting healthy eating habits similar to huesch et al research on public heath social media campaign ketterand avraham found out that during analyzing 10 place branding social media campaigns that the distinction between the components of source message and receiver fades as users gain more power and take an active role in the creation and distribution of campaign messages political campaigning via social media gained lots of focus as to glamorize mostly its effects the israel loves iran and iran loves israel facebook campaigns came about in march 2012 as means to counter the promilitary rhetoric emanating from both the israeli and iranian governments and has been a subject to extensive study ahmad and sheikh discussed the role of social media campaigns in triggering youth political participation among university students aragon et al studied political social media campaigns in spanish elections of 2011 carlson et al discussed political campaigning via blogging in finland wells et al compared social media usage between us and french presidential campaigns in 2012 hagar discussed municipal election social media campaigns in canada spierings and jacobs discussed the role of social media campaigns on preferential voting other types of activism research on religious usage of social media were spotted though including finnigan and rosss paper on mormon feminists usage of social media through facebook and blogs from 2004 to 2013 to connect with one another and navigate potential pitfalls in religious feminist activism it was apparent that past research recognized the maximum importance and effectiveness of social media in launching successful campaigns but some warned about the failure to control messages which might lead to inevitable problems researchers cant deny though that the rapid development in internet technologies provided new tools for campaigns social media in particular reduce dependency on mass media enable organizations to reach larger stakeholders and provide a platform for developing twoway communication with stakeholders thus facilitating participation majorobjectives and research questions the objective of the current research is to review qualitatively the social media platforms of the hashtag notinmyname initiated by renowned muslim british community namely active change foundation to launch their proislam and antiextremism campaign as a successful model of social media activism combatting the worsening image of islam through linking it with extremism as alleged by haters notinmyname campaign hashtag was chosen as a successful modelof proislam hashtags to be analyzed for its apparent success in gaining worldwide attention of at least 85000 people and 14000 tweets in less than a week from its launch early september 2014 converting it from a local community campaign hashtag to being honorably mentioned by former american president barak obama when addressing the un general assembly and former uk prime minister david cameron as well the research qualitatively reviews notinmyname social media accounts via twitter facebook instagram and you tube in a time period extending from paris attacks dated 13112015 till 1562016 three days past orlando shooting this time frame was purposively chosen due to islamic extremism escalating attacks on civilians all over the world during this time period that also witnessed muslim activists attempts to modify the highly negative image of islam via substantive social media efforts this effort comes to consider the role of social media to reinforce the true image of islam as a counterreaction to focused attention on islamic extremist content on the internet the increasing use of social networks by both sides demonstrates that it is a key arena in the battle for muslims around the world the current research poses two major research questions as follows 1 has there been any attempts to restore the image of islam and combat extremism through social media campaignhashtags other than not in my name 2 how are notinmyname social media accounts utilized to act as proislam platforms research methodology and sampling procedures notinmyname hashtag was revived strongly following paris attacks in 13112015 as the terrorist attacks erupted in paris people throughout the world mourned with france and appalled muslims turned to social media using the hashtag notinmyname reviving the notinmyname hashtag many muslims are sending messages and posting images that isis the group claiming responsibility for the attacks that killed over 129 people and left 352 injured does not represent islam since then muslims worldwide have resided to the hashtag to condemn and denounce every terrorist attack launched under the name of islam finally wrapping up with orlando shootings sunday june 12 after which social media have been ablaze with posts bearing the hashtag notinmyname with muslims across the world calling for peace and refusing to be stereotyped after the devastating orlando attacks in the aftermath many muslims took to twitter and instagram to express empathy for the victims using the hashtag notinmyname the hashtag which has been used after previous hate crimes is a reminder that violence is not condoned in the religion qualitative analysis then emerged as the only possible option to undergo the current research for matters of complexity overlapping incidentsand the multiplicity of terrorist attacks during thistime frame major findings the next part presents the major findings regarding the qualitative analysis of notinmyname official accounts via twitter facebook you tube and instagram as follows a review of not in my name twitter account another page on facebook and a youtube channel that will be reviewed hereafter this website was launched since launching the first phase of the campaign in september 2014 people tweeted their admiration and support of the campaign but some tweeted why so late violent islamism didnt show its ugly face since yesterday 6 even the campaign heading not in my name was used to launch footage shot via similar technique condemning different political governmental actions as the footage that was shot to condemn australian governmental actions towards banning refuge or to denounce european politicians sending back refugees to turkey the heading of the campaign was used as an international icon in itselfsymbolizing denouncing every action that was a disgrace in one way or another from the viewpoints of followers of the hashtag 7 not only footage but the heading itself not in my name was used extensively as a motto to launch different opinions in different matters that followers condemn so not in my name was used as a motto to combat racism in south africa in tweets starting 132016 also used as a motto to condemn bullying at schools and used as a motto by danish citizens in their campaign shame on denmark denouncing the acts of denmark in banning refugee entry to its territories 8 actually the heading of the campaign was used as a title to two songs one denouncing the acts of the british government cutting budgets privatizing health care and desubsidizing disabled and the second by the metal band ashestoangels denouncing wars and accusing war initiators of having blood on their hands the two songs were tweeted and retweeted on the hashtag in multiple occasions 9 notinmyname account was used extensively to condemn all terrorist attacks undergone by radicals paying allegiance to isis muslims and sympathetic nonmuslims defended islam and the hashtag american footage was shot in the same style as notinmyname videos in response to the endeavors of such campaigns supporting the diversity of the american community 12 several political social and economic issues were discussed using the hashtag as if notinmyname as many similar twitter accounts were set to be an uprising platform against all unjust actions taking place in different parts of the world tweets retweets news photos videos vines and caricature in many languages but mainly english arabic french and spanish tackled many controversial issues including trumps views childrens suffering british budget cuts refugee entry denial bombing yemen syrian war troubles in libya and voting against disability support several hashtags were also mentioned on the twitter account that link followers to such situations discussed especially the refugee matter that was often discussed during the review period 13 the emotional appeals were extensively apparent in all media displayed through the hashtag tragic pics of children horrifying videos of bombings and massive fires were displayed especially related to certain issues as child refugees banned from entering britain strong language was used as well including powerful phrases describing australia for example as disgracing humanity speaking on the behalf of europe as i am europe and i say no to the refugees offer sanctuary for people seeking asylum or addressing terrorism as stop hijacking islam to promote your terrorism 14 news from all over the world in different languages was posted on the hashtag some discussing the campaign especially after the different terrorist attacks or other crucial events under headlines as muslims launch powerful social media campaign against isis with notinmyname or muslims are taking twitter to express empathy for the victims by tweeting messages with notinmyname hashtag or people have taken to twitter to show their anger at the uks airstrikes in syria using notinmyname news on all the other issues discussed via the hashtag as refugee problems governmental problems and election problems were also posted frequently news on certain related events was also posted as the islamic awareness week in britain dated 2132016 or news on lectures held to defend islam as notinmyname muslims respond held by salim almarayati the president of muslim affair council in indiana us dated 1852016 a review of notinmyname facebook page the current research reviewed qualitatively the campaign page on facebook the facebook page was not well known as the twitter account or publicized as much the researcher tracked the same time interval and procedures as happened with the twitter account and deduced the following results 1 the facebook page of the campaign is a miniature copy of the main twitter account as mentioned before notinmyname twitter account turned out to be a rich platform concerning controversial debates on islam muslims refugees and various governmental actions on the contrary most of the posts on the facebook page included footage from the campaign and news about the campaign in the form of articles and videos in large proportions since launching the campaign back in september 2014 then reviving it the day following paris attacks and continuing until orlando shooting maybe the reason behind maintaining a less viable facebook page is that twitter was the major platform of the campaign in the first place even lots of articles mentioned twitter as being the main platform of the campaign notinmyname muslims condemn is through twitter campaign the other reason resides in the nature of twitter itself being a platform for every heated controversial issue worldwide 2 although the facebook page was less active than the twitter account they shared some similarities one of the most important was not in my name being used extensively as a motto to launch different opinions in different matters that people condemn on the page so not in my name was used as a motto to denounce uks airstrikes on syria or trumps hate speech of muslims after orlando shooting by members of lgbt declaring that he doesnt speak in their name news on these other matters was posted all around the facebook page 3 another point of similarity comes from the page being used as a platform of discussing several political issues as if notinmyname was set to be an uprising platform against all unjust actions taking place in different parts of the world but not with the same strength or frequency as the twitter account several controversial issues were tackled including trumps views of muslims in the us childrens suffering in syria condemning british decision to bomb syria refugee entry denial and asylum refusal gaza problems and defending islam in covering those issues different languages were used same as the twitter account 4 the major finding was that the coverage of the campaign was more effective than the campaign itself and thats the advantage of stirring issues via social media and this fact was apparent especially through facebook where hundreds of articles on the campaign and muslim solidarity moves were posted a review of not in my name you tube channel not in my name symbolized activism against all unjust actions and the motto itself was drawn and photographed in different colors and effects and posted all over the account 6 most pics and footage posted held opinions proislam but some held opinions antiislam as happened with all accounts per mentioned 7 pics and footage differed in the appeals used some hilarious using the humor appeal through mocking the statusquo others sharply criticizing the political situation and ones terribly tragic portraying horrifying images especially those of dead and injured children during attacks on different arab states especially syria 8 the major finding depicted here was that notinmyname via instagram acted as an activism arena of all unjust causes of the world through pics that are more powerful than a thousand words british european american isis and middle east issues were discussed under the heading notinmyname making the heading of the campaign more powerful than the campaign itself and lasting through social media even after the campaign activity ended based on the previous analysis the following discussion will hold the answer to the two key research questions followed by a general conclusion rq1 has there been any attempts to restore the image of islam and combat extremism through social media campaign hashtags other than not in my name results definitely suggested the existence of other campaign attempts aiming at the image restoration of islam although mostly lacking organization unified perspective and message consistency over the years many individual and group attempts were spotted to modify the distorted image of islam either online or offline many campaigns launched via different organizations preceded aligned with or followed not in my name campaign although mostly not that successful and gaining far less coverage by the general public • the heading of the campaign was used as an international icon in itself symbolizing denouncing every action that was a disgrace in one way or another from the viewpoints of followers of the hashtags • not in my nameheading was used extensively as a motto to launch different opinions in different matters that followers condemn so not in my name was used as a motto to combat racism or used as a motto to condemn bullying at schools or used as a motto by angry citizens defaming their nations one way or another • notinmyname accounts were used as a platform for discussing several political issues as if notinmyname was set to be an uprising platform against all unjust actions taking place in different parts of the world using the growing availability of usergenerated viral videos discussing all sorts of controversies • the major finding was that the coverage of the campaign was more effective than the campaign itself and thats the advantage of stirring issues via social media and this fact was apparent conclusion the major conclusion of this study was that proislam hashtags acquired unprecedented power to stir political and social movements especially regarding controversial and stagnant matters posts comments and shares on different social media platforms go viral stir discussions and trigger public opinion both virtually and in reality this campaign hashtags were not a launching base for the campaign as much as being an outlet breather for all pro and antiopinions regarding not only islam but every other controversial matter taking place in the world at the time social media are now the pathway to mobilize the crowd online to take an action in the real world since the new media can promote more inclusive social interaction that respects minorities and minority views muslims abroad instead of using social media activism as mostly reactionary muslim social media activism needs to do more than stop bad speech it also needs to help create good speech as uddin emphasized waiting to launch those hashtags after tragic and disastrous events ousts these efforts of their ultimate goals of image restoration and confines them to achieve temporary goals rather than permanent ones a well planned activism effort that teaches people abroad the true meaning of islam through employing wellorganized long term objectives can be launched using social media and offline acculturation activities as the islamic awareness weeks lectures advocacy… etc in order to abandon the scant ineffective individual efforts to achieve more systematic collaborative endeavors maximizing the ultimate positive outcomes

there have been so many acts of terrorism connected to radical muslims that its not surprising islam has a public relations problem pollsters historians and other experts say that the wests collective instincts toward islam have been shaped over decades by a patchwork of factors these include demographic trends psychology terrorism events foreign policy domestic politics media coverage and the internet therefore it is not surprising that muslims are the most negatively viewed faith community in some countries as the united states the objective of the current research is to review qualitatively the social media platforms of the hashtag notinmyname initiated by renowned muslim british community namely active change foundation as a successful model of social media activism combatting the worsening image of islam the major conclusion of this study is that hashtags launched by muslim activists derive from the social media platforms exacerbating and unprecedented power to stir political and social movements especially regarding controversial and stagnant matters posts comments and shares on different social media platforms go viral stir discussions and trigger public opinion these hashtags were not a launching base for a proislam campaign only as much as being an outlet breather for all pro and antiopinions regarding islam social media are now the pathway to mobilize the crowd online to take an action in the real world

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introduction the connection between migration and health has long been established but relatively little is known about this relationship for older persons particularly in subsaharan africa migration and health research in ssa has typically focused on individuals of reproductive ages with particular attention on adolescents and young adults this is partly due to the health measures of interest in this research which are more relevant for individuals of reproductive ages such as hiv infection infantchild mortality or fertility meanwhile older adults constitute a substantial and growing population in ssa in africa five percent of the population is aged 60 and older and this percentage is expected to steadily increase in the coming decades the annual growth rate of the 60 and older population in africa is expected to be higher than in other regions this population is projected to nearly double in size by 2030 and then double again by 2050 some of the above health outcomes are increasingly relevant for older populations in ssa hiv prevalence while lower than those of reproductive ages is nonnegligible at older ages and projected to increase with expanded access to hiv antiretroviral therapy hence research has called for increasing attention to hiv infection at older ages in ssa at the same time ssa is characterised by high rates of internal migration although migration data are limited populations in ssa have been considered more mobile compared to those of other regions shortand longterm moves are relatively common in many ssa countries and recent studies have documented increasing rates of migration in some countries in this research we investigate the intersection of migration ageing and health in the subsaharan african country of malawi specifically we examine migration health selection among older individuals or whether those who migrate differ from nonmigrants in health status before migration secondly since relatively little is known about the factors that influence migration among older adults in ssa we also identify factors influencing migration for this population background migration patterns among older adults the lack of research on migration patterns of older individuals in ssa is primarily due to data limitations common data sources like demographic and health surveys collect very limited information for individuals beyond reproductive ages while demographic surveillance sites collect data for older individuals this population is seldom the focus of analysis furthermore the limited available data are of questionable quality eligible older individuals may be systematically missed in some populationbased surveys although younger individuals are more likely to migrate in ssa mobility is not uncommon among older people as well across settings migration propensities are highest at younger ages and tend to decline with age but migration at older ages is nonnegligible both in ssa and elsewhere research shows that migration at older ages is less common than in young adulthood but not uncommon overall some characteristics of migration likely differ for older individuals while youngadult migration in ssa is primarily due to marriage and work the minimal literature on older ages suggests that primary reasons for moving are to return home either after retirement being unable to independently maintain the household marital dissolution or for palliative care by relatives this type of migration also implies that migration stream may differ by age whereas young adults often to move to urban centers ruraltorural and urbantorural migration may be more common among older individuals migration and health migration research has often examined the healthy migrant hypothesis or the tendency for migrants to be healthier than peers the health advantage of migrants is due in part to the physical and psychological demands of migration both in terms of the moving process as well as being able to successfully maintain residence in the destination because migration and successful relocation is often challenging migrants are often relatively healthier however the limited knowledge of migration and health in older age suggests reasons for both positive and negative health selection on one hand migration may select relatively healthier older individuals for older individuals successful movement and adaptation to a new environment may require better health just as for younger populations indeed the healthy migrant hypothesis has been supported for older individuals migrating to the us however there is also reason to believe that migration may select older individuals with relatively worse health research in ssa has documented the phenomenon of older individuals returning home to die or for palliative care and recent studies have shown that hivpositive individuals are more likely to migrate than the hivnegative migration health selection may also depend on the reason for migration and migration stream international and ruraltourban migration may occur primarily among individuals looking for or starting work therefore requiring them to be healthier but ruraltorural migration may occur after marital dissolution or for climaterelated reasons and the same relationship between migration and health selection may not hold although there is very little research on migration stream and health in any setting some studies have shown that urbantorural return migrants have worse health outcomes than those who stay in urban destinations research on migration and health often has important limitations in study design with crosssectional data it is challenging to discern whether differences in health status after migration are due to the effect of migration on health or due to healthier individuals being selected into migration therefore to examine migration health selection one would need information for individuals prior to migration however data for older individuals in ssa is rare and longitudinal panel data for this population is even less common methods setting malawi provides an instructive context in which to examine migration and health at older ages the population of malawi is growing and ageing the proportion of the population aged 60 years and older in malawi is expected to increase over the next several decades despite the growth of this population little is known about migration patterns among older individuals in settings like malawi or the relationship between migration and health as in other countries in ssa there is a close relationship between migration and hiv infection malawi has a high hiv prevalence of 106 with the highest prevalence in the southern region followed by the central region and the northern region icf macro 2011 research has found that migrants are more likely to be hivpositive than nonmigrant counterparts and this appears to be due to the selection of hivpositive individuals into migration malawi has experienced high rates of urban population growth in recent decades which are expected to continue in the coming years however the majority of ssa residents still live in rural areas and intrarural migration has consistently been the most common spatial migration pattern in ssa overall and in malawi in particular marriage and migration are closely linked in malawi and this relationship varies across regions and ethnic groups and by gender the northern region practices a patrilineal tradition with patrilocal or virilocal residence after marriage and inheritance traced through sons the yao a predominant ethnic group in the southern region follow a matrilineal system of descent and inheritance and residence after marriage is often uxorilocal the central region is less rigid in patterns of land inheritance and migration after marriage individuals typically move back to their homes after marital dissolution since marriage is nearly universal in malawi and malawi has among the highest divorce rates in ssa one would expect a close relationship between migration and marriage indeed previous research has found that migration patterns reflect the marital traditions in malawi with women more likely to move in the northern region and less likely in the southern research has also found that the reasons for migration are primarily marriagerelated for women and workrelated for men data we use a dataset that has the necessary characteristics for studying migration health selection among older adults a substantial sample of older individuals longitudinal panel data with migration information and measures of mental health physical health and hiv status the malawi longitudinal study of families and health started in 1998 with a populationbased sample of approximately 1500 evermarried women and 1000 of their husbands in three rural sites of malawi the mlsfh followed up with all respondents in 2001 2004 2006 2008 and 2010 the mlsfh initiated homebased hiv testing for all respondents in 2004 with followup testing in 2006 and 2008 more information on the mlsfh study design sampling and measures is available in kohler et al in 2008 the mlsfh added a sample of approximately 800 parents of mlsfh respondents most of whom were aged 45 and older to draw this sample the mlsfh team asked respondents in 2006 to list characteristics of their parents which were used in 2008 to identify and interview all parents who resided in a mlsfh sample village of mlsfh respondents aged 45 or older in 2008 a total of 1033 men and women were interviewed and tested for hiv of these 1033 respondents 783 were interviewed again in 2010 and 48 moved elsewhere ethical considerations the data collection and research conducted by the mlsfh was approved by the institutional review board at the university of pennsylvania and in malawi by the college of medicine research ethics committee or the national health sciences research committee measures functional limitations arise at earlier ages in malawi compared to developed countries thus a different definition of older age is necessary a study assessing physical limitations of men and women at ages 45 55 65 and 75 years found that disabilities begin at a relatively early age and are more severe than comparable ages in more industrialised settings life expectancy at birth in malawi is less than 60 years and life expectancy at age 45 is 231 years for men and 262 for women healthy life expectancy at birth is lower at 44 years for men and 46 years for women therefore previous research has identified 45 as an appropriate cutoff point for examining ageing in malawi which is what we use in this research in all waves of the mlsfh the most common reason for noninterview was migration out of the sample area our measure of migration is a binary indicator of whether the respondent who was interviewed in 2008 had migrated by 2010 migration by 2010 was measured by friends and family members in the origin village who reported that the respondent had permanently moved out of the mlsfh sample village by 2010 individuals who did not move permanently between 2008 and 2010 are considered nonmigrants as elsewhere we find that although the likelihood of migration declines with age migration is not negligible among older individuals approximately 11 of respondents aged 44 or less in 2008 migrated elsewhere by 2010 compared to approximately 6 of individuals aged 45 and older we focus on three health measures in this research mental health physical health and hiv status the measures for mental and physical health status are derived from the shortform12 the sf12 uses twelve questions about various aspects of health to create composite measures of mental and physical health the scores range from 0100 with higher scores representing better overall health status the sf12 has been found to be a valid and reliable measure for overall physical and mental health status including for older adults and has been validated in developing settings similar to malawi another health measure of interest is hiv status research has found in malawi that hivpositive individuals are more likely to migrate than those who are hivnegative but this has not been tested for older individuals in addition to healthrelated measures we identify other characteristics that influence migration in older age some of these measures are basic demographic controls such as age region of residence education wealth and marital status for wealth the mlsfh uses a continuous wealth index score that is obtained through principal components analysis using measures of asset ownership in addition to the demographic controls we examine the influence of previous migration experience number of living offspring household size and religious affiliation the household has been found to be an important source of social instrumental and financial support in this setting which may influence migration number of living offspring may also be associated with migration for older individuals having more offspring increases the chances that one or more are living close by and therefore they may not need to move to seek care previous migration has been shown to predict future migration in some studies we measure this with the question since you were age 15 have you stayed outside this district for 6 months or more finally some studies have shown that migration patterns are closely tied to religious status we measure religious affiliation in five groups muslim catholic mission protestant new mission protestant and pentecostalafrican independent church other which is a similar categorisation previously used in religionfocused research in malawi analytical methods we seek to identify migration health selection for older individuals in malawi to do so we compare 2008 health measures with migration status by 2010 therefore health status is measured before migration and we can examine if individuals who migrate by 2010 had different health status in 2008 we conduct our analysis in three stages first we examine bivariate relationships between our health measures and migration next we conduct multivariate logistic regression analysis using a lagged dependent variable approach where the dependent variable is the binary indicator of having moved by 2010 and independent variables are all from the 2008 mlsfh we begin with a pooled gender model and then test whether the relationship between migration and health differs for men and women by including interaction terms between mental health and gender and physical health and gender in our final models we examine factors predicting future migration separately for men and women results as shown in table 1 mobility is not uncommon among older mlsfh respondents similar percentages of older men and women moved between 2008 and 2010 at approximately 6 and many men and women moved prior to 2008 hiv infection is relatively low in this population at 55 for men and 37 among women for both men and women the highest percentage is in the lowest wealth quintile following with marital and migration patterns the largest percentage of men is from the northern region and the largest percentage of women is from the south bivariate tests show that several measures are strongly associated with future migration including one health measure most notably we see that older individuals who were hivpositive in 2008 were 273 times more likely to migrate by 2010 than those who were hivnegative we also see a relationship with wealth respondents in the middle wealth quintile were significantly more likely to move than the poorest individuals region of residence was also importantly associated with migration where residents of the central region were more likely to move than those from the north those with more children and larger households were less likely to migrate by 2010 our multivariate results show similar patterns as well as some new associations after controlling for other characteristics in the main effects model we find that being hivpositive in 2008 is associated with 369 greater odds of migration than the hivnegative and we see that individuals in the middle wealth quintile had 346 greater odds of migration by 2010 than those in the lowest wealth quintile we also find new associations between religious status and migration where mission protestants and those in the pentecostalaicother group were less likely to migrate than muslim respondents primary education or higher was also positively associated with future migration but the relationship is statistically significant only at the 90 level in the full model we find evidence of significant differences by gender the interactions terms for gender and health are both statistically significant which shows that at the same level of physical health and mental health the likelihood of migration is significant different for men and women but the exact relationship differs for mental and physical health where at the same level of mental health women are more likely to move and the same level of physical health women are less likely the main effects of mental and physical health are also statistically significant which shows that among men those with better physical health are more likely to migrate and those with better mental health are less likely to migrate finally we turn to the final set of regressions where the relationship between migration and health is conducted separately by gender for women we see that being hivpositive in 2008 is associated with a greater than nine times odds of migrating by 2010 than the hivnegative but we do not find a statistically significant result between hiv status and migration for men however mental health is associated with migration for men in which a one unit increase in mental health is associated with 9 lower odds of migration we also find differences by gender in other factors that are associated with future migration among older individuals the relationship with age and migration is in opposite directions for men and women where the likelihood of migration increases with age for women and decreases for men the relationship with wealth appears only for women where those in the middle and second highest wealth quintiles are more likely to migrate than are the poorest among men household and religious factors were important where men from larger households were less likely to move and mission protestants and those in the pentecostalaicother group were less likely to migrate than muslim respondents discussion we find that health and migration are strongly associated for older individuals in malawi but the exact relationship between migration and health differs by gender there is some evidence of negative health selection older women who are hivpositive are nearly ten times more likely to migrate compared to their hivnegative counterparts however for men those with better mental health are less likely to migrate in the future and those with better physical health are more likely to migrate we also find differences by gender in other factors that predict migration among older adults in rural malawi for women it appears that age and wealth are strong predictors of migration women in the middle wealth quintile are more likely to migrate than the poorest women which likely reflects their greater ability to afford costs associated with migration for men religious affiliation age and household size are the most important characteristics predicting migration the relationship with household size is not surprising given that men rely on household members particularly women for care in older ages overall our results are similar to findings from the limited research on migration and health in ssa and other settings previous research has found that hivpositive individuals are more likely to migrate than those who are hivnegative but for a younger population we find here that the same is true for older individuals as well although only for women differences in the relationship between migration and hiv infection by gender are compatible with research showing that hivpositive status is associated with greater likelihood of divorce and lower likelihood of remarriage for women only which is consistent with women moving home after marital dissolution this is also consistent with research showing that hivpositive residents of ssa often return to rural homes to be cared for by family members although they may not currently be physically sick since we do not find that those with worse physical health are more likely to move our results also fit within research on the health of older individuals in malawi as elsewhere we find that household and family structure are important determinants of health among older men which appears to be due to the support that larger families and households can provide for aging individuals in contrast older women are often burdened with caregiving responsibilities and may therefore not benefit directly from larger families or households similarly household composition has also been found to be associated with mental health outcomes like stress in older age other determinants of migration are similar to findings elsewhere although other studies have found lower likelihood of migration among muslims the greater likelihood for muslim men to migrate is likely explained by the fact that the yao ethnic group which is predominantly muslim practice a matrilocal tradition when the husband moves to his wifes home upon marriage this research also reinforces the importance of study design and measures in examining migration and health crosssectional data that compares the health of migrants and nonmigrants would not be able to distinguish between migration selection and the effect of migration on health here we demonstrate the importance of longitudinal data with preand postmigration information and show that there are significant differences in the health status of older individuals prior to migration which may contribute to the impact of migration on health in addition we demonstrate the importance of measuring mental health with regards to migration which is a health outcome that is relatively uncommon in migration and health studies our results suggest that older migrants in malawi may represent a vulnerable population as we find evidence of worse health among some migrant groups although individuals of reproductive ages are the primary focus of hiv infection programs hiv infection is also relevant at older ages older hivpositive migrants may be particularly difficult to connect to antiretroviral therapy due to their mobility unless the purpose of the move is to seek treatment this is even more challenging for mental health as services to treat mental illness are not well established in malawi our study has several limitations although the mlsfh data include larger numbers of older individuals than other studies there are small sample sizes for some characteristics such as the number of hivpositive and the number of overall migrants also in this research we focus only on permanent migration among older individuals research elsewhere has shown that circular migration and shortterm migration may also be importantly related to health outcomes nonetheless our research represents one of the first papers to empirically examine the relationship between migration and health in ssa and future research is needed to better understand this phenomenon for example we do not examine the impact of migration on health or changes in health status after migration this is an important issue as the mental health of men may improve after migration if they move in order to receive care from friends or family members similarly older hivpositive women may move due to marital dissolution or to gain easier access to hiv treatment which has different implications for health

the connection between migration and health has long been established but relatively little is known about this relationship for older persons particularly in subsaharan africa ssa in this paper we examine migration selection with regards to health status among older individuals in malawi by testing whether older migrants differ from nonmigrants in health status before migration to do so we use data from the malawi longitudinal study of families and health mlsfh a longitudinal panel dataset that includes a relatively large number of individuals at older ages we focus on three measures mental health physical health and hiv status we find that the relationship between migration and health selection differs by gender older women who are hivpositive are nearly ten times more likely to migrate compared to their hivnegative counterparts for men those with better mental health are less likely to migrate in the future these results suggest that although research in some settings shows that migrants have better health before moving some older migrants have worse health than their nonmigrant peers and may therefore add to the alreadyheavy burden on rural health centers in africa

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the covid19 pandemic has become a global threat to all aspects of life hampering social stability economic development and health security a daunting effect on peoples mental health and psychological state has been reported owing to pandemicrelated issues affecting aspects of mental health including fear anger sleep difficulties boredom hopelessness and frustration 1 these pandemicrelated effects have appeared to reduce physical movement and activity increase food and harmful junk food consumption and increase mental health symptoms such as those of depression anxiety and posttraumatic stress disorder across various groups 23 furthermore the combination of these stressors with mental health effects may contribute to suicidal ideation 45 suicidal behaviours among pwds suicide is a major public health issue as per the world health organizations recent estimate there is an annual suicide rate of about 700 000 suicide worldwide of which 77 of cases occur in lowand middleincome countries such as bangladesh suicide rates are higher among vulnerable groups including people with disabilities compared with the general population as people in these groups experience discrimination such as being treated less favourably and not receiving the same facilities as others this represents a pressing and complex public health issue 67 in a recent systematic review suicidal ideation and death by suicide were reported to be associated with functional disability the highest rate of suicide was reported in people with multiple sclerosis followed by those with spinal cord injury and intellectual disability 6 associations have also been found in people with other disabilities including autism spectrum disorders and huntington disease 89 suicidal behaviours in the context of the covid19 pandemic among pwds a recent study found that pwds experienced increased symptoms of depression substance use and suicidal ideation compared with people without disabilities during the covid19 pandemic 10 two other studies from the uk and usa also found an increased prevalence of suicidal ideation among pwds compared with those without disabilities during the covid19 pandemic 1112 despite such high rates of suicidal ideation among pwds relatively little research has examined the risk factors for suicidal ideation within and across populations on 15 march 2020 the first suicide case attributed to fear of covid19 in bangladesh occurred 13 later a systematic review from bangladesh identified the factors that lead to actual suicide completion and the prevalence of and risk factors associated with suicidal behaviors 5 the prevalence of suicidal ideation was reported to range from 5 to 19 across different cohorts and the rate of suicidal ideation increased over time due to the covid19 pandemic 5 minorand pwdrelated homicidesuicide has been reported in the context of the pandemic for instance a case study reported the alleged infanticide of a 6monthold baby with the suicide of an indian 30yearold mother in saudi arabia due to fear of infection 14 in addition a triadic suicide pact was reported in india where a disabled son and his parents had been alleged to die by mutual suicide 15 however no actual suicide occurrence among pwds during the covid19 pandemic has been reported to the authors best knowledge study objectives bangladesh hosts a huge number of pwds 16 million or 10 of the countrys population has some type of disability 16 a recent qualitative study conducted in bangladesh among pwds suggested that the covid19 pandemic created critical disruptions to the economy and decreased their food security social security and physical and mental health 17 as discussed above people with mental issues are more prone to suicidality 45 and it is anticipated that pwds might be at higher risk of suicidal behaviours however no other epidemiological study has been conducted in bangladesh among pwds considering suicidal behaviours during the covid19 pandemic thus there is a need for research on suicidal ideation to clarify the associated factors in order to develop suicide prevention strategies this study uses a crosssectional survey to address these research gaps and examines the prevalence of covid19related suicidal ideation and associated factors among bangladeshi pwds method study area this crosssectional study was conducted from february to april 2021 in the districts of kurigram lalmonirhat dinajpur nilphamari panchagarh and gaibandha these six districts were purposively selected from these six districts 15 upazilas were randomly selected and at least one upazila was selected from each district to collect the data study population and inclusion criteria the target population was people with various disabilities disability types described previously 1819 were assessed in brief people with locomotor disability amputation that causes loss or absence or inactivity of the whole or part of the hand or leg paralysis or deformity of joints affecting the normal ability to move self or objects were considered to be physically disabled people with serious difficulties seeing even when wearing glasses were considered to be visually impaired similarly people with hearing difficulties even if using a hearing aid were included in the hearing disability category people screened for leprosy and currently undergoing treatment were recruited as the leprosy group finally people who suffered from more than one of the aforementioned disabilities were considered to have multiple impairments pwds aged ≥18 years were selected for this study of note pwds who were critically ill during the survey unable to respond to the questionnaires or had preexisting depression anxiety or sleep disorder were excluded from the study ethical consideration the authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the helsinki declaration of 1975 as revised in 2008 all procedures involving human subjects or patients were approved by the patuakhali science and technology universitys human research ethics committee to participate in this study written consent was required from either the participants or their caregivers participants were aware that this publication was intended while taking part in the study sampling technique and data collection the final required sample size was 423 with a 95 confidence interval 10 nonresponse rate and an assumption of a 50 prevalence of suicidal ideation among the study subjects using the single proportion formula a total of 410 pwds were recruited the snowball sampling method was applied to access the pwds where team members identified additional participants based on the information given by the previous participants data were collected through facetoface interviews by trained interviewers in participants homes using a pretested structured questionnaire including sociodemographic information clinical characteristics and behavioural characteristics if any participants did not understand the consent process caregivers were interviewed and answered our questions on behalf of the participants importantly participants with hearing disability used hearing aids to improve their hearing and speech comprehension while participating in the survey measures sociodemographic measures sociodemographic factors included age locality marital status religion educational level occupation and living situation socioeconomic status was classified as follows less than 15 000 bangladeshi taka 15 00030 000 bangladeshi taka or more than 3000 bangladeshi taka clinical and behavioural measures clinical and behavioural measures included type of impairment onset of impairment comorbidity testing positive for covid19 covid19 symptoms current substance use and increased substance use because of covid19 sleeping hours were divided into three categories normal less than normal or more than normal mental health measures the bangla version of the depression anxiety and stress scale was used in this study 20 this scale is composed of 21 questions divided into three subscales with seven items per subscale depression anxiety and stress with scored using a fourpoint likert scale ranging from 0 to 3 predefined thresholds used for depression anxiety and stress in the present study were normal mild moderate severe and extremely severe the cronbachs alpha values for depression anxiety and stress were 070 073 and 079 respectively these values were acceptable fear of covid19 measures the bangla version of the fear of covid19 scale 21 was used to measure the level of fear of covid19 this tool for assessment of fear of covid19 comprises seven items on a fivepoint likert scale ranging from 1 to 5 with scores ranging from 7 to 35 scores of 021 are considered to indicate low covid19 fear and scores of 2235 are considered to indicate high covid19 fear 22 the cronbachs alpha for fear was 084 in the present study which was good covid19related suicidal ideation measure suicidal ideation related to covid19 was determined by a single question with a binary response based on the previous study 5 as the covid19 pandemic started on march 2020 in bangladesh and this study was conducted 1 year later the suicidal ideation assessment timeframe was pastyear statistical analysis data were analysed using the spss version 26 simple descriptive analyses were used to summarise the sociodemographic and clinical characteristics chisquared tests and unadjusted and adjusted logistic regression models were developed to assess the associations of the main outcome with independent variables the multicollinearity of variables was also assessed before regression analysis variables with p 025 in the unadjusted model were entered into the multivariable analysis model fitness was checked using the hosmerlemeshow goodness of fit test odds ratios and 95 confidence intervals were calculated for each variable included in the regression models with a pvalue less than 005 results sociodemographic characteristics and suicidal ideation table 1 summarises the sociodemographic characteristics and their relationship with suicidal ideation of the total participants 673 were male 445 were unmarried 778 were rural 580 were from lower economic status 812 were muslim 24 were students and 441 were living with parents about 239 of the participants reported experiencing covid19related suicidal ideation defined as pastyear suicidal ideation related to the covid19 pandemic and associated issues age gender marital status education level and living situation were significantly associated with suicidal ideation regarding age groups a 383 suicidal ideation rate was found among pwds aged over 35 years compared with 179 for those aged 18 to 35 years this difference was statistically significant females were more likely to report suicidal ideation compared with their male counterparts pwds also reported higher suicidal ideation when their marital status was divorcedwidowedseparated their education level was uneducated or they lived alone among participants who reported becoming disabled later in life a higher proportion experienced suicidal ideation compared with those who had impairment onset in early childhood and from birth those who reported sleeping for less than 7 h reported a higher suicidal ideation rate than those sleeping for normal or longer than normal lengths of time those who tested positive for covid19 and had current covid19 symptoms were more likely to have suicidal ideation in addition pwds who were substance users and reported an increment in substance use after the pandemic had higher suicidal ideation compared to those who did not meet these criteria finally none of the mental disorders was significantly associated with suicidal ideation but for fear of covid the association was χ 2 593 that is 3012 of pwds who had high covid19 fear reported suicidal ideation compared with 1967 for those with low fear of covid19 risk factors of suicidal ideation multivariate logistic regression analyses were performed using sociodemographic clinical and behavioural predictors to reveal the risk factors for suicidal ideation the results showed reference reference aor adjusted odds ratio ll lower limit ul upper limit na not applicable for multivariate analysis suicidal ideation in people with disabilities during covid19 of having suicidal ideation were 235 times higher among participants who developed a disability later in life than in those who had a disability from birth respondents who slept less than normal were 312 times more likely to have suicidal ideation than those who slept normally respondents currently using drugs had 298 times more suicidal ideation compared with their counterparts discussion this study investigated for the first time the magnitude of and factors associated with suicidal ideation among pwds in bangladesh about 239 pastyear suicidal ideation related to the pandemic was reported during the covid19 pandemic a very high prevalence rate factors significantly associated with suicidal ideation included age above 35 years female gender being uneducated having developed disability later in life reporting less sleep and current substance misuse unfortunately to the best of the authors knowledge no previous studies have been conducted among bangladeshi pwds to explore suicidality hence this studys findings were compared with those of earlier studies involving diverse cohorts methods and cultures conducted inside and outside bangladesh during or before the covid19 pandemic a recent prepandemic systematic review including studies of pwds concluded that the prevalence of suicidal ideation was 102 to 127 and 14 to 277 23 during the pandemic in the usa and uk prevalences of 306 and 207 for suicidal ideation respectively were found among pwds 1012 notably this study found the prevalence of pastyear suicidal ideation related to the covid19 pandemic to be 239 in the recent systematic review of covid19related studies the suicidal ideation rate ranged from 5 to 19 across different bangladeshi populations thus this studys suicidal ideation prevalence rate appears very high 5 however the present study covered a longer timescale than the previous bangladeshi studies and the cohort appears to be mentally vulnerable therefore we conclude that a large proportion of pwds are at risk of suicidality requiring emergency mental health support to prevent suicide during the postcovid19 pandemic period suicidal ideation was higher in this study among older pwds consistent with previous studies 23 during the covid19 pandemic this finding was also in line with those of another study conducted among disabled adults 10 although two other studies did not find such an association 1112 the higher rate of suicidal ideation in middleaged and older adults could be explained by the fact these individuals are less likely to express suicidal ideation before their death have greater determination and are less likely to be rescued owing to physical frailty this could reduce the prevention of suicide as well as limiting opportunities for intervening with those who have suicidal behaviour however only two age categories were considered in this study and the relationship of age with suicidal ideation might therefore have been overestimated thus the relationship between age and suicidal ideation among pwds is still unclear especially regarding suicidal thoughts and suicide attempts this requires further elucidation gender plays an important part in suicide and suicidality as estimated by the world health organization higher rates of deaths by suicide occur among males for instance 137 deaths per 100 000 population compared with 75 for females 24 however suicidal behaviours appear to be prevalent among female 25 and the prevalence of suicidal ideation as a way to cope with stress or emotions is higher among females than among males for example a us study among pwds conducted during the covid19 pandemic focusing on different aspects of psychological health found that 374 of the male participants had seriously considered suicide compared with 226 of the females 11 however more studies are recommended to investigate which gender is at higher risk of suicide and suicidality to better understand genderbased suicide risk and prevention consistent with this studys findings rahman et al and meltzer et al found lower educational attainment to be a potential risk factor for suicidal ideation among pwds 2627 although the effect of lack of education still remains controversial 28 individuals with lower educational levels may be at a higher risk of suicide owing to earlylife factors both decreasing educational opportunities and increasing mental health difficulties another notable finding of this study was that participants who had been disabled from birth were less likely to report suicidal ideation this could be explained by the fact that individuals disabled from birth might develop coping mechanisms from an early age find the support system that they need and increase their acceptance after many years of struggling to cope with life although further studies are needed to reach more robust conclusions consistent with the findings of the present study it has been well established that there is a strong relationship between suicidal ideation and sleeping problems 511 in the systematic review of bangladeshi studies a wide range of psychopathological factors including depression anxiety stress sleep problems history of suicidal behaviour and family history of suicide were found to increase the risk of suicidality during the covid19 pandemic 5 notably this study found no significant difference in suicidal ideation rates based on whether the pwds experienced depression anxiety and stress similar to the findings of other studies 2930 suggesting that depression anxiety and stress might not strongly contribute to the increased rate of suicidal ideation among pwds this is a very unusual finding in the context of the pandemic or otherwise thus the psychopathological factors in suicidality among pwds should be further investigated to better understand the indirect consequences of the covid19 pandemic variables directly related to the covid19 pandemic were included in this study we found that pwds who had tested positive for covid19 had more thoughts of suicidal ideation as documented earlier the pandemicrelated variables that were estimated to increase the risk of suicide in bangladesh included lower knowledge about covid19 practicing fewer preventive behaviours related to covid19 having elevated levels of fear of covid19 residing in covid19prone areas experiencing economic problems and experiencing covid19related deaths of family members or relatives 15 as aforementioned the first case of covid19related suicide in bangladesh was attributed to fear of covid19 13 later an indian study reported that covid19 fear was the factor with the greatest effect on suicide accounting for 21 deaths out of 69 31 consistent with other pandemic studies the present study identified fear of covid19 as a prominent stressor for suicidal ideation possibly owing to the increasing number of infections uncertainty and phobia 1315 the suicidalityrelated factors identified in this study and elsewhere should be considered when planning further studies or any preventive actions substance misuse and associated disorders have increased after the pandemic for instance a us longitudinal study found a 1336 increase in problems related to alcohol or illicit substance use across three groups adults without children parents and adolescents after the inception of the pandemic 32 in addition a hospital registry analysis reported a 590 rate of substance use disorders among ugandan adolescents which showed a nonsignificant increase to 980 after the pandemic 33 in this study 38 of pwds noted an increase in their drug use and drug use in general appeared as a risk factor for suicidality consistent with previous studies 10 11 12 these findings demonstrate a higher prevalence of substance use as well as a higher risk of suicidal ideation to cope with stress and emotions during the covid19 pandemic the present study had some limitations that are worth noting this study was crosssectional therefore the data cannot be used to infer causality in addition this study did not assess changes in disability status and suiciderelated outcomes over time owing to its crosssectional nature thus further studies are warranted to determine how disability is associated with suiciderelated outcomes over time besides suicidal ideation was measured using a singleitem question with a binary response future studies are needed to understand the continuum between suicidal ideation and suicidal planning before attempting suicide completion using a longitudinal study design moreover this study did not include a number of other important factors related to suicidal ideation including history of suicidality among friends and family social support loneliness and selfesteem 34 further studies with larger sample sizes and including people with other forms of disabilities could shed more light on this important public health issue in this study pwds tended to have a number of sociodemographic clinical and behavioural factors associated with suicidal ideation the findings provide essential baseline information on suicidal ideation among pwds during the covid19 pandemic which could direct preventive programmes or further studies inside andor outside bangladesh about 239 of the suicidal ideation was reported within 1 year of the pandemic which appears to be a very high prevalence rate this could be attributed to the massive lockdown measures and curfew situations thus care of this vulnerable population should be focused on accommodating and targeting their specific needs while planning for any lockdown situation in addition health education and awarenessrelated programmes in communities to increase knowledge about covid19 could help to reduce the incidence of covid19related suicide finally the public health system should consider longterm screening and treatment interventions to help prevent suiciderelated issues during the covid19 pandemic data availability the data supporting this studys findings are available from the corresponding author upon reasonable request declaration of interest none

evidence from pandemic and prepandemic studies conducted globally indicates that people with disabilities pwds have a higher risk for suicidality however none of these studies has assessed suicidality among pwds in bangladeshthe purpose of this study was to determine the prevalence of and factors associated with suicidal ideation among pwds during the covid19 pandemic in bangladeshusing a snowball sampling technique a crosssectional survey was conducted from february to april 2021 among pwds from six districts in the northern region of bangladesh information related to sociodemographic factors clinical characteristics behavioural factors and suicidal ideation was collected chisquared test and logistic regression were used to describe the data and explain the relationship of factors associated with suicidal ideationthe prevalence of covid19related pastyear suicidal ideation was 239 the factors associated with suicidal ideation included age above 35 years being female acquiring a disability later in life lack of sleep and current substance use in addition higher education appeared to be a protective factor against suicidal ideationthis study highlighted that pwds had an increased risk of suicide that is onefourth of them had pastyear suicidal ideation this may have been because of covid19related restrictions and stressors thus the government and policy makers need to pay more attention to developing effective suicide assessment treatment and management strategies especially for atrisk groups to minimise the impact of the covid19 outbreak

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introduction since the beginning of the hivaids epidemic women and girls have been most infected and affected the joint united nations program on hivaids reports show that globally more than half of the 377 million people living with hiv and aids are females 1 the numbers recorded in subsaharan africa are even more devastating approximately twothirds of the estimated 256 million people currently living with hiv and aids in subsaharan africa are females 12 mental health conditions affect females living with hiv and aids at substantially higher rates compared with men living with hiv and aids and hivnegative women 3 4 5 6 thus the established gender disparity in mental health disorders such as depression and anxiety is disproportionately increased in the context of hiv and aids 7 given the psychological distress associated with managing and coping with the illness a diagnosis with hivaids may cause or worsen preexisting mental illness symptomatology in women 48 flwhas relative vulnerability to mental health conditions may be due to several intersectional stressors such as unemployment financial stressors decreased psychological resilience limited social support and increased susceptibility to neuropsychiatric side effects of some antiretroviral therapies such as zidovudine and abacavir 5910 additionally flwha in lowand middleincome countries have higher rates of intimate partner violence stigma discrimination and social prejudice 101112 as well as increased psychosocial stress with hiv status disclosure and sexual and reproductive health management 1213 higher rates of depressive and anxiety symptoms have been reported amongst flwha in several studies 3 4 5 6 7 for instance 82 of survey respondents in a study of 832 flwha from 94 countries reported having symptoms of depression and participants indicated that their mental health concerns rose 35fold after receiving an hiv diagnosis 14 furthermore 289 of 357 flwha ages 18 years and above in an ethiopian study experienced moderate to high levels of anxiety as measured by a score of at least 11 on the hospital anxiety and depression scale 6 as depressive and anxiety disorders are frequently underdiagnosed among persons living with hiv and aids these rates are likely to be higher than reported 15 though a substantial burden of hiv associated depression exist in subsaharan africa 16 the majority of the mental health interventions for this population have been developed and evaluated in resourcerich settings and with a limited focus on flwha along with this limitation even exist a major gap as there is a lack of systematic reviews that synthesize the available research evidence on mental health illness among flwha in africa to direct policymakers to implement costeffective and evidencedbased genderspecific interventions that are peculiar to our cultural context as africans the overall goal of this review was to synthesize the current existing knowledge on the specific mental health issues faced by flwha in africa our study may have implications for the united nations 959595 treatment target by 2025 since the evidence shows flwha with untreated mental illness are less likely to adhere to their antiretroviral medication and more likely to experience virologic failure and hiv progression 17 aim of the review the primary goal of this review was to synthesize the current understanding of the specific mental health problems among flwha in africa and describe the relationship between hiv aids and mental health plos global public health objectives of the review 1 determine the prevalence of depression and anxiety among flwha 2 identify the risks and protective factors of mental health problems among flwha 3 describe the impact of hivaids on the mental health burden of flwha 4 describe the impact of mental health burden on hiv progression among flwha review question the main question that guided this systematic review methodology was does hiv and aids status negatively impact on the mental health of flwha methods this systematic review adheres to the preferred reporting items for systematic reviews and meta analysis guidelines 18 before the commencement of the review we conducted an initial search on prospero and cochrane library using the main concepts of the topic in table 2 to ascertain if the systematic review has been done already to avoid unintentional duplication and redundancy we noticed that systematic reviews were conducted in the general population but not specific to flwha again this search gave us a fair idea about the availability of literature on the topic during the building process for the search terms relevant synonyms were identified for each of the main concepts as shown in table 2 all the key concepts and their synonyms were combined to construct a comprehensive search strategy for the identified databases the protocol for this systematic review was registered via the prospero database the study focused on studies on mental health burden in females living with hivaids in africa inclusion and exclusion criteria articles were included in the review if they focused on mental health problems in females living with hivaids between 17 and 76 years and published in english in the last ten years from 2013 to april 2023 articles focused on pregnant and postnatal women were excluded because 1 systematic reviews exist in the literature in africa on this population and 2 pregnancy and its associated hormonal imbalance are considered covariates to mental health burden in flwha 1920 the details of the criteria for inclusion and exclusion have been described in detail in tables 3 and4 the electronic database search for the electronic search five major databases were selected a systematic search of electronic databases using predefined search terms supplemented by handsearching was undertaken in april 2023 these databases included pubmed scopus medline with full text plos global public health academic search complete and health source nursing academic edition additionally the reviewers searched google scholar engine who website unaids website ghanas mental health authority website and approved institutional websites reporting findings and statistics on hivaids and mental illness for both grey and published literature also the reference lists of the papers that were chosen for inclusion were used as a snowball for additional studies two reviewers conducted the final electronic search independently in the selected databases on 24 april 2023 with the help of the designed search strategy conducting the electronic search first articles retrieved from the various relevant electronic databases and the other sources were title screened by the reviewers to determine whether they were relevant for inclusion second the abstracts of the respective articles were also screened to ascertain whether their findings will contribute meaningfully to the research questions of the review third the full text of the respective articles was screened and those that were found significant were added at this stage reasons for exclusion of articles were provided duplicates plos global public health were removed manually during the selection process and also by the use of rayyan a systematic review software built with artificial intelligence selection of studies and data extraction all titles and abstracts identified through electronic database searching and hand searching were examined for relevance full text articles of any potentially relevant studies were obtained and assessed for inclusion based on the above inclusion criteria where uncertainty arose within the examination process full text articles were subjected to further scrutiny by the inclusion of a third reviewer sa who doubled as project supervisor and reviewer also assisted with validation and review of a subsection of identified titles and abstracts less than 5 discrepancies arose between the authors and the third reviewer these articles were not included in the review data from studies that met the inclusion criteria were extracted using an extraction format adapted from a recent systematic review 21 data extraction was carried out by the first and second authors and scrutinized by the fourth author information extracted from relevant articles included publication details such as simple size and its characteristics country measures used authors and year of publication the objectives of this review guided the extraction of the major findings in the included studies plos global public health data extraction from included studies using the adapted data extraction format relevant data was retrieved from each included study for the analysis the author and year of publication the title of publication the country where the study was done the sample size and characteristics measure used prevalence risks correlates protective factors impact of hivaids on mental health and the impact of mental health on hiv progression were extracted from each including special attention was paid to the methods of recruitmentselection of participants data collection approach and data analysis done for each of the studies data were extracted into tables with prespecified categories as stated previously for quantitative studies we collected data on prevalence of depression and anxiety associated risk factors impact of hivaids on mental health and impact of mental health burden on hiv progression main findings identified by the authors were summarised for the qualitative studies the authors collected information about the experiences of depressionanxiety risk and coping data was extracted and synthesized collaboratively by two authors the fourth author validated and made suggestions on the themes some were modified and subsequently included in the review assessment of quality and risk of bias of included studies the quality of the included studies were assessed using joanna briggs institute critical appraisal tools 22 this group of tools comprised checklists adopted for a range of study designs that includes a 9item checklist for studies reporting prevalence data 23 an 8item checklist for case reports 24 and a 10 item checklist for qualitative studies 25 the checklists pose a series of questions regarding presence of specific information with response options yes 1 no 0 unclear 0 and not applicable not scored to guide appraisers toward conclusions about the methodological quality of a study or analysis the 9item checklist was awarded an overall score of 9 with scores of 13 46 and 79 indicating low moderate and high quality the 8item checklist was awarded a score up to 8 with scores of 13 46 and 78 indicating low moderate and high quality the overall score of the 10item checklist was 10 with scores of 13 46 and 710 indicating low moderate and high quality the response score of each study were summed up to determine if the study was of low moderate or high quality results characteristics of the included studies the search and screening processes is illustrated in fig 1 a total of 19 articles were included in the review all of these studies were published between 2014 and 2023 out of the 19 articles 15 were quantitative 3 qualitative and 1 case study the participants were aged between 18 and 76 years in all 12299 made up the entire sample size for the nineteen studies the major findings in the included studies have been summarized in table 5 most of the studies were conducted in south africa followed by kenya uganda whilst the remaining were conducted in malawi tanzania ethiopia nigeria and parts of subsaharan africa one study was conducted both in zambia and uganda for this review the themes that appeared in at least two papers were kept plos global public health plos global public health plos global public health prevalence of depressive symptoms in flwha data on the prevalence of depression were published by thirteen studies 6 2634 36 4042 according to the data that were retrieved the prevalence of depressive symptoms varies from 59 among hivpositive women in nigeria 34 to 61 among hivpositive women in uganda 33 demonstrating the lowest to the highest depression symptomatology at different study locations high prevalence rates were reported by two studies conducted in south africa 563 27 and uganda 61 33 relatively lower rates of depression were reported in two studies thus 59 in nigeria 34 and 65 in south africa 32 in a case study conducted in kenya on a 42 year old unmarried flwha she indicated fifteen symptoms corresponding to mild depression on the beck depression index 35 prevalence of anxiety symptoms in flwha the prevalence of anxiety symptomatology was reported in three studies 62836 representing 158 the anxiety prevalence ranges from 289 among flwha in ethiopia 6 to 61 among flwha in uganda 36 the reported anxiety prevalence in these three studies in terms of severity ranges from 610 36 in uganda 530 28 in malawi and 289 6 in plos global public health ethiopia in all 704 flwha made up the entire sample size for the three studies two studies reported prevalence rates on both anxiety and depression 636 mostly used depression and anxiety assessment measures among the 19 studies that formally assessed anxiety and depression 16 used standardized scalesmeasures while 3 used semistructured interview guide 37 38 39 among the sixteen studies five used the center for epidemiologic studies depression scale 2732 39 40 41 four used the hopkins symptom checklist 26303336 three used the patient health questionnaire9 3142 five studies used different scales thus the patient health questionnaire2 29 becks depression inventory ii 34 becks depression index 35 the hospital anxiety and depression scale 6 and the emotional distress scale 28 most of the scales used were developed and validated in high income settings and therefore lacked contextual validity the reliability coefficient of the scales was not reported in a majority of the studies 6262930323335 37 38 39 43 risks factors of mental illness in flwha among the 19 studies included seventeen studies 6 2538 40 42 provided data on the risks correlates and predictors of anxiety and depression among flwha in different countries regardless of the country and the type of mental health outcome these risks factors appear corroboratory these risk factors arranged in decreasing order include physical intimate partner violence sexual abuse hivaids related stigma posttraumatic stress disorder childhood trauma and higher hiv vl category other risk factors included loss of selfesteem experiences of discrimination loss of life partners and or other family members poverty educational status victimization living with people other than direct family members homelessness being single or divorced in 11 of these studies 626 28 29 30 31 32 33 41 42 43 a univariate multivariate or logistic regression analysis showed that sexual abuse physical intimate partner violence loneliness enacted stigma childhood trauma posttraumatic stress disorder young age high viral load having no formal education divorce unemployment and low social support increased the odds of depression and anxiety in flwha and was statistically significant however one study 36 showed there was no significant correlation between depressionanxiety symptoms and educational status employment status and art treatment status plos global public health protective factors of mental health problems in wlwha among the 19 studies included in this review seven representing 368 reported on protective factors against anxiety and depression symptomatology in different countries 6273234363843 specifically five of these studies 627343643 reported on social support as a buffer against anxiety and depression however a study conducted by spies seedat 32 in south africa among flwha reported that whiles childhood trauma and posttraumatic stress symptoms contributed to depression severity resilience reduced the severity of depression acting as a protective factor one qualitative study found four coping mechanisms thus psychological reframing of negative situations mobilization of emotional and financial support from interpersonal networks churches and hiv support groups as protective factors 38 in the same study participants also sought expert help from traditional healers medical services andor social workers less frequently 38 impact of hivaids on mental health of flwha data on the impact of hivaids on mental health outcomes of flwha was gathered from seven studies representing 368 6262734373941 from four countries with relatively different sample characteristics among these studies hivaids was projected as a significant correlate for depression and anxiety for example the study conducted by spies et al 41 observed higher rates of depressive symptomatology among women infected with hiv compared to uninfected women however three studies representing 158 313840 reported that hivaids was not an independent driver of anxiety and depression among flwha two studies also reported that knowledge of hivaidspositive status and selfdisclosure of hiv status was significantly associated with a decrease in depressive symptoms 4042 impact of mental health on hiv progression from the included studies for this review 5 studies 2633404243 reported on the impact of mental health burden on hiv progression among flwha in sudfeld et al 33 tanzania it was noticed that depression at the start of art was significantly associated with a higher risk of death and an increased incidence of severe anaemia among flwha again in the same study depression was not found to be substantially linked with the trajectory of cd4 tcell reconstitution or the likelihood of immunologic failure but women with depression had increased incidence of oral thrush and wasting 33 in three studies 264043 higher levels of depression were linked to a lower likelihood of being virally suppressed in govender et al 40 this observation was more likely among younger women than older women higher score of depression was also highly significantly associated with less utilization of hiv care services and delayed initiation of art treatment 40 discussion over the past few decades there have been an increasing focus on the mental health of women and young girls living with hivaids particularly in africa due to their heightened vulnerability to mental illness in the context of hiv 6 secondly the overburdened social roles cultural religious and political marginalization of women 4 even in a postmodern philosophical era further threaten the mental health of these vulnerable population it is not surprising that research and publication on the mental health of flwha has gained a momentum boost plos global public health nonetheless these research and publications are stacked with individual journals and electronic databases making it difficult for policymakers and relevant stakeholders in the field to have a comprehensive synthesized understanding of the recent developments and evidence regarding mental health burden in flwha in africa prevalence of depression and anxiety based on the overall pooled prevalence estimates the prevalence of depression and anxiety was 59 to 610 and 289 to 610 respectively 6 26 27 2933 35 4042 moderately higher levels of depression 44 and anxiety 45 have been reported in the usa and canada this reveals the commonalities and realities of mental health issues among this population even across countries with different cultures geopolitics and socioeconomic indices that notwithstanding the literature shows people who are disadvantaged socially and economically are more likely to develop depression 46 the high prevalence rate in this review emphasizes the need to integrate mental health interventions in the hiv care cascade with special focus on women the prevalence rates varied substantially across the individual studies due to the different measurement scales 57 sample size and geographical context even for studies that used the same measurement scale information on the item number cut offs and number of included somatic symptoms varied explaining a part of the variability in the data on prevalence rates given the earlier concerns of under detection and under diagnosis of depressive and anxiety symptomatology in flwha in africa due to culturalreligious need to suppress the condition rather than reporting andor clinically manifesting symptoms 1547 prevalence rates higher than what is reported in this study is possible it is crucial that the existing measuresscales for depression and anxiety are modified and assessed for cultural validity dessauvagie et al 48 has argued that scales developed and validated in highincome settings may be inappropriate in diagnosing and quantifying the magnitude of mental health burden in resourcepoor settings the development of a single validated measure for assessing depression and anxiety in subsaharan african regions may be a step in the right direction risk factors of depression and anxiety in flwha our study highlighted a number of intersectional stressors that were considered as the most prevalent and strong predictors of depression and anxiety in the context of hiv these factors individually or jointly mediated at least a part of the relationship between mental health and hiv for instance intimate partner violence which affects about 30 of women globally and more prevalent in subsaharan africa 49 were identified by four studies 29 30 31 43 as a strong predictor of depression and anxiety in flwha stigma has shown to negatively impact the quality of life social and psychological health and wellbeing of persons living with hiv 450 the effect of stigma on qol is revealed in this review as five studies identified stigma 628313343 to predict mental health outcomes for flwha in africa a unaids 50 report uncovered that pervasive stigma and mental health issues are associated with barriers to access to and engagement in health care childhood trauma and posttraumatic stress disorder were implicated in two studies 3241 to independently predict depression in flwha the findings in this review align with findings from both lowand highincome countries 51 52 53 54 collaborative efforts of major stakeholders health workers and the community are needed to curb the deleterious mediating effects of these factors on the mental health of flwha community and healthcare sensitization against stigma 50 the empowerment of women and young girls 55 psychotherapeutic and cognitive behavioural interventions 4 may be crucial and advantageous at this point as such interventions have proven promising to ultimately impact the mental health outcomes of flwha protective factors against depression and anxiety social support and resilience may not only have main effects on the mental health outcomes of women living with hivaids but may moderate or buffer the negative effects of external and internal stressors on mental health of flwha in one of the studies 6 pearsons rank correlation showed that social support had a significant negative correlation with depression seven studies 6 27 3234 36 43 reported on the buffering effects of social support and resilience on depression and anxiety in addition to their main effects social support and resilience may function as moderators 56 to decrease the effect of stigma intimate partner violence sexual abuse childhood trauma and posttraumatic stress disorders on the mental health of flwha therefore women and young girls living with hiv in africa may benefit greatly from mental health interventions that focus on building social support and resilience impact of hivaids on the mental health of flwha in africa there is enough evidence to suggest that depression is a commonplace for flwha and previous research have argued that an hiv diagnosis may exacerbate preexisting mental illness or lead to depression and anxiety symptomatology given the psychosocial distress associated with managing hivaids 48 especially in africa in this current review hivaids was projected as the consistent and enduring risk factor for depression and anxiety by seven studies this is supported by a previous systematic review and metaanalysis 57 that mental health burden is a logical outcome of hivaids however contradictory findings on hiv and mental health outcomes emerged in this review three studies 313840 observed that hiv diagnosis was not an independent predictor of depression and anxiety nonetheless its association with other risk factors are enough to evoke psychological distress among people living with hivaids 38 in addition the review identified that knowledge of hiv positive status was significantly associated with a decrease in depressive symptoms 4042 these divergent outcomes in the evidence is likely because as discussed previously mental illness in clinical practice is highly underdiagnosed in ssa 15 secondly the lack of a single validated culturally sensitive scale 57 may also contribute to these discrepancies lastly the lack of training for clinicians and the poor integration of mental health in routine hiv care contribute to the under detection and underdiagnosis of depression and anxiety 57 albeit a unaids 50 report also had this to say depression anxiety and hiv are mutually reinforcing impact of mental health on hiv progression the presence of depression in flwha in the present review was associated with delayed initiation of art treatment decreased likelihood of virologic suppression increased in opportunistic infections less utilization of hiv care services and higher hivrelated mortality 2633404243 previous studies have also established a relationship between mental health and hiv disease progression 456 it is possible that mental illness may have clinically measurable biological and physiological implication on viral load and physical outcomes of people living with hivaids 26 relationships in the opposite direction is also likely as a few studies have identified art mediated viral suppression to be associated with a decrease in the severity of depression symptoms 58 the findings from this review suggest that the lack of screening for and treatment of depression and anxiety among flwha 4 has detrimental effects on their hiv related health outcomes the integration of mental health services into the hiv care plos global public health continuum may be an important step towards the achievement of unaids 959595 treatment targets by 2025 and may as well address the bidirectional links between mental health and hiv 59 cointegrated mental health services within hiv clinics have been found in both lower and middleincome countries to significantly improve the timely identification and management of depression and anxiety among hivpositive individuals 9 60 61 62 this integrated approach reduces the stigma associated with seeking mental health support 62 strengths and limitations of this review this review has several strengths including the use of evidence from 19 studies furthermore the reviewers followed a clear predefined criteria for including and excluding studies this approach minimized the potential for article selection bias also this review was conducted following welldocumented protocols and the methods used are transparently reported facilitating the reproducibility and replicability to other disciplines the methodological quality of the included studies was assessed to be of a generally moderate quality allowing for a more objective evaluation of the evidence the majority of the studies included in this review assessed depression and anxiety using standardized scales in spite of these strengths this review has potential limitations first the papers in the final sample cannot represent what has been done in the field of mental health and hiv due to the purposive inclusion criteria used to guide this study additionally our search was limited to 5 databases and so it is possible that other relevant articles could have been left out articles published in languages other than english were excluded potentially leading to a skewed representation of the evidence however they were eliminated because of the cost of translation implications for future interventions and practices the reviews findings highlight the critical need for the development of costeffective and culturally appropriate mental health therapies for african women living with hivaids in order to address the specific challenges and disparities they face groupbased interventions that incorporate culturally relevant practices such as storytelling or traditional healing may show promise in promoting mental wellbeing among african women jesse et al 63 has demonstrated the effectiveness of a culturally tailored group therapy program in alleviating depression and anxiety symptoms among south african women taskshifting initiative which involves training nonspecialist healthcare workers or community health workers to provide culturally sensitive counseling therapy to african flwha within the hiv care can be adopted in zimbabwe the friendship bench intervention designed by chibanda et al 64 to train lay health workers to deliver evidencebased talk therapy has shown to be costeffective and feasible in addressing common mental disorders such as depression and anxiety cointegrated psychoeducational therapies rooted in the cultural context of african women can improve mental health awareness and coping skills among flwha mitigating the impact of delayed detection and treatment of depression and anxiety conclusion and recommendation there was high prevalence of depression and anxiety among flwha in africa this review revealed that the increased burden of mental health issues among this population were mediated by intersectional stressors such as stigma intimate partner violence and trauma social support and resilience appeared to moderate the relationship between hivaids intersectional stressors and mental health burden among flwha a mediation and moderating analysis are needed in the future to authenticate this there were contradictory findings on predictive main effect of hiv on mental health burden while some studies showed an increased in depression and anxiety symptomatology in the face of an hiv diagnosis others findings suggested there was no significant relationship between hiv and mental health burden in flwha the lack of existing true experimental findings on hiv and mental health outcomes could account for these discrepancies and the lack of conclusive evidence future studies should focus on establishing a causal relationship between hiv and mental illness through experimental studies the current evidence on depression and anxiety among flwha in subsaharan africa is inadequate and nonwidespread as the majority of the studies reporting on this public health menace is concentrated in the south and east of africa there also exist substantial methodological limitations in most of the studies small sample size unclear justification of sample size used and unclear methods of recruitment resulting in selection bias a decrease in the statistical power and increased alpha future studies should employ standardized methodological approaches use sufficiently large samples and utilize a robust statistical analysis given the frequency of stresses and mental health issues that flwh experience as well as the relationship between the symptoms of mental illness and suboptimal disease treatment a costeffective feasible mental health interventions tailored to the unique and cultural needs of this population are crucial 4 all data underlying the findings in this manuscript has been submitted as supporting information

mental health problems particularly depression and anxiety are common in women and young girls living with hiv aids particularly in lowand middleincome lmics countries where womens vulnerability to psychiatric symptoms is heightened due to the prevalent intersectional stressors such as stigma and intimate partner violence however no synthesized evidence exists on the mental health burden of females living with hivaids flwha in africa this systematic review aimed to synthesize the current evidence on the mental health burden among flwha in subsaharan africa a systematic literature review of articles published from 20132023 was conducted using the preferred reporting items for systematic reviews and metaanalyses guidelines prisma five electronic databases pubmed medline with full text scopus academic search complete and health source nursing academic edition were searched for articles published in english nineteen articles 15 quantitative 3 qualitative and 1 case study from over 7 african countries met the inclusion criteria the majority of the studies quality was determined to be moderate the prevalence of depression ranged from 59 to 61 and anxiety from 289 to 61 mental health burden was a logical outcome of hiv diagnosis predictors of mental health outcomes in the context of hivaids were identified as intimate partner violence ipv stigma childhood traumas sexual abuse poverty unemployment and social isolation social support and resilience were identified as protective factors against mental illness in flwha mental illness had a deleterious effect on viral suppression rates among flwha resulting in delayed initiation of antiretroviral therapy treatment and increased mortality but had no impact on immune reconstitution in the face of art adherence given the high prevalence rates of depression and anxiety and their relationship with hiv progression it is crucial that mental health care services are integrated into routine hiv care

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introduction noncommunicable chronic diseases are responsible for about 41 million deaths each year that is 71 of all deaths in the world of which about 15 million deaths occurred in individuals with ages between 30 and 69 years which are therefore considered premature deaths 12 cardiovascular disease ranks first followed by cancer respiratory diseases and diabetes 2 these four groups of diseases are responsible for more than 80 of all premature deaths from ncds 23 ncds and their risk factors tend to be higher in populations of low socioeconomic status residing in poor or marginalized communities they also represent an important cause of the impoverishment of families and exacerbate economic inequalities within societies 4 reducing morbidity and mortality from ncds requires policies that considerably reduce behavioral risk factors such as tobacco and alcohol use reduce metabolic risk factors such as systemic arterial hypertension and strengthen interventions such as case followup access to diagnoses as well as the effective highquality preventive and curative care for all who need it 56 therefore coping with ncds involves ensuring access to treatment and other care health promotion and prevention as well as organizing surveillance and monitoring of these diseases in addition to mitigating social determinants through poverty reduction and of social inequality themes that are integrated to the sustainable development goals 237 resumo objetivo investigar a utilização de serviços de saúde e a limitação das atividades habituais entre adultos e idosos com e sem doenças crônicas não transmissíveis segundo estratos sociodemográficos métodos estudo transversal no qual foram analisados dados da pesquisa nacional de saúde de 2019 a amostra final correspondeu a 88531 domicílios com entrevistas referentes a indivíduos maiores de 18 anos as prevalências de uso de serviços pela população com doenças crônicas não transmissíveis foram comparadas às da população sem essas patologias e estratificadas por variáveis socioeconômicas e demográficas razões de prevalência e intervalos de confiança de 95 foram calculados resultados em 2019 476 da população referiu ter uma ou mais doenças crônicas não transmissíveis a população com registro dessas patologias realizou mais consulta médica nos últimos 12 meses utilizou mais o serviço de saúde nas duas últimas semanas referiu mais internações e mais limitação da realização de atividades em comparação com a população isenta desse tipo de registro observouse gradiente doseresposta positivo entre número de comorbidades e uso de serviços em todos os estratos socioeconômicos e demográficos a prevalência dos indicadores foi mais elevada em pessoas com doenças crônicas não transmissíveis conclusão a presença dessas doenças associouse à maior frequência de uso de serviços de saúde e da restrição das atividades habituais em todos os estratos socioeconômicos e demográficos palavraschave doenças crônicas não transmissíveis acesso aos serviços de saúde desigualdades em saúde inquéritos epidemiológicos rev bras epidemiol 2021 24 e210003supl2 several studies and population surveys seek to investigate the use of health services to understand factors associated with users demand for these services 89 the authors highlight that the sociodemographic characteristics socioeconomic status available resources provision of health services types of health systems among other factors interfere in the use of health services 1011 the perception of health status and the presence of diseases also increase the demand for these services 10 analysis based on data from the 2013 brazilian national health survey identified that brazilians with ncds used health services more than those without such diseases and that this use increased with the expansion of the number of chronic diseases in the same individual 7 thus it is important to monitor inequalities in the use of health services by different population segments aiming to guide health policies that promote equity in the provision of these services and that act on other determinants of use from this perspective this study aimed to investigate the use of health services and the limitation of usual activities by adults and elderly people with and without ncds according to sociodemographic strata methods this is a crosssectional study through the analysis of data from the 2019 pns a populationbased household survey carried out by the brazilian institute of geography and statistics in partnership with the brazilian ministry of health the pns questionnaire was divided into three parts the first part referring to household information the second part referring to information from all residents and the third part referring to information about a randomly selected individual the pns sampling plan consisted of a cluster sampling conducted in three stages of selection in the first stage the primary sampling units were selected by simple random sampling consisting of census tracts or sets of census tracts in the second stage a fixed number of households was chosen in each selected psu totaling 108525 households in each household selected a resident aged 15 or above was also selected by the srs making up the third stage of selection 12 the final sample consisted of 94114 households with an interview with a response rate of 936 in calculating the sample size the mean values variances and delineation effect were considered the databases were weighted including a correction factor for losses 1213 the information on access to and use of health services was obtained through the household informant who answered the questions for all residents however in this study only information referring to individuals aged 18 and above who answered the specific questionnaire for the selected resident were used thus the final sample analyzed consisted of 88531 interviews the variables obtained in module j related to the limitation of usual activities and the use of health services were analyzed and referred to the following questions in this order rev bras epidemiol 2021 24 e210003supl2 a in the last 2 weeks did you stop performing any of your usual activities due to your own health b how many times have you seen a doctor in the last 12 months c in the last 2 weeks did you look for any health service place or professional for care related to your own health d in the last 12 months were you hospitalized for 24 h or more from module q questions referring to the diagnosis of ncds were analyzed in order to identify whether the respondent had a previous diagnosis of one or more of these pathologies considering the positive answers for the following diseases for most ncds the questions referred to previous medical diagnoses chronic back pain was selfreported and in the case of depression it was considered a previous diagnosis by a doctor or professional specialized in mental health the relative frequency of use of health services by the population who reported at least one ncd was compared with that of the population who declared to have no ncd according to the following demographic and socioeconomic variables sex age group education health plan beneficiary income and region of residence prevalences crude prevalence ratios and adjusted prs were calculated using the poisson model comparing the use of health services by those who have ncd with those who have not in each of the strata prs were adjusted for sex age and education the aprs of use of services and limitation of usual activities were also calculated according to the number of comorbidities the respective 95 confidence intervals of the prs were also calculated rev bras epidemiol 2021 24 e210003supl2 as the data were collected with a complex sampling plan the statistical analysis of the data was performed using the stata software version 140 through the survey module which considers the effect of the sampling plan and the unequal selection probabilities pns 2019 data are available online for public access and use the research was approved by the national commission for ethics in research for human beings of the ministry of health results in 2019 476 of brazilian adults and elderly people reported one or more ncds of which 268 reported only one disease 125 two diseases 52 three diseases and 32 four or more diseases individuals who reported having at least one chronic disease had more frequent medical appointments in the last 12 months in all socioeconomic and demographic strata it was observed that the presence of ncds increases the prevalence of consultations some strata had a higher prevalence of medical appointments in individuals with or without ncd women the population with ncds used health services more in the last 2 weeks the use of health services in the last 2 weeks in all socioeconomic strata was higher among the population with ncds however the prevalence of use was higher among women elderly those with higher education those with high income those with health insurance and those living in the southeast region the aprs comparing those who have and those who do not have ncds showed that the presence of chronic disease increased the number of consultations in recent weeks in the segments with less education and lower income and without health insurance hospitalization prevalence was about twice as high among those who reported ncds in all sociodemographic strata there was a higher prevalence of hospitalization in individuals with ncds the prevalence of hospitalization among these 3 adults with ncds stopped performing usual activities due to health reasons more frequently than adults without ncds in all sociodemographic strata the prevalence of not performing activities due to health reasons was higher in people with ncds among them the prevalence was more frequent in women in elderly in those with worse socioeconomic conditions without education low income and without health insurance and in residents in the north and northeast regions compared with the south region the aprs comparing the limitations in carrying out usual activities between those who have and those who do not have ncds were higher in the population with low education and lower income nonbeneficiary of health insurance and living in the south region when analyzing the use of health services according to the number of comorbidities a positive doseresponse gradient is observed medical appointments by those without ncds were 7254 and increased to 8578 9308 9590 and 9769 among those who have one two three or four and more ncds respectively the prevalence of use of health services in the last 2 weeks was 1447 in those without a diagnosis of ncd and increased to 2538 3256 4091 and 4896 respectively for those who have one two three and four or more ncds the hospitalization prevalence in the last year was 472 among those without ncds and increased to 783 1085 1685 and source own elaboration pns data 2019 ncds noncommunicable chronic diseases apr adjusted prevalence ratio 95 ci 95 confidence interval 0 absence of noncommunicable chronic diseases 1 presence of one noncommunicable chronic disease 2 presence of two noncommunicable chronic diseases 3 presence of three noncommunicable chronic diseases and 4 presence of four noncommunicable chronic diseases b a 2430 for those with one two three and four or more ncds respectively likewise the prevalence of not performing usual activities due to health reasons increased with an increase in the number of comorbidities from 482 among those who do not have it to 91 144 201 and 337 among those who have one two three and four or more respectively discussion the results show that almost half of adults and elderly people reported having one or more ncds and the use of health services was more intense by this population those who reported having ncds showed a 21 increase in medical appointments in the last 12 months a 100 increase in the use of health services in the last 2 weeks a 110 increase in the occurrence of hospitalization and a 152 increase in limiting the performance of usual activities the number of comorbidities also influenced the use of health services reaching about five times more hospitalizations among those with four or more comorbidities socioeconomic and demographic factors also influence the use of these services in general women and elderly people use health services more as well as individuals with better socioeconomic conditions who have health insurance higher education and income and live in the southeast region in contrast not performing usual activities due to health reasons was more frequent in those with worse socioeconomic conditions pointing to social inequalities this study identified that almost half of brazilian adults and elderly people reported at least one ncd these chronic diseases represent the greatest burden of disease in the world the prevalence increases with age and among the most vulnerable populations 41415 making it a greater challenge in terms of equating access to health services studies have shown that individuals with ncds are among the users of health systems that most demand actions procedures longitudinal monitoring and health services due to the high burden of diseases and the long period of evolution and impairment 717 this study identified that the use of health services in the last 2 weeks as well as hospitalization in the last 12 months was about twice as high among users with ncds all indicators were higher in those with ncds which was described in another study due to the greater disability related to these comorbidities 17 the greater demand and consequently use of health services by those with ncds have been shown in other studies 1819 some authors emphasized that the use of health services stems from the perception of the severity of the disease feelings such as pain or disability as well as the feeling that the search for these services can help alleviate suffering 811 rev bras epidemiol 2021 24 e210003supl2 in addition ncds monitoring protocols indicate the need for longitudinal monitoring of the primary health care services naturally expanding the use of health services by these populations 20 this study also identified a significant increase in the use of health services as the number of comorbidities increased people with four or more ncds used about three times more health services compared with those without them the greater use can be justified by the severity of the disease multimorbidity and complications 7821 in this study elderly people with ncds had more medical appointments and more hospitalizations in general the use of health services and care by this age group as well as access to them is relatively high 22 analysis of data from the brazilian longitudinal study of aging identified that 83 of individuals aged 50 years and above had at least one medical appointment in the last 12 months of which the largest proportion comprised those with access to a health insurance plan 22 furthermore elderly people with multimorbidity health insurance and residing in areas covered by the family health strategy are more hospitalized 23 some authors have described greater use of health services by women 81124 which was found in the current study these characteristics have been explained by the greater perception of risk and greater care of women for seeking these services early and undergoing more tests and procedures with a greater chance of diagnosis prevention and treatment this study also pointed out that women without ncds uses health services more than men however data not presented in this study showed that men with four or more comorbidities had more hospitalizations in the last year which can be explained by the greater severity of the health status lower demand for health services and less longitudinal followup by males studies have shown that mortality rates from ncds are higher among men as well as a higher prevalence of risk factors such as tobacco systemic arterial hypertension alcohol obesity among others 1725 differences were also observed in the use of health services due to socioeconomic conditions individuals with higher education higher income and health plan beneficiaries had more medical appointments and more access to health services compared with those with lower income a similar situation was identified in the national household sample survey in 2003 and in the pns in 2013 724 socioeconomic conditions are associated with more access to health services whether due to greater availability of financial resources better clarification on the importance of access to these services and more availability and offer of network of services in health plans 724 furthermore evidence indicates that health plan users have more access to health consultations and procedures 72627 as well as they have more access to a wider and more funded service network 26 however regarding hospitalization there was no difference according to socioeconomic conditions which indicates the importance and extent of brazils unified health system in providing health care in the country for more than 75 of the brazilian population only the strengthening of the sus will make it possible to reduce the existing rev bras epidemiol 2021 24 e210003supl2 inequalities and guarantee universal access integrality and equity it is noteworthy here that the freeze on public health expenditure due to constitutional amendment no 952016 may in the short term lead to a setback it is urgent to recover and expand the sus funding 28 researches show that economic disparity is an important explanatory factor for inequalities in the use of health services indicating that lowincome population segments despite having more health needs use these services less and receive less health care 42930 a study with a south african population argues that this context may be related to the lack of social structure and financial support which are the conditions that limit the access to health services either because of the distance or because of the inability to bear the costs of traveling 30 studies have shown that the burden of ncds is higher in lowand middleincome countries where ncds mortality rates are almost twice as high as in highincome countries 31 the double burden of disease burdens health systems in these countries 32 which is also made worse by the lack of access to phc and its high costs 33 the current study reveals that in brazil unlike other countries the sus has shown its ability to meet and respond to the demands of access of the population with ncds and greater social vulnerability ensuring better access to medical appointments and the use of services health care and hospitalizations compared with the population without diseases however there were differences between socioeconomic groups it is noteworthy that the greatest inequality in the current study was found in the restriction of performing usual activities due to a health problem with a greater degree of limitation in 2 weeks before the survey in short lowincome populations had more disadvantages and limitations in daily life among the limitations of this study the crosssectional design stands out which although advantageous due to its speed and low cost adds inherent disadvantages such as the possibility of reverse causality selfreported medical diagnosis depends on access to health services which may be lower in more vulnerable populations in addition this study used two different modules of the pns the selected resident answered about the selfreported ncds while the health services use module was answered by one of the residents not necessarily the one drawn which can lead to an underreporting of information on the use of health services from the data analyzed in this study it was concluded that people with ncds used health services more as well as women people with a greater number of comorbidities with a health insurance plan and with a high level of education investing in sus is essential to improve ncds indicators in the country which includes strengthening the health system financing governance management human resources in health health information and access to technologies and medicines 47 knowing the differences in the access to and the use of health services can guide the design of public policies for inclusion which promotes equity and sustainability of actions within the scope of the sus

the objective of this study was to investigate the use of health services and limitations in performing usual activities by adults and elderly people with and without noncommunicable chronic diseases ncds according to sociodemographic strata methods this is a crosssectional study in which data from the 2019 national health survey were analyzed the final sample corresponded to 88531 households with interviews carried out referring to individuals aged 18 years and above the prevalence of use of services by the population with ncds was compared with that of the population without ncds and stratified by socioeconomic and demographic variables prevalence ratios prs and 95 confidence intervals 95 ci were calculated results in 2019 476 95 ci 470483 of the population reported having one or more ncds population with ncds had more medical consultations in the last 12 months adjusted pr apr 121 95 ci 120123 used more health services in the last 2 weeks apr201 95 ci 191211 were referred to more hospitalization apr211 95 ci 189236 and had more limitations in performing usual activities apr252 95 ci 230276 compared with the population without ncds a positive doseresponse gradient was observed between the number of comorbidities and the use of services in all socioeconomic and demographic strata the prevalence of indicators was higher in people with ncds conclusion the presence of ncds was associated with a higher frequency of use of health services ie consultation use of services and hospitalization and the restriction of usual activities in all socioeconomic and demographic strata

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introduction the olimpiadi di problem solving informatica e pensiero computazionale nella scuola dellobbligo is an initiative of the italian ministry of education university and research to foster both problemsolving and teamworking skills in a single action 5usually in the education world the expression olympics of x means a competition aimed to single out and promote exceptional skills at the individual level in the age of 1618 however ops are mainly training activities the core of ops are the training contests followed by two rounds of competitive contests ops are mainly teamwork activities ops are aimed at all the compulsory education age range activities are organized at three levels the last two years of primary school lower secondary school the first two years of upper secondary school ops are aimed to reach all students and not only exceptional ones each school is encouraged to participate with as many teams as possible ops are gender neutral each team is required to have people of both genders it was noted by nobel laureate carl wieman 11 that competitions outside of school fail to improve stem education since 2008 miur has promoted ops as trainingcompetition within the school system to pave the way for a more widespread introduction of informatics in curricula and to foster the learning of effective competences for general problemsolving the remainder of this paper is organised as follows section 2 discusses the variety and diffusion of contests focusing on informatics organized worldwide in the last decades section 3 describes main features and goal of ops and the structure of the competitions furthermore it proposes some examples of standard problems and presents how the training and the contests at the different levels are organized section 4 presents some data about participation in the initiative and a preliminary analysis of the results obtained by the students in the last editions to evaluate the training effect on students on their problemsolving skills section 5 proposes the question of digital gender gap and evaluates the involvement of girls and boys in ops finally some considerations close the paper promoting informatics through competitions several contests focusing on informatics have been organized worldwide in the last decades they vary in design difficulty levels and type of audience they cater to such events mainly result from two attitudes of mind one focused in selecting particularly talented students and another one aimed at spreading the basic concepts of the discipline to a vast audience of students this section only shares a few examples to show the variety and diffusion of such events see 1 and 8 for recent reviews about contests classification criteria and a selection of existing online programming contests acm international collegiate programming contest 6 is the most sought after programming competition in the world every year the icpc contests include contestants from over 2000 universities and colleges from across the world the contestants receive problems that they have to solve providing a program written in a widespread programming language such as c c or java ieee also proposes a contest namely the ieeextreme programming competition 7 which lasts 24 hours and is dedicated to teams of students all the teams receive a set of programming problems and as for acmicpc they have to solve the greatest number of problems among the events targeted to secondary school students the international olympiad in informatics 8 is the most popular worldwide like in icpc contestants are challenged to provide in few hours programs written in mainstream programming languages that solve problems of algorithmic nature unlike icpc and ieeextreme programming competition ioi is an individual contest a lot of countries do have online programming contests to make the selection for their national team to be sent to the ioi just to mention some of them usa computing olympiad italian olympiad in informatics franceioi indian computing olympiad frenchaustralian regional informatics olympiad all those contests are following the same philosophy as the ioi encouraging young talent from high schools to programming challenges the bebras contest 4 is a competition organized on an annual basis in several countries since 2004 in the past few years the number of the bebras participants has been notably growing the contest has been spreading over 40 countries involving various activities eg several rounds of the contest discussion on informatics topics task solving seminars teacher workshops and task developing events the bebras challenge has been developed for all primary and secondary school pupils the second full week of november is the official time for the bebras challenge in participating countries several countries have established a second round of the bebras challenge usually at the end of january or beginning of february and it is dedicated for the best participants of the first round challenge it is a wellknown consensus in the community around informatics contests that the difficulty of these contests progressively increases as observed for example by verhoeff et al in 10 kelevedjiev and dzhenkova 6 mention that in many countries the age at which children start with programming is already as low as ages 11 to 12 thanks to this early start the set of topics used in contest tasks is growing kiryukhin in 7 describes the development of the russian olympiad in informatics since 1995 the focus in programming contests started to shift from implement a correct algorithm towards the much harder implement a correct algorithm that is as efficient as possible as a result and even more so than previously only the best students are involved in these kind of competitions all the other students lose the opportunity to develop in an engaging way fundamental problemsolving knowledge and skills required for living and working in our society having applicability in the entire sphere of economic social political and cultural life the dissatisfaction with this state of affairs motivated miur back in 2008 to start ops with the goal to spread problemsolving and computational thinking across all the compulsory education age range which in italy goes up to grade 10 moreover ops are aimed to reach all students and not only exceptional ones ops an inclusive education model for learning informaticscomputational thinking main features and goals the main goal of ops is to disseminate problemsolving skills and computational thinking 12 in italian education since no explicit provision of problemsolving teaching is present in the italian guidelines for primary and secondary education ops promote activities in this area with a transdisciplinary approach trying to captivate teachers of various disciplines being activities directly offered to classes as contests they are appealing and have an immediate impact on the participating youngsters 3 however no real successful participation is possible without support and training from local teachers this implies that teachers should develop and promote curiosity interest and consensus in their own classes teachers themselves are therefore stimulated to engage in the game even if skills and competences needed are foreign at least explicitly even for them the collaboration is recognized as one of the most effective means of spreading problemsolving skills and also allows for significant motivational and relational benefits for this reason the ops foster collaboration by offering mainly team work activities in designing the teaching strategy for ops we have taken into account the dual nature of team competition actually this strategy offers many possibilities when facing a heterogeneous group of student 9 problemsolving as interpreted in ops is intended as one of the most effective paths to the acquisition of computational thinking attitudes for this purpose one component of ops is the ability to understand simple formal structures and to follow simple algorithms expressed in semiformal languages thus forming the background on which an explicit teaching of programming and informatics may be based this component is further strengthened by administering some problems that require the execution of calculations to be repeated a number of times so large to make the solution infeasible unless one writes and executes a program another important feature of the ops which differentiates it from most of the similar initiatives is the fact that they favor incremental learning by offering explicit training sessions for both students and teachers during every entire school year after each training session the scientific committee of the ops releases the solutions and the comments to the solutions for the various exercises proposed both the involved students and the teachers judge in a very positive way the usefulness of the solutions for the incremental acquisition of skills we may therefore summarize the main goals of ops offer explicit problemsolving training to students at the compulsory education age range involve the teachers in such a way that they also acquire and consolidate the needed skills use semiformal setting and pseudo language to embed problem solving in the context of computational thinking with the perspective of acquiring programming skills offer training sessions during the entire school year to both students and teachers joining the ops participation is on a voluntary basis italian teachers are expected to participate in additional activities as well as to teach their discipline miur promotes various initiatives that qualify as additional activities ops is one of them in septemberoctober miur issues the annual bylaw for ops with the dates of the contests since participation in the project is the responsibility of the scholar institution teachers have to negotiate adhesion with the principal involved teachers form teams within their classes again participation of the students is voluntary but very often discussion about ops problems assignment of exercises and study of problemsolving techniques are extended to the whole class and are not limited just to the team this fact is the main added value of ops structure of competitions at the beginning ops were exclusively based on contests where students receive problems that are asked to solve in a welldefined time frame students participating to contests of this kind are divided in three levels grades 45 grades 68 grades 910 in the first editions ops consisted in three series of team contests one for each level each team is made up of 4 students possibly with gender equality in the last few years two more series of contests of the same nature have been added for individual students of the second and third levels in each ops edition all series have the same number of contests usually six all the contests except the last two are training contests which means that the score achieved by a team is only provided as a feedback the last two contests are competitive the first one is used to select for each series the best teams of each italian region while the final one decides the winners the team contests consist of 12 problems the amount of work to be done in the allotted time to solve them largely exceeds the effort that can be expected from a single participant hence planning collaboration specialization and teamworking are necessary the individual contests consist in 8 slightly simpler problems in the same amount of time the given problems are prepared by means of a controlled process with a strict time schedule which involves two committee the problem editors define the problems and write texts and commented solutions while the problem reviewers check for errors and difficulty more recently along with the above classic ops that remain the core contests of the competition other team contests have been added as side activities coding where students engage with creative programming activities realizing a project on a topic chosen by the committee with suitable environments programming where students solve a complex programming task making where student realize a physical project using electronic boards on a topic chosen by the committee in the following we refer only to classic ops with particular focus on team contests the original and distinguishing contests of the ops topics ops proposes at the three levels the same kinds of problems with differences in size or abstractness each year five o six topics are chosen from these standard problems come up in the last school years the chosen topics where formal deduction from a set of rules paths in a maze or in a chessboard knapsack hierarchies graph covering graph traversal cryptography subsequences and readingtracing of procedures written in a pseudocode a semiformal syntax about terms lists strings is used in problems and answers additional topics are comprehension of a text and non standard problems each time of a new kind to stimulate creativity and the ability to deal with new situations examples of standard problems examples of a standard problem are shown in appendix figures 4 5 and 6 the first problem was part of the second training for primary school problems on the same subject in following contests were gradually more complex and the solution had to be chosen among up to a dozen of paths the second problem was part of the fifth training for secondary school the third problem was part of the final contest for lower secondary school as you can see it involved a lot of programming structures introduced gradually during the training contests commented solutions a key feature of the ops is that along with the solution to each problem after each contest comments are provided often this section makes up an outline for the indepth study and analysis that teachers are invited to follow along with the students in this way knowledge and skills are spread among teachers and students as you can see in the examples in appendix as the level and the difficulty grows the comments become much longer and elaborate the training contests in a training contest on a fixed date problems are proposed on a secure web platform and are accessible for a suitable interval of time schools connect to the platform when they deem suitable and under the supervision of local teachers the teams and the individual students participate to the contest problems are administered and their solutions should be entered within 120 minutes from the first access during the contest each teamindividual is allowed to use any additional material as it sees fit the ability to quick retrieve and organize relevant information being one of the key components of effective problemsolving when the access to problems is closed correct solutions and comments are made available then answers are evaluated and teams ranked three to five different training contests are organized in this way from november to march the difficulty of the problems is gradually increasing then for each level each school selects teams and individual students for a regional competition the winning teams and individual students of each region meet in cesena for the final competition the final contest the final contest is a fierce competition around twenty teams and twenty individual contestants for each level are invited in cesena the final contest takes place in the department of computer science and engineering university of bologna under control of a jury and with strict rules 1 each team has the same type of workplace available which includes one workstation 2 teams are allowed to bring books notes and an extra pc 3 participants are not allowed to communicate with other persons during the contest except with members of their own team and the jury 4 use of hardware other than watches medical equipment the pc and the provided workstations is not allowed 5 a team can be disqualified for any activity that jeopardizes the contest 6 when a team presume that a problem is ambiguous or incorrect the team can ask a clarification to the jury the jury will respond and if the answer is relevant to all teams the jury will communicate the answer to all teams the jury determines the final team ranking as follows teams are sorted by the number of accepted solutions in nonincreasing order when two or more teams have the same number of accepted solutions these teams will next be sorted by total time in ascending order the total time is the time passed between the start of the contest and the time at which the last solution was submitted there is no penalty for unsolved problems participation and results ops were proposed organized and developed with the guidance of several working hypotheses among which those that participation to ops fosters and develops problemsolving skills both at the personal and the class level enhances the success level in standardized performance tests like italian invalsi or oecds pisa is an effective way to induce computational thinking habits in the students facilitates the introduction of explicit disciplinary teaching of computer science although we have qualitative indicators confirming these hypotheses available data are not sufficient to discuss here all these farreaching goals we report only on the first one the first 10 editions of the ops have recorded a noteworthy participation both in terms of students and teachers involved as shown in table 1 these data show that the ops are among the most successful initiatives in terms of participation for the diffusion of computational thinking in italy first results the comparative impact of ops on participants is difficult to establish due to a selection effect in fact participation in ops is voluntary so we expect that the best and most innovative teachers are better represented among those participating in ops moreover we cannot rule out that participating teams are made up of some of the smarter students in their classes this selection bias is difficult to asses and avoid in data analysis a comparison of the educational careers of those who have participated in ops and students from another sample is an extremely delicate task on the other hand the training effect on students is clearly visible especially because problems from contest to contest become progressively more difficult some examples can be given by considering the average scores obtained by the teams who participated in the project during the last 5 editions9 on algorithmic problems which are the most indicative of computational thinking competencies for grades 45 the trend in each edition has no marked fluctuations this related to the progressive increase in the difficulty of the problems indicates a development of the problemsolving skills of the pupils it can be noted that in the second or third contest there is often a slight lowering of the performances which corresponds to the introduction of problems that are considerably more difficult than those proposed in the first contest of each edition data for grades 68 highlight in most of the editions two contests in which the scores decrease which is explained by a more rapid increase in the difficulty of the problems in this level the trend however remains positive and strong growth in the two competitive contests at the third level we register more differences between one edition and another this can be explained by the fact that the set of problems proposed at this level changes more from year to year in any case the trends are similar to those shown in the other levels with a more marked improvement in correspondence with the competitive contests typical of the greater commitment that students to this level of maturation can profuse another impact difficult to assess is on teachers it was noted that the competitions encourage teachers to learn more to support their students currently besides a qualitative confirmation it does not seem possible to measure this effect ops and gender a recent european parliaments policy department for citizens rights and constitutional affairs study attempts to reveal the links between the different factors which prevent women from having equal access to digital technology 5 while icts are recognised as having the potential to promote gender equality and womens empowerment a digital gender divide has been identified whereby women access and use icts less than men increasing the number of women in ictrelated education could be a policy consideration women may also have more to gain from ict than men in time freedom and opportunities addressing the underlying causes of digital gender disparities is vital as dealing with the symptoms without fighting the causes would lead to superficial measures we attempted to evaluate the involvement of girls and boys in ops by calculating the number of participants per gender on the three school levels the goal is to try to understand at what time the disinterest of the girls towards the computer disciplines occurs so as to suggest the best time to propose remedies we evaluated the numerical participation of girls and boys on the three levels of school it is almost equal in elementary school then the number of girls involved in competitions concerning first and second grade of secondary school drastically decreases these results are similar to those found in another independent miur initiative to promote informatics and computational thinking 2 based on our experience the measures that can be taken to combat digital gender gap must be implemented in the early years of elementary schools doing it later can be useless because the factors that cause the digital gender gap have already pushed away the female component conclusions we presented ops an italian initiative to disseminate problemsolving skills and computational thinking activities with a transdisciplinary approach ops are targeted at all the compulsory education age range and are aimed to reach all students and not only exceptional ones in the past few years the number of participating students and teachers has been notably growing as a testament to the validity of the initiative among the advantages of the ops approach we may cite interactivity collaborative work inside the group active participation challenge versus duties and motivation for the students to explore their own topics on problemsolving skills and computational thinking to support the challenges the best feedback obtained is probably the feeling of the involved students and teachers preliminary data show an increase in scores of algorithmic problems from the first contest to the last in each school year at all levels given that the difficulty of problems increases from one context to the next this may indicate an increase in algorithmic problem solving skills in pupils large direct feedback from the teachers involved in ops makes evident a positive correlation between participation to ops and general performance of students this has been a working hypothesis of our work since the firsts editions of ops turning this hypothesis into a scholarly acceptable evaluation is one of the main directions of our current work on the evaluation and assessment of ops 1 the list l1 that describes the shortest procedure to deduce a knowing c m 2 the list l2 that describes the shortest procedure to deduce c knowing m g 3 the list l3 that describes the shortest procedure to deduce d knowing m g criterion for the lists list the rules in the order that corresponds to the sequence of application of the rules the first element of the list must be the number that corresponds to the first rule to be applied if there are several rules that apply at the same time give priority to the one with lower number l1 l2 l3 solution l1 843 l2 8617 l3 84612735 comments to the solution to solve the problem you can use the backward method that is start from the unknown and try to find a rule to derive it if there is a rule whose antecedents are all known the solution is found otherwise you look for a rule whose antecedents are not all known and you continue to look for rules to derive the unknown antecedents for the first question it is immediate to check that a appears as consequent only of rule 3 which has as its antecedent p q and c the first two are unknown the last is given p is deductible only by the rule 8 directly from m q is deductible only with rule 4 from m and p just deduced the procedure is illustrated by the tree in the figure below the list l1 is 843 for the second question we immediately verify that c appears as the consequent in the rules 7 and 9 the rule 9 has antecedents e and f both unknown e is deductible by the rule 12 which has antecedents f and s the latter can not be deduced with any of the given rules therefore to deduce c only rule 7 is usable this rule has antecedents p and h both unknown p is deductible only with rule 8 directly from m h is deductible only with rule 1 from f and g at the end f is deductible by rule 6 from m and p or by rule 14 from a and u it is clear that we must choose the first alternative the proceedings is illustrated by the tree in the figure below the list l2 is 8617 appendix problem in a map there are towns and roads between them this situation can be abstracted with a graph in which nodes represent cities and the arcs represent roads an arc of the graph can be described by a term like arc which means that there is an arc between node n4 and node n8 and its length is 5 two nodes connected by an arc are said adjacent a path is a list of adjacent nodes a simple path does not contain repeated nodes comments to the solution after a few attempts the graph can be drawn in such a way that the arcs do not intersect as in the following figure note that a major difficulty lies in drawing the graph so that the arcs do not intersect it is necessary to proceed by trial and error by placing nodes in various ways until the drawing is satisfactory this can be done in many ways note also that the lengths that appear in the terms are not proportional to those of the arcs of the graph the graph describes a circuit and it is easy to see that the possible paths between n1 and n6 and the relative lengths are the values of k and t before the second while loop and after each of the iterations of the cycle are shown in the following table value of k value of t before the loop 6 0 after the first iteration

the paper presents the olimpiadi di problem solving a mild and inclusive competition aimed to promote computational thinking and general problemsolving in italian schools we describe motivation teaching strategies behind the initiative as well as its structure organization and give some sample of the problems proposed to students we also present some data that show the broad participation of italian schools to the initiative and a preliminary analysis of the results obtained by the students in the last 5 editions which suggests that the competition fosters deep learning of computational thinking knowledge and skills

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introduction i mproper diagnosis and treatment due to medical error lead to tens of thousands of deaths every year while there is a significant body of research analyzing the nature causes and effects of medical error as well as the effectiveness of various errorreduction strategies the medical error literature has historically undertheorized a specific kind of errornamely epistemic errorthat is brought about by epistemic schemas linked to groupor identitybased biases rooted in categories such as race sex gender sexuality and disability in this paper we turn to the field of social epistemology with the double aim of filling this gap in the literature as well as better understanding the role that epistemic schemas play in the production of medical errors that disproportionately affect patients from marginalized social groups kennedy institute of ethics journal • september 2019 206 our argument moves in three stages first we sketch dominant taxonomies of medical error define what we mean by epistemic schema and epistemic error and situate our project in the context of the larger literature on epistemic injustice second we look at the socially uneven distribution of epistemic error by using ableism as a case study ableism which we here explore in terms of its role as an epistemic schema plays a pernicious role in patientprovider communication it distorts communication between nondisabled physicians and disabled patients subjecting the latter to various forms of epistemic injustice and exposing them to a higher risk of medical error and consequently harm our analysis of this case study will demonstrate that even though the possibility of medical error impacts everyone it does not impact everyone equally socially vulnerable patients such as disabled patients are more likely to be affected by it finally we contend that medical errors due to epistemic schemas rooted in prejudice such as ableism are issues of justice that must be addressed at all levels of health care practice we offer this analysis in the hope of clarifying the role that epistemic schemas play in the production of medical errors and reducing the number of lives hurt or lost in their wake kinds of medical error medical errors take many forms to better understand them and to assist in efforts to reduce their frequency researchers have developed various taxonomies of medical error most of which are based on their causes or effects for example taxonomies that carve the joints of medical error along the lines of effect often classify errors as fatal life threatening serious or significant meanwhile those that track differences in origin produce rather different tables of elements taking this approach aronson classifies medical errors as knowledgebased rulebased actionbased or memorybased 2 taxonomies are powerful resources that help us conceptualize phenomena in specific ways and frame how we think about issues like all conceptual resources however taxonomies come with limitations taxonomies of medical error that focus on effects for example can be misleading because not all medical errors have observable consequences many errors as weingart et al note do not produce injury they are caught in time the patient is resilient or luck is good similarly taxonomies based on origin can misconstrue or entirely miss errors that are multifactorial or whose source of origin is either unknown or hard to discern peñaguzmán and reynolds • medical error and epistemic injustice 207 in this paper we focus on the specific kind of error that aronson describes as knowledgebased knowledgebased medical errors result in one way or another from deficient knowledge on the part of providers as aronson defines them these errors involve any type of knowledge general specific or expert it is general knowledge that penicillin can cause allergic reactions knowing that your patient is allergic to penicillin is specific knowledge knowing that cofluampicil contains penicillin is expert knowledge ignorance of any of these facts could lead to a knowledgebased error for aronson a central way doctors can inadvertently harm their patients is by failing to know or otherwise being ignorant about things that they ought to know at the moment that they ought to know them this could be due to a lack of true beliefs about x or due to the possession of false beliefs about x in the example aronson gives one might not know that a patient is allergic to penicillin or one might falsely believe that a patient is not allergic to it in the literature on medical error knowledgebased failings such as these are typically referred to as epistemic errors even though epistemic errors are frequently referenced in this literature they are often equated with what we call factical errors which stem from a lack or misapplication of information factical errors occur for example when not all the medicallyrelevant information provided by a patient is made available to all the medical experts the patient interacts with at different stages of care when information is missing from key medical spaces at key medical moments or when providers are ignorant of new research methods or protocols we call these errors factical because they pertain to the possession or nonpossession of relevant facts and beliefs rather than pertaining to cognitive and perceptual habits as is the case with schematic errors the unstated assumption in much of the extant literature on medical error seems to be that if experts knew all the relevant facts they would not make errors we disagree with this assumption because not all epistemic errors are factical in nature surely medical errors can occur based on what providers know but one of our chief claims in this article is that medical errors also depend on how providers know it is a mistake therefore to equate epistemic errors with factical errors since these categories are related but not coextensive the latter is a subset of the former all factical errors in other words are epistemic but not all epistemic errors are factical to improve medical practices and institutions we must attend to the plurality of medical error types and recognize that different types of errors have different causes and effects epistemic errors in particular require us to look not only at the information that is available to medical providers at various moments but also at the broader social character of medicine because the production operationalization and dissemination of medical knowledge is a social and relational process that goes beyond the brute application of facts when it comes to the epistemology of medicine factical errors are only the tip of the medical error iceberg schematic errors beyond medical facts over the last few decades social epistemology has emerged as a burgeoning field of philosophical inquiry on the whole the field is based on the premise that knowledge is fundamentally social which is to say produced shared interpreted and transmitted through complex human practices interactions and institutions this insight which grew primarily out of feminist scholarship on the relationship between knowledge and power can help us make sense of those medical errors that cannot be traced to purely factical concerns and that involve how rather than what providers know we call these errors schematic rather than factical because they are outgrowths of epistemic schemas that shape the larger processes judgments and pool of hermeneutic resources upon which providers draw epistemic schemas are thereby central to how medical providers position themselves relative to their patients and as we explore below this can have especially significant ramifications for patients who are perceived to be unlike a provider in different regards especially patients who come from historically marginalized social groups the concept of a schema has been widely and variably used in linguistics cognitive psychology the philosophy of mind and even the philosophy of science in this context we understand epistemic schemas simultaneously as manifold cognitive structures exerting influence over memory encoding and retrieval and structures which make it possible for epistemic agents to arrive at shared meanings or frames of reference epistemic schemas then are constellations of implicit and explicit values norms biases impulses desires fantasies and assumptions that condition what counts as knowledge who counts as a knower and how knowledge claims are interpreted assessed and adjudicated within a given epistemic community 3 at once perceptual cognitive and hermeneutical they are structures that shape how epistemic agents participate in the life peñaguzmán and reynolds • medical error and epistemic injustice 209 of a community by making sharing interpreting and communicating knowledge claims and because they influence how we experience reflect upon and communicate information about the world we share we others these schemas are more than simple biases or habits yet like biases and habits epistemic schemas are often implicit rather than explicit meaning that typically most of us are unaware of the pull they exert over our thoughts actions and ways of knowing and the various ways in which we have been socialized into them our use of the concept of an epistemic schema is thus related to concepts such as body schema and gender schemas that capture how networks of information are interpreted through a dynamic process of filtering and framing by definition schemas are informationfiltering mechanisms that downgrade the import of some information while amplifying and prioritizing the significance of other information but they are not passive sieves that merely let information pass they are also meaningmaking processes that present information in a certain light that frame the information they themselves filter in senseconferring ways this is why we ought to think of epistemic schemas as meaningmaking mechanisms that have a significant influence on how people think about themselves and their place in larger social formations epistemic schemas can grow out of religious philosophical and even scientific worldviews but the ones that interest us here are tied to social markers of identity such as race ethnicity gender sex sexuality class and disability among others racism for instance is a social material and political reality that profoundly affects the lives of racial minorities and shapes the larger society as a whole it can also function as an epistemic schema in our sense of the term because it affects how differently racialized agents think about and communicate with one another racism understood as an epistemic schema structures how one knows what one knows which voices and bodies of knowledge one includes or excludes and how and more broadly the ways in which one engages in the world as a knower as an organism who gathers processes judges and communicates about its experiences to itself and others although schemas such as racism and sexism do not offer an ordered interpretation of all ones experiences they can determineand in some cases wildly overdeterminehow epistemic agents interact with one another as knowers which is to say how they interpret the meaning validity and force of one anothers claims in other words although they may appear to be domainspecific their impact easily bleeds into all sorts of knowing activities and while not all epistemic schemas are rooted in prejudices of these sorts those that are typically lead to epistemic injustice one reason epistemic schemas and especially those rooted in prejudice are so powerful and recalcitrant is because they reinforce epistemic ignorance which is to say modes of knowing that depend upon ignorance concerning others and the world in such a manner as to maintain the privileges of the knower 4 historically philosophers have understood ignorance quite simply as the absence of knowledge recent work in epistemology much of which draws heavily upon earlier feminist and antiracist work suggests instead that ignorance may be better defined as the other side of knowledge because there are cases when someones ignorance is predicated upon and a boon for extant social injustices put simply what one is ignorant of is no simple matter and does not absolve one from culpability on the contrary ignorance is shot through with ethical social and political choices that carry profound effects epistemic ignorance this literature demonstrates is a driver of epistemic injustice it leads to harms against marginalized groups and individuals in their capacity as knowers fundamentally prejudicial epistemic schemas such as those of racism sexism and ableism are problems not just because of the way they lead epistemic agents to know but also because of the way they lead agents not to know ignorance can be comparably unjust to unjust ways of knowing if not more so in these cases then it would be inaccurate to describe ignorance as an innocent lack of knowledge and more accurate to talk about it as the controlled effect of a system of power that actively seeks to keep certain things unknown linda alcoff writes the study and analysis of epistemic ignorance poses some special epistemological questions beyond the expected sociological and educational ones questions having to do with how we understand the intersection between cognitive norms structural privilege and situated identities in what follows we explore the role that epistemic schemas play in fostering epistemic ignorance through the case of ableism we demonstrate that ableism understood as an epistemic schema leads to medical error by fostering epistemic ignorance rooted in privilege and prejudice on the part of health care providers and we use research on ppc with respect to patients with disabilities to illustrate our point peñaguzmán and reynolds • medical error and epistemic injustice 211 case study ableism while the philosophical literature on social epistemology has made significant strides in exposing how systems of oppression such as racism and sexism mold peoples experience of medical care this literature has paid comparatively little attention to ableism aside from the notable exceptions we discuss below in this section our principal objective is to show that ableism affects the quality of care that people with disabilities receive by exposing them to a higher than average risk of medical error and consequently medical harm given that people with disabilities make up the largest legallyprotected minority group of health care users and given that the types of epistemic ignorance associated with the schema of ableism and the epistemic injustices that result from it lead to people with disabilities being impacted by medical error disproportionately this is a serious lacuna one of the chief ways that ableism brings about this regrettable state of affairs is by undermining effective patientprovider communication which is to say by generating communication failures between disabled patients and their typically nondisabled providers 5 an important caveat is in order here because empirical research on ableism and ppc is scarce much of our analysis will be speculative in nature hence in articulating some of the mechanisms by means of which ableism warps ppc we take ourselves to be hypothesizing rather than proving a potential causal connection between these terms and we take ourselves to be calling for further empirical research that might confirm or deny our hypothesis more than anything we offer this analysis in the hope of providing a research program for other medical humanists clinical researchers and social scientists to pursue in greater detail one of the reasons there is so little research on the subject of ableism ppc and medical error is because of the lack of dialogue between two bodies of research the medical literature on ppc and the fields of disability studies and philosophy of disability 6 on the one hand the medical literature on ppc is extensive but comparatively little of it deals specifically with disability that which does however typically does not deal with ableism understood as an epistemic schema that affects both what and how providers know disability and interact with people with disabilities as epistemic agents on the other hand since at least the 1980s experts spanning the humanities and social sciences who work in disability studies have shown that ableism harms people with disabilities in a number of ways for example kennedy institute of ethics journal • september 2019 212 it harms them economically socially and politically yet what these experts have not documented in an equally nuanced manner is how the harm of ableism manifests itself in relation to medical error when medical experts investigate misdiagnosis patterns failures in ppc and the causes of low patient satisfaction among other things they rarely investigate it along the lines of disability and specifically with respect to ableism understood as an epistemic schema the result is a gap in the literature that demands rectification this paper is a first step in tackling this lacuna by demonstrating the central and general role of epistemic schemas in poor ppc leading to medical errors and secondly by arguing more specifically that ableism is a significant contributor to poor ppc with patients with disabilities poor ppc leads to preventable medical error since at least the 1980s it has been well established in the medical communication literature that ppc plays a key role in determining health outcomes a vast body of clinical and social scientific research shows that effective communication between patients and providers leads to better health outcomes 7 and that conversely poor communication harms patients increasing the likelihood of medical error indeed studies of semistructured interviews between patients and providers and of medical malpractice lawsuits overwhelmingly suggest that while not the only variable in play breakdowns in ppc lie at the heart of the problem of error in medicine communication failurewhich includes any situation in which what alvarez and coiera dub the communication space of medicine is diminished obfuscated or obstructedleads to medical error in at least two ways first whenever an encounter between patient and provider is not conducive to mutual understanding patients are less likely to be forthcoming about their symptoms and concerns this may be because they do not feel comfortable enough to share them with their physician or because they dont understand what might count as medically relevant information and what might not either way communicational failure peñaguzmán and reynolds • medical error and epistemic injustice 213 reduces the amount and quality of diagnosticallyrelevant information that a medical expert receives from the patient even in cases where patients have a condition for which an objective diagnostic test exists diminished communication can threaten the diagnostic moment as anyone with clinical experience will attest not all salient information can be gleaned from diagnostic tests and even information that can be gleaned from them cannot always be properly interpreted in the absence of patient input second poor ppc can destroy the trust that patients need to have in providers in order for the clinical encounter to run smoothly although many people think of the experience of going to the doctor as a oneoff event that exists largely in isolation this is rarely the case much of the time medical care is a protracted process that requires multiple visits to the clinic interaction with testing laboratories and even more encounters between the patient and what at times appears to be an interminable flow of medical knowers for this entire process to work patients and providers must build a framework of trust that enables them to recognize each other as partners in a mutually reciprocal relationship unfortunately poor ppc erodes this trust by making patients feel unheard and undervalued as if the very experts on whom they depend do not see them as persons to be cared for but as names on a list to be crossed off a trusting relationship between patient and provider determines the extent to which patients listen to what doctors say whether or not they adhere to medication protocols and even whether or not they seek out care when nonemergency medical incidents arise again in the future trust in short has a substantial effect on the quality of care and on overall health outcomes repairing that trust after it has been broken is no easy task the feelings of desperation isolation and frustration experienced by patients who report poor ppc eat away at the mutual trust that is the bedrock of medical practice although medical error can change peoples experience of the health care system for the worse and corrode their trust in this system it also kills morale among health care providers which research shows can further compromise quality of care and most importantly it harms patients in tangible and sometimes horrendous ways the medical error literature is replete with illustrations of the catastrophic effects that medical errors can have on patients which range from intense physical and psychological suffering to severe chronic illness or death ableism as an epistemic schema within both social epistemology and medical error research the concept of ableism is rarely utilized to understand the types of epistemic injustices and harms pertinent to people with disabilities this claim is true both with respect to studies examining epistemic injustice in relation to mental illness and those that discuss a wider range of disability experiences even in the philosophy of disability the concept of ableism sometimes plays a secondary analytic role for example in the minority body elizabeth barnes defines ableism not in terms of an epistemic schema but as social prejudice and stigma directed against the disabled in virtue of the fact that they are disabled 8 more often than not she deploys the term as a way to understand counterfactual claims about the badness of disability in a world without ableism while ableism certainly involves prejudice and stigma we hope to show it involves much more than that we argue in this section that specially insofar as our knowledge about people invariably involves assessments of and knowledge about their abilities ableism can regularly impact how we interact with others as epistemic agents in other words because ability expectations are central to the conception of any given individual ableism serves to determine in essential ways how and what people know and do not know about their own experiences and that of others it is in light of the breadth and depth of ableisms impact that we suggest research on epistemic justice medical error and their connection would be improved through a greater focus on ableism and the ways in which it functions as an epistemic schema with respect to its role as an epistemic schema we will use the term ableism to mean the assumption that forms of embodiment considered abnormal are necessarily experienced both differently and negatively in comparison to forms of embodiment considered normal ableism functions as a framework for preemptively knowing about the abilities and ability expectations of bodies based upon their perceived disability status including even what it is like to have a particular body and mind ableism leads providers to otherize patients with disabilities 9 like racism and peñaguzmán and reynolds • medical error and epistemic injustice 215 sexism the concept of ableism involves both descriptive and normative aspects ableism is a way of understanding the quality meaning value and differences of human life through the lens of abilities and ability expectations shaped via socially dominant conceptions of normality while the idea of normality is historically and culturally variable in modern medical contexts it takes on a far more specific meaning 10 modern medicine invariably makes assumptions about normal bodily shape size motion and function it also perforce makes specific assumptions based upon statistical analyses of bodily metrics ranging from those that determine everything from normal blood pressure to normal levels of anxiety part of what is so pernicious about the way ableism functions inside of medical institutions and across various domains of medical practice is the way that it forecloses upon the vast range of meanings of disability as a fact of human life as well as the vast range of discrete disability experiences the term disability is notoriously hard to define serving to cover everything from albinism to cystic fibrosis to autism to deafness to short stature to adhd ableism flattens out these differences in deeply problematic ways consider that since the origins of the field of disability studies in the 1980s a core distinction has been made between medical and social models of disability on the medical model disability is a personal tragedy or hardship resulting from a congenital abnormality environmental accident or result of old age in other words disability is a bad thing that befalls one on social models of disability a core distinction is made between disability and impairment one is impaired insofar as ones body is different in ways that impact ones ability to function in the world as compared to most people one is disabled however insofar as one is negatively impacted by the treatment of others on account of ones impairment including impacts due to larger societal norms and institutions what is crucial about social models of disability is the way they point to the social cultural political and historical factors that shape how one is treated including how one is treated by medical experts on account of ones particular body and mind 11 ableism persists in medical contexts especially through the dominance of the medical model of disability inside of medical education ranging from premed to residency to continuing education and spanning across all manner of medical institutes and centers insofar as medical providers assume that a disabled patient is automatically a person dealing with a personal tragedy or hardship they operate with an epistemic schema that results in them prejudging and misjudging their patients the epistemic schema of ableism leads providers to not only misunderstand the lived experience of their disabled patients but also to think that they know what being disabled is like 12 ableism thus leads to epistemic ignorance about disability in multiple respects and to epistemic injustices as a result as we will discuss in greater detail in the next section it leads providers to dismiss and remain ignorant of the qualitatively distinct differences between different kinds of disabilities to exhibit overconfidence concerning claims about disability experience in general as well as specific types of disability and to distrust discredit or otherwise dismiss people with disabilities as experts about their own experiences and that of their communities the negative effects of the epistemic schema of ableism are manifold to better understand the effects of this epistemic schema we will now lay out the four principal mechanisms by means of which ableism undermines ppc ableisms impact on ppc four mechanisms let us begin by observing that we already know ppc failures are more common when it comes to people with disabilities and patients with disabilities suffer more misdiagnoses than nondisabled patients for example people with intellectual and developmental disabilities are systematically misdiagnosed well into at least the 1990s people with moderate hearing loss were misdiagnosed as mentally retarded today people with cerebral palsy are at three times the risk of experiencing adverse events as compared with adults without preexisting communication vulnerabilities meanwhile physical impairments are regularly underdiagnosed in people with intellectual disabilities as are cognitive impairments in people with spinal cord injury all this we know what we need to investigate further is how these failures in communication and misdiagnoses come into being and interact with one another what causes these breakdowns in ppc and produces such an asymmetrical distribution of the possibility of error along the lines of disability we argued above that the answer turns on a dominant schema through which people without disabilities see and know disability which is to say the schema of ableism ableism brings about these disastrous effects by means of at least four mechanisms 217 the first is what fricker calls testimonial injustice this is a form of epistemic injustice wherein a speakers testimony is unfairly downgraded in credibility thanks to a prejudice on the hearers part put otherwise testimonial injustice occurs when a social agent does not take someone elses testimony as credible because of the social identity of the testifier this kind of injustice treats its targets as agents incapable of contributing to a communitys shared knowledge resources an injustice which is associated with treating them as lacking the very capacity to reasona feature typically held to be central to the attribution of personhood the social epistemology literature has produced a number of illustrations of testimonial injustice such as the case of black slaves whose testimony was not seen as authoritative in american courts unless validated by the testimony of a white man or the case of women rape victims whose testimony is not believed by the men in their lives because those men impute onto women a credibility deficit concerning sexual violence testimonial injustice occurs in medical spaces when for example a doctor holds a groupbased belief that black people have higher pain thresholds than those who are not black in doing so they commit a testimonial injustice against their black patients by discounting the validity of their testimony concerning the extent and quality of pain they are experiencing similarly a disabled person with a mobility impairment suffers from an arbitrary credibility deficit when medical knowers for example discount their testimony concerning the specific reason they entered the clinic focusing instead on their impairment and tying diagnosis solely to it this example is not an innocent instance of misunderstanding because the person with a disability is being seen through the schema of ableism on that schema being disabled means being worse off by virtue of ones disability and so even information that is not clearly related to an impairment can easily become a reason for potentially any medical issue by not treating the person as a fullyfledged epistemic agent but instead interpreting them through an ableist lens their testimony is downgraded in credibility as this happens more frequently mistrust on the part of the patient increases testimonial injustice then is not simply a phenomenon that occurs interpersonally insofar as it results from epistemic schemas that track historically oppressed groups and that depend upon prejudicial knowledge and forms of knowing patterns of testimonial injustice can be systemic and pervasive these patterns can become historically entrenched within the social political cultural and even economic norms of a community 13 according to jackie leach scully medical experts often ascribe a global epistemic incapacity to people affected by impairment because they assume that any disability whether cognitive or physical manifests itself as an incapacity to engage in meaningful dialogue with nondisabled agents in one of the few but growing number of studies of epistemic injustice in health care carel and kidd contend that medical professionals frequently and presumptively attribute characteristics like cognitive unreliability and emotional instability to people with disabilities in ways that downgrade the credibility of the testimonies of people with disabilities this is confirmed by research in disability studies and the philosophy of disability for example in the meaning of illness a phenomenological account of the different perspectives of physician and patient s kay toombs describes her experience of going to the doctor in a wheelchair with her husband she reports that people would talk to her husband as if she were not there assuming that being in a wheelchair meant she was nonverbal this feeling of not having ones word heard by those in positions of power is widespread among people with disabilities which indicates that ableism brings about the regular disregard of the knowledge claims and lived experiences of people with disability smith claims that people from all over the disability spectrum report a feeling of invisibility in medical spaces she writes those with a disability are significantly more likely than persons without a disability to perceive that the physician does not listen to them does not explain treatment so that they understand does not treat them with respect does not spend enough time with them and does not involve them in treatment decisions and the invisibility is not just social but also testimonial a good example of this is a recent study that concluded that medical experts overwhelmingly do not believe the testimony of people with chronic fatigue syndrome this problem takes on a particularly acute form when it comes to people with communicative disabilities a second mechanism through which ableism bankrupts ppc is what cassam calls epistemic overconfidence 14 we have seen that ableism produces credibility deficits for people with disabilities which results in an imbalance between social agents on the basis of disability status this imbalance is compounded by another factor that is not unique to disability but that has unique implications for it given the way that disability is often seen solely via a medical lens this second factor is the credibility excess medical experts enjoy as a matter of course 15 we habitually extend long lines of epistemic credit to medical experts especially physicians we assume that they must know what they are talking about even in cases where the evidence points to the contrary in some sense of course it makes sense that we would give medical experts a credibility excess in medical settings since the reason we go to see a doctor is precisely because we assume that the doctors knowledge of health and illness far outstrips our own the problem is that doctors often internalize this epistemic privilege riding on the back of their expert status to such a degree that it can mutate into epistemic overconfidence this term refers to an excess of selfassurance about what one knows and how far ones knowledge extends epistemic overconfidence impedes the ability of doctors to exercise the kinds of epistemic selfmonitoring we expect of them and that is expected of them by their own profession it can lead to medical error by making experts less likely to question first intuitions to request further diagnostic tests to entertain alternative hypotheses to consider referring patients to other specialists to get a second opinion to reflect more critically about social conditions and determinates of health and so onall of which can culminate in a misdiagnosis and can serve to undermine trust with a patient in short it produces in experts an active ignorance that blocks them from recognizing the limits of their own knowledge and its impact on care for example it has been reported that epilepsy is regularly misdiagnosed among people with intellectual disabilities because doctors cannot tell the difference between epileptic events and nonepileptic selfstimulatory events yet the problem is not necessarily that doctors do not know how tell the difference per se the problem is that they often do not know that they do not know how to tell the difference and they jump straight to a diagnosis when they should be getting a second kennedy institute of ethics journal • september 2019 220 opinion discussing things further with the patient more substantively educating themselves about epilepsy as well as about various expressions of certain sorts of intellectual disability or referring the patient to a more qualified expert as cassam formulates it epistemic overconfidence can affect all patients independently of disability status but we argue that ableism amplifies it in particular ways consider the socalled disability paradox this term refers to the fact that nondisabled people rate the quality of life of people with disabilities significantly lower than people with disabilities do albrecht and devlieger formulate the paradox this way why do many people with serious and persistent disabilities report that they experience a good or excellent quality of life when to most external observers these individuals seem to live an undesirable daily existence one would expect that among nondisabled people health care providers would buck this trend since presumably their expert knowledge of medicine translates to a better understanding of impairment than the average person but the exact opposite turns out to be true medical experts have an inaccurate perception of the quality of life of disabled people and they systematically rate the quality of life lower than the average nondisabled person does 16 what is more because of their expert status medical practitioners are unlikely to call into question their own assumptions which are continuously reinforced by the medical model of disability in which they have been reared and to which in most cases they remain committed research concerning the disability paradox suggests that doctors often walk into a consultation with fixed and fundamentally flawed assumptions about disability bioethicist anita ho argues that this disabilityspecific overconfidence on the part of experts puts disabled patients in a dangerous catch22 situation in which they may put themselves at risk if they do not trust their doctors and somewhat paradoxically they may put themselves at even higher risk if they do trust them trust may increase epistemic oppression and perpetuate the vulnerability of people with impairments a doctor who believes that he or she is the leading authority on disability even when a disabled person is in the room may put this patient in harms way even if unintentionally ho continues while more empirical evidence is necessary to ascertain the multiple determinants of patients dissatisfaction numerous studies show that health care providers continue to hold negative attitudes and assumptions toward impairments and the quality of life of people living with these impairments reported negative attitudes raise questions of whether these patients can take professionals proclaimed good will for granted when the good will of the medical expert can no longer be taken for granted all bets are off for people with disabilities how could one in good faith ask disabled patients to put their trust perhaps even their lives in the hands of a provider who believes that their quality of life is poor anyways and who is so confident about this belief that they see no point in even putting it up for debate this has serious ramifications not just for particular providers but for medicine as a whole as grasswick has argued when an institution such as medicine has historically failed members of a specific community the latter have good reasons to mistrust the institution as a whole even if they do not necessarily mistrust the particular individuals who represent it to be clear it may be true that a provider has more medical information about a particular impairment and rightfully considers themselves to be an expert in that sensebut medical information is wholly insufficient to understand the lived experience of person with a particular impairment an experience saturated with social cultural political and historical complexities typically untouched by even the best and most capacious forms of medical education it is the transferal of confidence in medical knowledge concerning impairments to confidence in knowledge concerning the meaningfulness of living with a given impairment that helps produce epistemic overconfidence a third mechanism operative in medical spaces is epistemic erasure epistemic erasure functions by removing entire categories or swaths of hermeneutical resources from a communicative space where they would otherwise reside because the speakers perceived social identity is erroneously thought to render those subjects categorically inapplicable 17 in the case of disabled patients epistemic erasure vitiates communication by removing entire subjects of possible medical interest from conversation and thereby foreclosing from the outset certain avenues of dialogue that might not have been foreclosed in the absence of disability consider sexual health one of the ways in which ableism operates is by turning people with disabilities into objects of pity which is often accomplished through the desexualization of disabled bodies 18 in light of this desexualization many abledbodied individuals express surprise or even shock upon learning that many disabled people have typical sex kennedy institute of ethics journal • september 2019 222 drives and lead fully active sex lives healthcare providers are not exempt from this way of thinking and like the rest of the population tend to desexualize people with disabilities this prejudice is likely to rear its ugly head in the personal lives of providers including in the choices they make about who counts for them as a possible object of romantic or sexual interest and who does not but this prejudice will also arise in their professional lives as it may cause them not to pose certain questions such as questions concerning sexual health to their disabled patients even if those questions are typically routine for example shakespeare et al note by assuming that people with disabilities are not sexually active physicians may exclude them from health information or screening that nondisabled people receive as a matter of coursefor example for sexually transmitted diseases cervical cancer or hiv of course the desexualization of disabled bodies is offensive but it is medically dangerous too the route from epistemic erasure to medical error is both direct and indirect directly we can say that epistemic erasure does not lead to medical error but is itself an expression of it indirectly it leads to medical error in the same way testimonial injustice doesthat is to say by limiting the information patients are called upon to provide as well as that which they feel comfortable in providing and consequently the sorts of diagnoses providers are in a position to make 19 people with disabilities often report being treated by abledbodied individuals as objects of a violent and voracious curiosity as freaks to be looked at and gazed upon this is because ableism teaches nondisabled people to reduce people with disabilities to their disabilities thereby objectifying them in the perceptual field of one under the sway of ableism a person with epilepsy registers simply as an epileptic object a blind person as a walking cane on the precipice of danger and a person in a wheelchair as one confined and bound to everlimited selfor otherpushing as van de ven et al point out sometimes the only way to explain ablebodied peoples behavior in the presence of disability is to assume that somehow they only see the disability and not the person behind it disability which is to say ableist assumptions about disability crowds their perceptual field so thoroughly that they are incapable of not looking at it not talking about it not being distracted by it the tricky part here of course is that it is not the disability that is responsible for producing this effect but the way in which the disability is perceived and interpreted by the abledbodied individual it is an effect of ableism as a way of knowing about the world and others the problem lies in the gazeand epistemic schemasof the ablebodied like all of us medical experts are a product of their environment yet medical experts are also part of an institution with a long and dark history concerning disability historically medicine has played a central role in the construction of disability as both spectacle and tragedy as something to be gawked at and pitied this explains in part why the disability community tends to distrust the medical establishment and its historically teratological understanding of disability 20 and while dominant social narratives of the inevitability of social progress incline us to believe that we have transcended this dark history the ongoing experiences of people with disabilities suggest otherwise they suggest that medical providers too often continue to treat disability as something to be poked and prodded as a fascinating object to be stared at and squinted at the fourth mechanism by which ableism leads to medical error depends on this unique dynamic whereby disability becomes so visible indeed hypervisible that it derails ppc from the real locus of medical concern we call this epistemic derailing epistemic derailing occurs when the qualities and features assumed to track a speakers perceived identity overdetermine hermeneutic space preemptively shutting down more relevant hermeneutic resources and pathways we here use the term epistemic derailing to pick out one of effects of the medical and ablebodied gaze it erroneously narrows the communicative space between a disabled patient and a provider 21 it can prevent medical experts from truly listening to what the patient has to say by making providers assume from the start that the patient is in front of them because of their disability ableism derails the conversation and places an undue epistemic burden on the patient to constantly redirect the doctors gaze back to what matters from a medical standpoint their actual symptoms let us briefly look at a case of epistemic derailing that is not directly connected to paradigmatic cases of disability the treatment of hivpositive people hivpositive patients often find that doctors cannot seem to get past the fact that that they are hivpositive and assume that whatever complaints they make are due to their status this is why depression is severely underdiagnosed in people living with hiv doctors held epistemically captive by the concept of hiv may assume that patients are simply sad about having contracted hiv here the overattentiveness to hiv status interacts with other background assumptions such as beliefs about how sad and meaningless life with hiv kennedy institute of ethics journal • september 2019 224 must be to create a magnetic field that pulls ppc in a specific direction and that ultimately leads to medical error and medical harm 22 in summary patients with disabilities experience this derailing effect of ableism in terms of an overinquisitiveness on the part of providers about their disability status and a cascade of assumptions about patients with disabilities that are untethered from any concrete facts or judgments based upon the patients actual experience this levies a hefty epistemic taxon people with disabilities who suddenly shoulder the burden of educating a nondisabled person in this case a medical provider about disability it also undermines the dialogue between patient and provider because the patient now understands that his or her disability takes so much space in the providers imaginary that the latter will devote most of her or his epistemic resources to it and perhaps it alone 23 both of these forms of testimonial injustice or oppression can lead to what dotson calls testimonial smothering wherein the speaker perceives ones immediate audience as unwilling or unable to gain the appropriate uptake of proffered testimony and thus selfcensors dotson continues testimonial smothering ultimately is the truncating of ones own testimony in order to ensure that the testimony contains only content for which ones audience demonstrates testimonial competence testimonial smothering exists in testimonial exchanges that are charged with complex social and epistemic concerns in the contexts under discussion a patient with disabilities may purposely limit the information they provide because they know that if included additional information will not be heard and may even exacerbate the epistemic and communicative issues at play motivated to combat this phenomenon shakespeare et al draw an important distinction between need to know and want to knowquestions the first category refers to questions that providers should ask the second to those they tend to ask out of ignorance and curiosity whenever disability enters the scene the dark side of want to knowquestions is that aside from reenacting medicines historical treatment of people with disabilities as freaks and monsters they cast a shadow on need to know questions when providers cannot see anything but the disability they cannot think of anything but the disability and when this happens they cannot come up with the questions whose answers they really need to know these questions drop out of focus and before providers realize it their hyperattentiveness to the patients disability snowballs into a situation in which patients and providers may be technically exchanging words but are not communicating in ways that will promote positive health outcomes ableism and contributory injustice the four aforementioned mechanismstestimonial injustice epistemic overconfidence epistemic erasure and epistemic derailingare all functions of the ableist schema that mediates how providers think about and relate to their disabled patients but what is it about providers or the medical establishment more generally that cultivates this ableism we submit that at the root of these mechanisms is the medical communitys lack of engagement with critical nonmedical modes of knowledge concerning disability including and especially with respect to knowledge created by disability communities themselves as well as bodies of work which draw directly on such knowledge as literature in disability studies and philosophy of disability regularly does in other words a root cause of ableism in medicine is medicines own understanding of disability as an objective lack rather than as a diverse set of phenomena that are thoroughly socially mediated this reliance constitutes a form of what dotson calls contributory injustice which turns on the willful exclusion of a certain set of hermeneutical resources from the worldview of a sociallyprivileged agent dotson writes contributory injustice is caused by an epistemic agents situated ignorance in the form of willful hermeneutical ignorance in maintaining and utilizing structurally prejudiced hermeneutical resources that result in epistemic harm to the epistemic agency of a knower contributory injustice results from histories of epistemic exclusion and entrenched relations of power dotson explains miranda fricker in her book epistemic injustice seems to assume that there is but one set of collective hermeneutical resources that we are all equally dependent upon i do not share this assumption we do not all depend on the same hermeneutical resources such an assumption fails to take into account alternative epistemologies countermythologies and hidden transcripts that exist in hermeneutically marginalized communities among themselves epistemic exclusion is the notion that social position and power align with certain forms of epistemic power that is power over the ways in which knowledge is accumulated within acknowledged by and disseminated through communities with the result that some kinds of knowledge can be kept out of mainstream sight contributory injustice is thus one form of epistemic exclusion for example a white provider who has completed her medical education may see no reason to learn about the history of medical practice much less the way that its history affects the differential treatments of patients along lines of racialization today she may assume that her education especially if it comes from a privileged institute of higher education is sufficient she may assume that her life experience has taught her all she needs to know about social relations why would the provider need to draw upon hermeneutic resources from communities of color to learn about racism and its history and contemporary role in medicine or analogously sexism or cissexism or ableism by not attending to such bodies of knowledge a provider commits contributory injustice perhaps the simplest way to think about contributory injustice is in terms of which bodies of knowledge register to people in positions of privilege as legitimate or illegitimate and which simply fail to register at all contributory injustice is about the ways in which relations of oppression can be produced and exacerbated by the implicit choices we make about which hermeneutic resources matter and which do not as dotson notes one assumption of the theory of contributory injusticeand in this regard she differs from frickeris that there is no such thing as the pool of hermeneutic resources because not all members of a political community interact with the world using the same stockpile of hermeneutic resources rather different communities develop different modes of thinking about the world that may or may not coincide with the mode of thinking that happens to be dominant hence when we witness instances of epistemic injustice it is possible that the problem is not that a socially privileged agent unjustly doubts someones testimony or that the community is at a loss for the kinds of hermeneutical resources the testifier needs to shed light on an important aspect of her experience in these cases the problem is that while there are hermeneutic resources that tackle the specific problem at hand the socially privileged agents are not peñaguzmán and reynolds • medical error and epistemic injustice 227 familiar with them because they have no interest in learning about them since doing so is likely to challenge their own epistemic schemas they may in fact have a vested interest in not learning about them insofar as that ignorance maintains their privileges and attendant experiences in the world an illustration will make this clearer genderaffirmation surgeries are often discussed in the medical and bioethical literatures as controversial because medical experts disagree about whether they count as therapy or enhancement but this way of thinking about gas leaves trans individuals in a terrible double bind on the one hand if trans communities accept the therapeutic interpretation then they must also accept the secondary claim that gas are essentially a corrective a fix for the condition that the dsmv calls gender dysphoria this in turn implies that to be trans is to have a mental disorder as emma inch rightly observes this medicalization of trans identities fuels transphobia and contributes to the ongoing marginalization of trans subjects on the other hand if trans communities opt for the enhancement interpretation of gas which is not to exclude other interpretations including gender euphoria as a way of resisting the adverse effects of medicalization they can be left in a medicallyvulnerable situation since under contemporary medicallegal frameworks trans people often need a diagnosis to change their names in legal documents and to offer a sociallyintelligible explanation of their situation to friends and family members in many places a diagnosis is required for gas a medical diagnosis in addition to exercising a social control function in modern societies can help individuals gain access to care and treatment genderaffirmation surgery and hormone treatments are very expensive and the fear is that neither publiclyfunded health providers nor private medical insurance schemes will pay for treatments that are not prescribed with the intention of relieving a diagnosed condition some trans people ultimately view the label of disorder as the price that must be paid for access to treatment for some medical treatment truly is a matter of life or death and they fear the removal of it from diagnostic manuals could have devastating consequences members of the who working group acknowledge this quandary and insist that diagnostic manuals like the icd find a balance between the competing issues of stigma versus access to care the double bind between medical stigmatization and access to medical services is real and painful but it may not be inevitable this bind is only an inevitable effect of the specific hermeneutic resources the medical kennedy institute of ethics journal • september 2019 228 community mobilizes when it thinks about gas and trans identity which is what makes it a good example of contributory injustice as soon as the hermeneutic resources of the medical establishment are used to frame discussions of gas it becomes difficult to think about this complex phenomenon in any other way but the trans communityespecially trans scholars working in the field of trans studieshave generated an entire body of knowledge that affords radically different understandings of what it means to be trans the trans community in other words has generated its own hermeneutic resources to think about trans identity in ways that evade the therapyenhancement double bind if the therapyenhancement double bind continues confining trans people this is because the medical establishment continues to approach gas using hermeneutic resources that are outmoded illsuited prejudicial and ultimately harmfulresources that have been historically produced without the direct input of the trans community itself from the standpoint of social epistemology the medical establishment commits contributory injustice against trans individuals by privileging a set of hermeneutic resources that are prejudiced but do not register as such and by ignoring alternate resources including those directly from the trans community the same can be said in relation to the disability community because the medical establishment on the whole embraces the medical model of disability it relies on hermeneutic resources that were not designed with disabled people in mind and that are often directly at odds with how disability communities understand the meaning of disability and with how disabled people experience their own lives the four mechanisms of epistemic injustice we have outlined here result from an active ignorance on the part of providers about how disabled people understand themselves and their own experiences not to mention how the medical model harms people with disabilities in a world in which multiple alternative models of disability exist and the medical community has the power to access them engage them and incorporate them into its institutional structure failure to do so constitutes contributory injustice because it reflects a decision on the part of the medical community that the harms its hermeneutic resources inflict on disabled patients do not matter as much as the comfort it itself takes in the continued use of these resources peñaguzmán and reynolds • medical error and epistemic injustice 229 medical error in a historical and social context we have argued that testimonial injustice epistemic overconfidence epistemic erasure and epistemic derailing undercut ppc and expose people with disabilities to an unjustifiably high risk of medical error and medical harm of course medical errors that terminate in suffering are always harmful insofar as they cut against the grain of the two most fundamental interests of patients irrespective of disability status their interest in getting better and their interest in not getting worse while error is obviously good for no one we argue that medical errors are particularly harmful when they happen to people with disabilities and other marginalized identities because they tend to not only have firstorder physical effects but also secondorder symbolic effects furthermore they are particularly harmful at a firstorder level insofar as they contribute to the disproportionate distribution of error against an already marginalized group this symbolic harm however can be interpreted in a different way when a disabled patient suffers a firstorder medical harm at the hands of experts because of the ableism that permeates the institution of medicine this harm takes place not just in a historical context in which the history of medicine is implicated but also in a social context in which the collective imaginary already conflates disability with pain and suffering what reynolds calls the ableist conflation is the persistent conflation of experiences of disability with experiences of pain suffering and disadvantage that is why the most common reaction to disability is an uncritical rush to pity and an assumption of low qualityoflife by equating disability with suffering in this way nondisabled individuals construct in their minds an identity for people with disabilities that denies the latter agency and the possibility of a rich meaningful life while it is possible for the nondisabled to suffer the ableist conflation leads nondisabled people to think it is impossible for the disabled not to suffer restricting both the facts and imagined possibilities of a life this conflation produces a pernicious master narrative that defines what it means to be disabled from the vantage point of the nondisabled we have also argued that schematic epistemic errors deserve more attention in the medical error literature while epistemic errors are frequently referenced in this literature most of the time they are reduced to what we call factical errors which are errors resulting from lack of information but we showed that medical errors can occur not only because of what providers know but also because of how they know schematic kennedy institute of ethics journal • september 2019 230 epistemological errors pertain to ways of knowing that involve entire constellations of values norms biases impulses desires fantasies and assumptions of which we are sometimes unaware but which nevertheless shape our activities of knowing in any given milieu it is these schematic epistemological errors we hypothesized that are largely responsible for the unequal distribution of medical errors finally we would like to close by suggesting that schematic epistemic errors deserve special attention in the medical error literature because of their recalcitrant nature schematic epistemic errors not only involve the ins and outs of a hypercomplex health care system but also the ways in which epistemic agents interact with this system with one another and with the broader local national and international environments of which this system is only one component epistemic errors can persist despite improvements in medical education and the efforts of individual providers and teams aimed at reducing medical error in short they are obdurate because they are not explicit easily localizable or particularly amenable to change on the contrary they are distributed implicit and resistant to change often they are the result of longacquired habits of thinking and knowing that sediment and ossify with the passage of timeand these habits reflect entrenched hierarchies of social power that reinforce difficulties faced by patients from vulnerable populations for this reason individuals often lack the will not to mention the ability to uproot them calls to mobilize against them can even be met with collective resistance schematic errors can serve to undermine care even when providers are actively working to address facticalbased errors and actively working to provide equal care across populations schematic errors present a special problem for patients with disabilities given the fraught historical relationship between disability and medicine medicine has surely contributed to improving the lives of some people with disabilities but it has also defined disability and treated people with disabilities in ways that harm them medical errors due to ableism literally add insult to injury insofar as they crystallize the medical institutions historical disregard for and disparagement of the lives of people with disabilities preventable medical errors due to ableism only fuel this conflation and further reentrench an identity that has been constructed for people with disabilities without themthe inverse of one of the most important maxims of the disability rights movement nothing about us without us and this forms a vicious circle peñaguzmán and reynolds • medical error and epistemic injustice 231 ableism leads to medical error error leads to firstorder harm firstorder harm makes people with disabilities suffer this suffering when perceived by others under the aegis of ableism reinforces the ableist conflation upon which ableism rests and contributes to secondorder symbolic harms and damaging master narratives at some point persistent medical error ceases to be a purely medical problem connected to a doctors fiduciary and ethical duties to their patient and becomes a political problem tied to the question of justice we can think through the connection between error and justice using a rawlsian framework although rawlss understanding of justice is traditionally framed in terms of the fair distribution of goods such as material resources and political rights this could easily be expanded to include the fair distribution of potential harms of course no social institution can immunize itself against the possibility of accident but all institutions should strive to ensure that the possibility of accident is not so unfairly distributed among its population that certain subsections of it bear all or even most of the brunt of it when such an imbalance occurs we can infer that there are deep structural problems that need to be addressed in the interest of justice especially if we also have compelling reasons to believe that the accidents in question could be prevented with due diligence if our analysis above is correct and the possibility of medical error is indeed not evenly distributed among all social groups in medical spaces justice would demand that we strive to uproot the cause or causes of this asymmetrical distribution one such cause is ableism notes 1 each author contributed equally to the conception research writing and editing of this article for helpful feedback on earlier drafts we thank sandra l borden fritz allhoff derek anderson and two anonymous reviewers 2 aronson presents his taxonomy specifically in relation to medication errors but it is clear that it suitably extends to medical errors more generally 3 for us epistemic schemas include both epistemic elements as well as elements that traditional theories of knowledge may not consider properly epistemic schemas are conglomerations of beliefs intentions values norms and biases through which epistemic agents arrive at an ordered interpretation of their experience or of important aspects of it 4 while here we describe the relationship between epistemic schemas and epistemic ignorance as causal in reality the relationship is dialectical schemas and ignorance are mutually reinforcing insofar as schemas generate various types of epistemic ignorance which in turn reinforces the schemas by shielding them from conscious reflection and therefore the possibility of criticism they are both causes and effects of one another 5 we do not mean to suggest that ableism negatively impacts only people with disabilities though we cannot defend the point here insofar as what counts as being ablebodied and normal intersects with assumptions about race gender sex sexuality and the like it can have a negative impact on people who are not disabled or who do not have impairments we are however assuming that those most negatively affected by the epistemic schema of ableism in a medical context are disabled people 6 the society for disability studies defines disability studies as an interdisciplinary field born in the second half of the twentieth century that encourages perspectives that place disability in social cultural and political contexts there is disagreement within disability studies scholarship and disability activism across the globe concerning whether persons with disabilities disabled persons or some other such term should be used in recognition of the underlying pluralism about ways of conceiving of the relationship between disability and personhood that these voices and ensuing disagreements represent as a whole we will use both terms interchangeably 7 street et al posit seven pathways through which communication can lead to better health increased access to care greater patient knowledge and shared understanding higher quality medical decisions enhanced therapeutic alliances increased social support patient agency and empowerment and better management of emotions 8 to be fair it is entirely possible that by using the terms prejudice and stigma to describe ableism barnes was in fact thinking of something along the lines of an epistemic schema our only point is to show that otherwise insightful and important analyses of disability have not engaged the concept of ableism especially with respect to its role as an epistemic schema as fruitfully and as in depth as they might 9 on the concept of othering see shapiro roberts and schiavenato 10 for a fantastic study on the concept of normality and its connections to the natural and the normative see weiss 11 one might counter that our analysis does not attend sufficiently to the differences between intellectual and physical disability although our examples are indeed taken more often than not from examples of physical disability and although we agree that there are crucial and often substantive differences between intellectual and physical disability with respect to the topics at hand we nevertheless maintain that our more general analysis is a boon to analyses of medical error and people with disabilities of either type it should also be noted that the concept of impairment as well the social models of disability more generally have come under significant criticism from disability theorists and philosophers of disability these debates though important are orthogonal to our concerns here 12 there are many drivers of ableism in medicine one of them which we do not have space to discuss here has to do with how disability becomes a synecdoche for human vulnerability as such which ignores the fact that vulnerability comes in many forms scully for instance distinguishes between contingent and intrinsic vulnerabilities rogers mackenzie and dodds similarly distinguish between inherent situational and pathogenicvulnerabilities following scully we hold that many dependencies and the vulnerabilities that come with them are not incompatible with full autonomy there are no vulnerabilities inherently and uniquely connected with disability as such vulnerabilities emerge as a product of the relationship between an individual and his or her environment as historians of disability and disability studies scholars more generally have shown many of the vulnerabilities disabled people face result from environments designed to not support or which are actively hostile to them whether due to inaccessible built environments ableist ideologies underdeveloped assistive technologies or medicalized understandings of disability impairment and vulnerability etc 13 our thanks to one of the anonymous reviewers for nudging us to reflect upon this point with respect to sexist and racist epistemic injustices medina offers an illuminating analysis with respect to testimonial injustices experienced by people with chronic illness see kidd and carels analysis of what they call pathocentric epistemic injustices 14 jones also discusses this phenomenon in a general way our thanks to derek anderson for pointing us to this reference and those in the next footnote 15 among other sources that discuss credibility excess see medina davis yap medina 16 according to ho in the case of people with chronic conditions this pessimistic judgment can inadvertently thwart physicians motivation to treat a patients other conditions aggressively on the assumption that the patients overall quality of life is poor anyway scully also notes that while the disability paradox needs to be taken seriously as an indicator of the prevalence of ableism that impairments come along with an average quality of life is not always the case especially not for more recently disabled people whose impairment constitutes a significant loss and who are still struggling to adapt to their changed circumstances 17 with regard to both epistemic erasure and what we discuss shortly below as epistemic derailing we take ourselves to be exploring forms of what pohlhaus calls willful hermeneutical ignorance to be clear by coining these terms we do not take ourselves to be the first to point to these issueson the contrary we are using these phrases to point to experiences that we take to be well attested in disability studies writ large 18 in 2016 interalia a journal of queer studies published a twopart special issue on the subject in the introduction to the special issue lets talk about sex tomasz sikora and dominika ferens note that the various contributions are important reminders of disabled peoples struggle for sexual recognition endless narratives depict people with disabilities as either asexual or nonsexual indeed as barely having sexual organs in the first place according to sikora and ferens this contributes to the oppression and marginalization of the disability community 19 epistemic erasureamong other types of epistemic injustice we discuss in this articletakes on a different form and can have different effects with respect to invisible disabilities due to space we are limiting our discussion here primarily to visible disabilities and hope that further research in this vein will explore questions relating to invisible disabilities 20 clare observes that medicine played a key role in the medicalization of disability in the early twentieth century one of the first tools used by medical experts to turn disabled bodies into objects of interest was the language of teratology the centuries old study of monsters 21 throughout this paper we have assumed that the medical provider in question is ablebodied this is of course an assumption that leaves out disabled providers it is sadly beyond the scope of this paper to address the specific types of challenges disabled providers might face with respect to ppc ableism and epistemic injustice more generally see eg meeks insofar as disabled providers experience ableism along the lines we discuss here we hope that this paper may mutatis mutandis afford some insights 22 people who are hivpositive are not the only ones who feel this pull in the context of ppc overweight patients do too often when patients who are overweight obese or as some prefer to be called fat show up to the clinic they are confronted with a labyrinthine setting in which all paths lead to the same destination it is because of your weight as in the case of ableism fatism narrows the providers field of vision and causes them to fail to make inferences that they otherwise would have likely made this would explain why conditions such as mood disorders and sleep disorders are underdiagnosed among overweight patients 23 to be clear epistemic erasure is closely related to epistemic derailing keeping to our primary example the former is when a topic of medical relevance disappears from the doctors perceptual field and really is invisible the provider might express surprise at the patient who insists on talking about it by contrast epistemic derailing is a subtle deviation in the conversation where one topic slowly pulls the conversation in its direction even though the conversation begins or should reasonably go somewhere else derailing is a question of hypervisibility each then are like the inverse of one another put more simply erasure occurs when the epistemic schema of ableism puts patients in a situation where their impairment has the effect of hiding something from a provider that is relevant and derailing occurs when their impairment becomes so bright as it were that nothing else can be seen

this paper argues that epistemic errors rooted in groupor identitybased biases especially those pertaining to disability are undertheorized in the literature on medical error after sketching dominant taxonomies of medical error we turn to the field of social epistemology to understand the role that epistemic schemas play in contributing to medical errors that disproportionately affect patients from marginalized social groups we examine the effects of this unequal distribution through a detailed case study of ableism there are four primary mechanisms through which the epistemic schema of ableism distorts communication between nondisabled physicians and disabled patients testimonial injustice epistemic overconfidence epistemic erasure and epistemic derailing measures against epistemic injustices in general and against schemabased medical errors in particular are ultimately issues of justice that must be better addressed at all levels of health care practice

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background embeddedness in social networks has always been a defining characteristic of our human species social networks are known to influence peoples health above and beyond the influence of their individual attributes and these relational structures have been recognized as strong determinants of health throughout the life course 1 2 3 a large body of research has linked social networks to various physical and mental health outcomes 4 5 6 7 health behaviors 8 and longevity 29 the basic association between social networks and mortality has been demonstrated more than fourty years ago 10 and more recently the independent effect of social neworks on mortality has been established with a magnitude of this effect being comparable to wellestablished risk factors like smoking and obesity 11 research from highincome countries strongly suggests that social networks are instrumental for healthy aging by protecting against a range of negative health outcomes including chronic noncommunicable disease morbidity 12 13 14 15 by slowing down or aiding recovery from agingrelated impairments 1617 cognitive decline 1819 disability 20 21 22 23 and mortality 101124 many ncd risk factors spread through social networks 2526 and studies have also suggested that social networks affect patterns of health care utilization predict institutionalizations 2728 and influence ncd selfmanagement among aging populations 2930 however the generalizability of these associations to aging populations in lowand middleincome countries is not well established 6 despite the general consensus that social networks have an effect on health there is a lack of a clear theoretical understanding of how they affect health ie the intervening mechanisms and pathways linking social networks to various health outcomes 431 social networks are commonly viewed as multifactorial constructs that can be characterized by their structural and functional components at the individual family community or society levels 32 structural indicators are commonly quantitative in nature while functional aspects refers to the functions provided by a network the conceptualization and operationalization of social network indicators varies largely between studies and behind each concept may be different mechanisms and pathways at work recognizing that social networks are embedded in and operate through various multilevel phenomena berkman has presented a conceptual model of how social networks impact health 4 the framework embeds social networks into a larger cascading causal process in which upstream macrolevel socialstructural forces condition the structures and features of mezzolevel social networks which in turn provide opportunities for a set of microlevel psychosocial mechanisms to fall into motion these downstream mechanisms operate through the provision of social support social influence social engagement or by providing access to resources and material goods ultimately this affects health through proximate pathways including direct physiological responses psychological states and traits and health behaviours in our study we focus on social network diversity being a structural indicator network diversity is defined as the number of different network domains in which respondents are actively embedded in 33 particularly for older adults there are several advantages why more diverse social networks confer health benefits over and above other commonly used structural indicators such as network size network diversity is an indicator for heightened social integration and participation which has been associated with various mental 34 and physical health benefits 11 among aging populations greater diversity indicates the availability of more diverse types of support which is particularly useful for aging populations with increasingly varying and enduring health and social needs 35 and given the tendency for decreasing network size and the clustering of network losses among older adults greater diversity offers multiple opportunities to compensate for such structural network holes during the aging process while those with diverse networks are likely to be embedded into a largesized network the reverse may not always hold and it is therefore crucial to more clearly outline the role of social network diversity in the aging process in many lowand middleincome countries due to various hindrances including a lack of resources data and political will epidemiological studies and thus policy responses on the health effects of social networks for particularly aging populations are still uncommon 636 studies have shown that specifically in lmic settings social networks function as important safety nets especially for older adults 37 38 39 particularly given the widespread nonavailability of formal support structures in such settings the provision of informal support from various sources may be more crucial for maintaining health and wellbeing as compared to highincome settings and thus the importance of interpreting adult health outcomes in terms of social networks becomes critical health insecurity and limited social welfare protection in health stemming from weak and fragmented health care systems lack of adequate health insurance schemes and financial and geographical access barriers have become a major concern in many lmics 40 crosscultural research has shown that in many nonwestern cultures social networks tend to be larger by means of extended family structures and strong community bonds but studies investigating the role of network diversity remain scarce in such settings particularly research on the health effect of network diversity among vulnerable populations such as older adults remains limited with a traditional focus on children mothers infectious diseases and nutrition health care systems in lmics are in many ways overburdened by population aging and its rising demands for care addressing ncds agingrelated physical and cognitive decline and the provision of longterm geriatric services especially due to the chronic incapacitating and disabling nature of ncds the growing numbers of older adults in lmics rely on support from their informal social networks that is family friends or other informal groups to enhance their chances of health and wellbeing thus intervening in the social networks of older adults can be an investment in population health with manifold implications for health and public policy however to formulate policies one should know the degree to which social networks influence health which aspects of health are affected and which groups should be targeted the indonesian setting indonesiathe worlds fourth most populous countryrepresents a particularly interesting case for the study of social networks and adult health and aging during the past decades indonesias population has aged undergoing a swift demographic transition from high to low levels of both fertility and mortality as a result life expectancies have risen from 55 years in 1971 to 67 years for men and 72 years for women in 2017 41 42 43 indonesias age structure has gradually transitioned towards higher age groups in the 1970s people over the age of 60 years made up 45 of the population but in 2015 this figure had risen to 85 and projections estimate that it will almost double to 16 by 2035 4445 such a development will have farreaching socioeconomic implications and put pressure on the existing intergenerational support systems 414647 predictions based on population censuses show clearly that many of the countrys older people will need more economic aid as their labour force participation declines and social pensions are often not sufficient 4344 many will need to engage in incomegenerating activities past retirement age to meet their basic needs 4849 oldage care responsibilities traditionally lie with children 50 but there will also be a growing number of older couples with fewer children on whom they can depend 4151 additionally indonesia is facing the feminization of aging with a larger number of women many of them widows living alone these women will reach old age while facing a range of challenges imminent to their lower educational attainment and labour force participation 41424548 intertwined with this demographic transition of indonesia is the epidemiological transition towards a rising burden of ncds a rising prevalence from 48 in 1990 to 70 in 2010 shows that over the past decades ncds have decisively replaced infectious diseases and malnutrition as the leading causes of death and disability in indonesia 5253 the latest data show that ncds result in 73 of all deaths in indonesia identifying cardiovascular diseases cancers diabetes and chronic respiratory diseases as the leading causes of death 54 the proportional mortality rates due to ncds are especially high among adults over 50 years of age 55 the risk of premature mortality due to ncds increased from 23 in 2014 56 to 26 in 2018 with stroke and ischemic heart diseases being the main causes 54 agingrelated disability likewise increased specifically the percentage of adults aged over 60 years who reported at least one disability increased from 11 in 2007 to 26 in 2018 5357 scholars and policy makers are only beginning to recognize the health and social policy challenges of population aging in indonesia this development could generate an unprecedented increase in the number of patients in need of longterm chronic care and geriatric services 58 and present a major challenge to the countrys ambition to achieve universal health coverage and health system equity 59 60 61 despite the importance of interpreting adult health outcomes in terms of social networks particularly in lmics the empirical research on indonesian populations is limited and policy attention is lagging 4662 a systematic review synthesizing the evidence from indonesia between the years 2000 and 2016 emphasized the need for more social network research involving health among aging populations 61 several qualitative and ethnographic studies have been conducted in east java and west sumatra offering insights inter alia into issues like intergenerational family support systems 63 childlessness and oldage vulnerabilities 64 or care dependencies in relation to family network gaps 6566 during the past years few quantitative studies have emerged on related concepts such as social capital 67 and social engagement 68 to the best of our knowledge no epidemiological social network studies on aging populations are at present available for the larger indonesian context this study not only offers to fill this gap but also responds to calls eg 4669 to provide more evidence on the causal associations between social networks and health and particularly to strengthen the evidence base for certain subpopulations such as older adults in lmics novelties rational and analytical hypotheses compared with other studies scrutinizing aspects of the social networkhealth relationship we believe that this study offers two novelties firstly it is to the best of our knowledge the first to adopt an outcomewide epidemiological approach 70 to the investigation of the effects of social networks on health in general and older adults health in indonesia in particular by utilizing this approach one can see the effects of a specific exposure in our case social network diversityon multiple health outcomes simultaneously as opposed to studies focusing on one exposure and one outcome at a time or exposurewide epidemiological studies the results of such an approach are particularly useful for decision makers when they need guidance on prioritizing certain public health recommendations over others secondly we implemented a multimethod causal inference approach comparing the results from two methods that estimate causal effects by confoundercontrol approaches with an instrumentbased approach 71 with the premise that no single method is perfect or guarantees a true answer employing different methods each with different limitations can give greater confidence to the validity of ones conclusions additionally by applying both confounder control and instrumentbased approaches we are able to draw conclusions both on individual and population level since these techniques produce effect estimates which apply to different populations 7273 while the confounderbased approaches shed light on questions such as if greater social network diversity confers better health outcomes for individual respondents the instrumentbased approach is meant to inform decisionmaking on a population level ie will an increase in network diversity among older adults at population level lead to bettter health outcomes it has been widely acknowledged that such multiplemethod analytical approaches are a key ingredient of any serious evaluation strategy 7475 we believe that this study is the first attempt to apply a multimethod approach to the investigation of social networks health effects on older adults in a lmic setting the aim of our study is to outline more clearly the role of social network diversity in the aging process in indonesia our primary research question centres on whether and to what degree there is an association of social network diversity with adult health in indonesia to answer this the present study takes an outcomewide analytic approach 70 to examine prospectively the associations of social network diversity on a wider battery of adult health outcomes to frame our outcomewide approach we apply verbrugge and jettes sociomedical disablement process model 76 in this model agerelated disability is generally regarded as the common endpoint being not only a function of preceding pathologies impairments and functional limitations but also the result of an adaptive process subject to various intraindividual extraindividual and risk factors we focus on social networks as being one such factor affecting for example speeding or slowing the pathway from pathology to disability via impairments and functional limitations in relation to this we propose three broader sets of hypotheses first based on the premise that gender is a crude indicator of the broader macrosociocultural context of social interactions 4 we particularly aim to explore the differences in the healthprotecting potential of womens and mens social networks second given that the findings on the relationship between social networks and adult health have so far varied with studies reporting positive negative or no associations 7778 we hypothesize that the doseresponse relationship between social network diversity and health outcomes along the disablement process model is not linear and we expect heterogeneous health effects very likely varying by sex gender in this sense there is further added value in applying an outcomewide approach because it has been noted that the application of an outcomewide approach is particularly beneficial if the exposure does not equally affect all health outcomes in the same direction 70 third with the disablement process model as the conceptual base for our analyses and the notion of social networks being a psychosocial determinant of health we seek to clarify whether there is a gradient within the model from weaker associations between social networks and outcomes manifested on cellular or body system levels to larger effects on dimensions relating to the person or the persons relation to society this hypothesis is based on other studies that have investigated the mediating role of psychosocial determinants such as social integration social support or loneliness within the disablement process 79 80 81 we specifically chose to focus on network diversity that is the number of different network types in which a respondent is embedded based on the longstanding notion that more diverse networks may produce health benefits over and above the crude network size 103382 particularly for aging populations networks with greater diversity represent opportunities for various types of support which may not be available for older adults with large but less diverse networks methods data source the indonesian family life survey the data for this analysis were sourced from the fourth and fifth waves of the indonesian family life survey hereafter referred to as ifls4 and ifls5 8384 the ifls is a continuing longitudinal socioeconomic and health survey that started in 1993 making it the longest panel study outside oecd territory 85 the ifls is also one of few surveys in an lmic setting that has implemented the largescale collection of biomarkers using dried blood spots testing 86 the ifls1 baseline sample from 1993 contains 30000 individuals from 7224 randomly selected households representing about 83 of the indonesian population living in 13 provinces almost 88 of the original ifls1 dynasty has been interviewed in all 5 waves for this study we use ifls4 and ifls5 which were fielded in 200708 and 201415 on the 1993 households and their splitoffs the dynasty recontact rate in ifls4 and ifls5 was 94 and 92 respectively the recontact rate of ifls5 with ifls4 households was 91 for those who had died since the completion of ifls4 interviews with a knowledgeable proxy were conducted further details of the iflss sampling scheme and recontact protocols are available elsewhere 838487 the ifls data are open for public use upon registration on the website of the rand corporation rand survey meter and gadjah mada university which undertook ifls4 and ifls5 obtained ethical approval measures exposure social network index the primary exposure variable is the diversity of each respondents social network at the baseline this was measured through a composite measure a social network index combining information about the household size together with the range of social ties with whom respondents had active contact across six different types of role relationship including a spouse parents children siblings neighbours and members of groups without and with religious affiliation all these variables were sourced from ifls4 for the calculation of the sni we followed with few modifications the procedures described by cohen and colleagues 33 one point was assigned to each type of relationship and we gave equal weight to intimate kin and nonkin relationships therefore a respondent living in a household with more than four persons who is married whose parents coreside in the same household who provides andor receives instrumental or financial support tofrom siblings and children and who participates in social and religious activities monthly received the full score of seven points and thus was classified as a respondent with a diverse social network the ifls is not particularly geared towards measuring social networks or their diversity therefore we needed to employ a variable which measured reciprocal instrumental and economic support tofrom siblings and children as a proxy for indcating the presence of such kin networks this is a strength of our index as we can control to some extent for the correlation between structural and functional characteristics of social networks because the common assumption that more diverse networks should automatically be associated with increased receipt of support may not always be true the cronbach alpha of the sni was 0718 based on the datadriven median split we then dichotomized the respondents into those with low social network diversity and those with a diverse social network most respondents had no missing data for any of the 7 indicators used to compute the sni the remaining 469 had two or less missing responses but could still be assigned a sni the risk for exposuredependent misclassification of this approach was low and affected 1 of respondents approximately 1 of the respondents reported null network diversity which further confirms that our study is primarily examining the effect of network diversity and not related concepts such as social isolation on adult health outcomes further details of the derivation of the analytical sample size are provided below outcome battery in our study a wider battery of 19 health outcomes measured in 201415 were considered guided by the disablement process model 76 we grouped these outcomes into four interrelated components eight pathologies five impairments four functional limitations and two disabilities table 1 presents a summary of the different outcomes further details are available in the ifls5 field report 84 and the dbs data user guide 86 biomarker data for creactive protein and glycated haemoglobin levels are only available for a random subsample of respondents for details see the annotations in table 1 immunological impairments 10 chronic inflammation based on creactive protein levels 2 biomarker crp concentrations from fingerprick dbs specimens measured using validated enzymelinked immunosorbent assay method continuous variable binary variable 0 yes 1 no 5 muscoskeletal impairments 11 mean hand grip strengths physical performance test hand grip strengths was measured by a trained ifls interviewer using a baseline smedley spring type dynamometer respondents were asked to squeeze the dynamometer in each hand twice beginning with the dominant hand two measurements per hand were recorded including information on any recent surgery swelling inflammation severe pain or injury on one or both hands and recording of dominant hand continuous variable 12 arthritis andor rheumatism selfreported physician diagnosis 1 0 yes 1 no sensory impairments 13 hearing andor vision problems selfreported physician diagnosis 1 0 yes 1 no iii functional limitations physical functional limitations 14 upperbody functional limitations 6 selfreported physical functioning measures including show cards question if you had … could you do it 1 to carry a heavy load for 20 m 2 to draw a pail of water from a well 3 to sweep the house floor yard 0 yes 1 no 15 lowerbody functional limitations 7 selfreported physical functioning measures including show cards question if you had … could you do it 1 to walk 1 km 2 to bow squat or kneel 3 to stand up from sitting on the floor without help 0 yes 1 no covariates following caliendo and kopeinig we selected a rich set of 15 covariates that satisfied the unconfoundedness assumption necessary for the later estimation of treatment effects 88 guided by the disablement process model 76 and a systematic review providing information on the social determinants of adult health in indonesia 61 the following individual and household sociodemographic covariates were chosen sexgender age educational attainment quartiles of monthly household per capita expenditure residential stability and area of residence we decided to group people into two age groups dichotomized at the age of 57 the 2014 average indonesian retirement age the pce was precalculated by the ifls from the monthly total household expenditures for food and nonfood consumption and expenditures including purchased goods services and durables as well as housing and table 1 overview and assessment of the outcome battery outcome type of measurement response scale version of the ravens progressive matrices 8 a nonverbal selfpaced test in which each item contained a pattern with a missing part the respondent had to infer the rules underlying the pattern and apply these rules to discover which of the answer options provides the correct completion for a total of eight items answer range 08 points iv disabilities 18 activities of daily living limitations 9 selfreported physical functioning measures for five basic tasks of everyday life including show cards question if you had … could you do it to dress without help to bathe to get out of bed to eat to control urination or defecation continuous variable binary variable 0 yes 1 no 19 instrumental activities of daily living limitations 10 selfreported ability to perform iadls items including show cards question if you had … could you do it to shop for personal needs to prepare hot meals to take medicine to do household chores to shop for groceries to manage your money continuous variable binary variable 0 yes 1 no annotations table 1 for more details see strauss j witoelar f sikoki b the fifth wave of the indonesia family life survey overview and field report santa monica rand 2016 and ifls questionnaires available at 1 includes diagnoses by paramedics nurses and midwifes 2 hba1c and crp values are only available for a subsample in ifls5 dbs for crp assays were introduced in ifls4 for a random sample of ifls1 dynasty households in ifls5 the target sample for repeated crp assays and hba1c was the subset of respondents who had dbs taken in ifls4 there are 7579 observations with crp data and 7524 observations with hba1c in wave 5 further details on sampling for the dbs and sampling weights are available in herningtyas eh hu p edenfield m strauss j crimmins e witoelar f et al ifls wave 5 dried blood spot data user guide santa monica rand 2018 in our analyses we have crp data for 1913 and hba1c data for 1887 respondents 3 cutoffs based on the international expert committee report on the role of the a1c assay diagnosis of diabetes diabetes care 2009 32 132734 4 respondents with controlled hypertension uncontrolled hypertension and hypertension without treatment were classified as hypertensive hypertension definition adapted from who expert committee on hypertension control hypertension control geneva world health organization 1996 5 cutoffs are based on speidl ws zeiner a nikfardjam m geppert a jordanova n niessner a et al an increase of creactive protein is associated with enhanced activation of endogenous fibrinolysis at baseline but an impaired endothelial fibrinolytic response after venous occlusion journal of the american college of cardiology 2005 45 304 6 cronbachs alpha for three ubfl items 07863 7 cronbachs alpha for three lbfl items 07306 8 raven j the ravens progressive matrices change and stability over culture and time cogn psychol 2000 41 148 9 cronbachs alpha for five adl items is 08319 adl items adapted from katz s assessing selfmaintenance activities of daily living mobility and instrumental activities of daily living j am geriatr soc 1983 31 7217 10 cronbachs alpha for six iadl items is 09043 iadl items adapted from lawton mp brody em assessment of older people selfmaintaining and instrumental activities of daily living the gerontologist 9 179186 educationrelated expenditures in indonesian rupiah divided by the number of household members 89 we used the household pce as a proxy for income and living standard being a potential barrier to social network development we decided to include a variable indicating residential instability the information was drawn from ifls4 but refers to the time window between ifls3 and the 8 years leading up to the fielding of ifls4 besides these we included the following health behaviours and biological risk factors respondents physical activity level smoking status and body mass index other healthrelated covariates included overall selfrated health selfreported depressive symptoms general health checkup in the past 5 years and health insurance coverage for the bmi we used the anthropometric cutoff points suggested for asian populations 90 to rule out reverse causation we controlled for the presence of ncds and disability at the baseline all 15 covariates and the sni with baseline descriptive statistics are presented in table 2 statistical analysis the distributions of the 200708 baseline characteristics and the prevalence of health outcomes in the 201415 followup are presented in tables 2 and3 continuous variables are presented as the mean with standard deviation and compared with fishers ttests numbers and proportions are presented for categorical variables which are compared with pearsons chisquared tests a pvalue below 005 signifies statistical significance following pearls transdisciplinary causal inference framework 7191 three methods were used to estimate the effects of social network diversity on adult health outcomes two confoundercontrol approaches and one instrumentbased approach in the first we used regression adjustment models to break the association of confounders with the outcome and propensity score matching models to break the association of the confounder with the exposure in the later similar to a natural experiment approach we address potentially unmeasured confounding and measurement error of the exposureoutcome association by leveraging an exogenous source of variation in form of an instrumental variable all the models are based on complete case analyses multivariable linear and logistic ra models were used to estimate the independent association between the sni and any health outcome for the total analytical sample and then for men and women separately controlling for the 15 covariates described above variables associated with outcomes at p 005 were subsequently included in the multivariable regression models prior to running the final models we checked for potential multicollinearity between variables with bivariate correlation and variance inflation factor tests and none of these exceeded a critical value since the sni was not randomly assigned to this population we performed confirmatory psm analyses following the conventional ra models psm is a method that allows the use of observational data to estimate treatment effects and make causal inferences based on counterfactuals 92 it is a multivariable scoring method that collapses the predictors of a treatment into a single value that represents the probability of being treated conditional on all the observed covariates matching based on the ps produces samples with the same distribution of covariates in treated and untreated subjects it should be noted that in this study we used observational data and thus refer to the sni as an exposure not a treatment we followed the steps described by caliendo and kopeinig to estimate the ps using a logit model and to calculate the average treatment effect 88 we used nearestneighbour matching without replacement with a ratio of 12 and a 025 standard deviation caliper width to match respondents with a high sni with ones with a low sni 9394 we performed psm to isolate the effect of the exposure a high sni above and beyond respondents individual characteristics because the method allowed us to estimate the effect of having a diverse social network on the subsequent health status in a nonexposed sample if that same sample would have had a high sni prior to running the psm models we inspected balance plots of the distribution of the propensity scores before and after matching all the plots suggested a good support scenario that is they showed substantial overlap of the ps for the exposed sample and the controls after matching lastly we performed an iv analysis as opposed to traditional risk adjustment methods that rely on observable measures an iv factor in unmeasured or unobserved factors is a potential source of confounding 95 in our study residential stability the length of exposure to an ecological setting was our instrument of choice this choice was based on our review of the existing literature backing up the association between residential stability and social networks and we created this variable from a question in ifls4 inquiring how many times did you move since the interview in 2000 ie ifls3 between villages and stayed for six months or more after confirming the validity and strengths of our chosen iv we performed a health checkup in the past 5 years 3 twostep iv regression analysis in which we regressed the coefficients of poor health outcomes on the instrumental probability of having a diverse social network to determine whether social networks were associated with health outcomes through networks relationship with residential stability after the iv model fit we tested whether residential stability qualified as an endogenous and strong instrumental variable both the durbin and the wuhauser statistics confirmed the endogeneity of our iv the ftest also confirmed the overall strengths of the instrument all the iv models were adjusted for the same covariates as the ra and psm models for all three methods we applied an outcomewide epidemiological approach in which a single exposure is examined and its effects on multiple outcomes are considered simultaneously 70 we used longitudinal panel data covering eight years in order to investigate the effect of the baseline sni on 19 outcomes along the disablement process over time all the analyses were performed using statase v142 we used statas regress and logit functions the teffects psmatch and psmatch2 packages and ivregress for the ra psm and iv analyses respectively the coefficient plots were produced with coefplot 98 results in this study we restricted the analyses to respondents who were aged 50 years or older at the time when ifls4 was fielded and who were subsequently interviewed for ifls5 complete social network data were available for 5521 respondents the final analytic sample consisted of 3060 respondents the analytic sample size for the biomarkers was smaller for details see the annotations in table 1 in the full analytic sample respondents predominantly reported a low sni and there was no statistical difference in the mean sni score between men and women a slightly higher percentage of respondents were women and at the study baseline the mean age was 58 years men were more likely to reside in rural areas but also changed their place of residence more often than women furthermore the educational profiles baseline srh and disability and health behaviours between men and women varied significantly further details about respondents baseline characteristics are shown in table 2 respondents health profile at followup according to their baseline sni is presented in table 3 the results from the ra psm and iv models for men and women are displayed in the coefficient plots in figs 1 2 and 3 overall for the total sample the ra models yielded the largest number of significant results followed by the psm and iv models we found the highest level of concordance between the results from the ra and psm models in both the total sample analyses and the sexgenderstratified models there was no concordance between the iv models and the ra or psm models our results showed that among women a strong sni subsequently affected all the dimensions of the disablement process while among men its effects were restricted to the functional limitations and disability dimensions further the effect sizes were generally larger and more heterogeneous among women than among men with regard to pathologies we found that among women pulmonary diseases were associated with the baseline sni the ra models showed significant positive associations with selfreported asthma and other chronic lung diseases the application of psm likewise confirmed that the propensity for exposure to a high sni had a subsequent effect on asthma and other chronic lung diseases the only statistically significant results for impairments were derived from the psm models among the female sample we found a significant negative association between social network diversity and immunological impairments measured by categorized crp levels elevated levels of crp above 1 mgl were associated with prior propensity for exposure to a strong sni the continuous crp values show that a strong sni increased the inflammatory levels among women by 60 social network diversity was significantly associated with physical functional limitations both the ra and the psm model showed that women with a high sni at the baseline had significantly better abilities in both selfreported upperbody and lowerbody functions at followup no statistically significant effect of the sni on physical functional limitations was detected among men both women and men with a higher sni at the baseline reported better abilities to perform adl and iadl tasks disabilities in five adl tasks were associated with a low sni at the baseline for women in both the ra and the psm model and for men in the psm model likewise the ability to perform iadl tasks was significantly associated with a strong sni for both women and men fig 1 results from the multivariable regression adjustment models for men and women annotation figure 1 the following confidence intervals were truncated to a 2 to 2 interval lung diseases 95 ci cancer 95 ci and cancer 95 ci all the models were controlled for age education household per capita expenditure residential stability area of residence physical activity smoking bmi srh depression health checkup in the past 5 years health insurance coverage baseline ncds and disability when regressing the 19 different health outcomes on the instrumented probability of having a strong sni the results showed that only cognitive functional impairments were associated with network diversity through the relationship of each respondents sni with his or her level of residential stability men with a strong sni at the baseline had better episodic memory functions at followup compared with men with a low sni women with a high sni however scored significantly higher in ravens test measuring visuospatial abilities discussion to provide additional insights into the causal effects of social networks on older adults health in this study we appied an outcomewide 70 multimethod approach 7475 to longitudinal panel data to examine prospectively the causal associations of social network diversity with a wider battery of health outcomes among a subsample of 3060 indonesian men and women above the age of 50 years who participated in the fourth and fifth waves of the nationally representative ifls including a large battery of health outcomes and applying three statistical approaches to infer causal inference this study has produced a large and complex scope of results to aid the reader we have organized the discussion section in the following way first we shortly review to which extend the three initial hypothesis have been confirmed or not after that we turn to a more detailed discussion of the significant results and situate these within the indonesian context additionally we try to situate our findings into the overarching framework of the berkman model and attempt to identify the underlying psychosocial mechanismsm and pathways behind the snihealth associations in this indonesian sample of older adults since the results from the iv models fig 2 results from the propensity score matching models for men and women annotation figure 2 the following confidence interval was truncated to a 1 to 1 interval grip strengths 95 ci all the models were matched on baseline age education household per capita expenditure residential stability area of residence physical activity smoking bmi srh depression health checkup in the past 5 years health insurance coverage ncds and disability obviously stand out we do not only compare the results for functional cognitive outcomes with the existing literature but also discuss the iv method and the role of the instrument in our study we then turn to strenghts and limitations and conclude with some implications for policy and practice social network diversity and adult health gender differences heterogeneous health effects but no gradients along the disablement process using the disablement process model 76 as a paradigm for our analysis of the social networkadult health association this study found that greater network diversity shows statistically robust associations with various health outcomes along the disablement process as hypothesized we identified several genderspecific effects womens social networks exercised a greater healthprotecting potential compared to mens social network diversity affected womens health along the entire disablement process while among men only endpoint disability was affected in addition the effect size of the sni on adl and iadl disability was overall larger among women compared to men many have attempted to explain such social networkrelated gender differences in health through dispositional or personality differences between men and women 99100 others taking a sociostructural approach have linked the diverging health effects of social networks to the differential impact of socioeconomic position occupational status and educational background on social network structures and functions among the two genders 101102 another body of research addressed gender differences by assessing genderspecific social network changes and dynamics across the life course and particularly assessing agingrelated network changes 38 particularly events such as retirement widowhood or the onset of a chronic disease have differential longfig 3 results from the instrumental variable analysis models for men and women annotation figure 3 the following confidence intervals were truncated to a 10 to 10 interval grip strengths 95 ci episodic memory 95 ci visuospatial abilities 95 ci adls 95 ci and iadls 1360297 all the models were controlled for age education household per capita expenditure area of residence physical activity smoking bmi srh depression health checkup in the past 5 years health insurance coverage baseline ncds and disability iv residential stability wuhauser instrument strengths f 1958 term effects on network size composition and functional aspects for men and women 1 in our study we considered the overall sni as exposure and did not account for genderspecific differences in the seven sni components however descriptive analyses showed that many of the widowed respondents were women and that remarriage was common only among men with advancing age social activities and thus nonkin ties to neighbors or community members decreased for both men and women but more strongly for women and with advancing age more women than men were providing and receiving support from close kin furthermore men and women in our study differed significantly in their educational background which possibly implies a strongly gendered nature of the structural and functional aspects and dynamics of their work and familyrelated social networks and their effects on health as hypothesized we identified heterogeneous health effects of social network diversity while greater social network diversity was protective against a range of pulmonary pathologies functional limitations and disability outcomes it also resulted in increased inflammatory levels measured by raised crp values this duality has been previously reported by studies focusing also on other inflammatory markers 103 and dysfunctional allostasis 104 a recent review identified support failures patterns of rejection or neglect and misdirected control or undermining of healthy practices as three distinct pathways of how negative social exchanges among network members affect health 78 again our aim was to determine whether there are heterogeneous efffects and future studies should look into the exact pathways and mechanisms that link greater social network diversity to increased inflamation or other negative immune responses as described further below we in our study hypothesized that for our female respondents network strain from caretaking obligations may play a major role in explaining these heterogeneous health effects we did not find support for our last hypothesis with regards to a gradient of social network effects across the disablement process we post hoc stratified our sample by age groups but these results did likewise not exhibit a clear gradient in effect size along the disablement process model to the best of our knowledge there is no other wideoutcome study using a comparable social network indicator and testing its effect across a range of adult health outcomes to which we could compare our findings however some studies testing mediating relationships within the disablement process model have found that main pathway variables have indirect effects on disability outcomes though different psychosocial factors such as social integration 80 social support 81 or loneliness 79 these studies conclude that psychosocial factors despite being potential buffers to disablement their effect along the disablement process is relatively small these findings may be to some degree comparable to our findings and partly explain the significant effects of social network diversity on adl and iadl disability but none to limited effects on the preceding main pathway variables in the future additional analyses repeating our approach with another social networkrelated indicators such as network size or distinguishing between different network types could draw a more nuanced picture of potential effect gradients along the disablement process specific effects along the disablement process and potential mechanisms and pathways after providing an overall picture of our results we now turn to a more detailed discussion of the specific health outcomes which were significanlty related to social network diversity these findings are discussed in light of berkman et als conceptual framework which postulates the mechanisms through which social networks affect health 4 since the aim of this study was to establish whether there are causal effects of network diversity on adult health outcomes and to determine the size of these effects we had only limited possibilities to identify the underlying psychosocial mechanisms and pathways behind these associations however in our discussion below we attempt to provide a few possibilities within the framework of the berkman model by adding some supplementary results derived from post hoc data stratifications and dissecting the sni into its single indicators diverse social networks benefit womens pulmonary outcomes the first point to notelimited to women in our study is the finding of an association between social network diversity and pathologies that is pulmonary conditions such as asthma and other chronic lung diseases this finding is in line with other studies that likewise have provided empirical verification of the relationship between social networks and pulmonary health outcomes supportive social networks have been shown to be protective of asthma and other breathing problems particularly among children 105106 and among adult patients with chronic obstructive pulmonary disease and social support from social network members has been shown to benefit selfefficacy treatment adherence and selfmanagement regimes as well as a number of physical and mental health outcomes 107108 according to berkmans model there are several potential pathways through which a diverse social network may affect respiratory health among indonesian women a low sni among older adult women in our context may be associated with a tendency to remain at home leading to heightened exposure to indoor triggers of respiratory diseases or lower pulmonary fitness levels such as allergens indoor air pollution or reduced physical activity another pathway is through the phenomenon of social influence which is based on the notion that when people are connected to others their behaviours are influenced by them social influence flows through networks and health behaviours like smoking have been found to be socially transmitted across social network ties 26 data from the world health organization from 2016 show that the prevalence of smoking among adults aged 15 years in indonesia is high and that there are large differences between men and women 54 in our data the prevalence of smoking among women was 8 compared with 77 among men our data show further that women with a low sni were more likely to smoke than women with a high sni however for men the sni did not affect their smoking status the general religious and sociocultural norm in indonesia for women is not to smoke 109110 more diverse networks may be associated with stronger enforcement of this norm vice versa the gendered experiences of the smoking stigma may also intensify social isolation marginalization 111112 or feelings of loneliness among indonesian women 113 in addition women are generally perceived as the caretakers of healthfor their own health and the health of their family 114 owing to this women tend to use more health promotion programmes and have higher health literacy than men it remains to be tested whether smokingprohibiting norms and stigmatization are enforced in much stronger ways within womens social networks whether there are other qualities present that spread health awareness and resilience to smoking or whether a combination of factors is at work diverse social networks negatively affect womens crp levels our results show significant negative associations between sni and crp values again only among women serum crp levels become elevated in response to acute infections inflammatory conditions or trauma and increase with age 115 a metaanalysis of 83995 individuals from 14 studies has shown that elevated crp values can independently predict the risk for allcause cardiovascular and cancer mortality 116 and a literature review of more than 70 studies has shown that social behaviour and inflammation are intricately connected 16 many studies have indicated that there appears to be a reliable relationship across the life course between social network disruptions in the form of social separation negative social interactions loneliness or widowhood and increased proinflammatory activity in terms of an elevated crp 117 stnfαrii 103 or il1ra and il6 118 these studies have shown that strong and more diverse social networks increase the odds of receiving instrumental or socioemotional support which can either lead directly to lower inflammation or prevent or lighten the effect of stress and thus lower inflammation 119 however our results indicate the opposite namely that more diverse networks might in fact exercise stress for example from the burden from or conflict with networks members using the sni as a composite measure of network diversity we cannot draw a definite conclusion about which exact features of womens social networks exercise stress that is whether stress comes from a larger number of network members or whether some subjective quality plays a role however a post hoc examination of the data shows that after retirement age there was a stronger negative effect of the sni on crp levels among women one possible explanation for this may be that retired womendespite having a diverse networkare increasingly facing unmet needs for social support or are notably confronted with growing demands from their network members future research should identify the individual or social burdens that lead to strained relationships between network members and affect particularly older womens health the literature has suggested that the socalled socially or physiologically defined elbow points namely entering retirement widowhood the onset of disease or disability or informal caregiving obligations may play a role in the social networkhealth relationship 1 but this remains to be tested in the indonesian context social network diversity positively affects older adults physical functioning and disability outcomes in our study among women more diverse social networks were associated with better outcomes in two functional limitation domains measured via six selfreported items of upperand lowerbody functions as well as disability in five adl and six iadl tasks only the ability to perform all adl and iadl tasks independently was significantly associated with a diverse social network in both men and women butexcept for iadls in the psm modelshowed stronger associations for women our results are generally supportive of our hypotheses and in line with a number of studies that have reported positive associations between network diversity and fewer functional health declines 120 or disabilities in later life 2223 we initially hypothesized to observe stronger effects of social network diversity towards the end of the disablement process that is on outcomes that affect respondents activities of daily life and their role in society due to increased functional limitations while we did not idenfity such a gradient in effect size throuhout the whole disablement process we could still observe a decrease in social network effects along a continuum of severity in disability ranging from less severe iadl disability related to basic tasks of everyday life to more severe adl disability related to selfcare tasks that allow independent living however in the literature the evidence on the effect of social networks on the different domains of disability among older populations is far from conclusive as only a few studies have reported on both adl and iadl outcomes in relation to a social network indicator we found that our results generally correspond to the results from studies on communitydwelling older adults in mexico 121 and spain 122 but contrast with the findings from studies on american 123 and singaporean older adults 124 which have reported in general more beneficial effects on the performance of adl tasks such mixed findings may reflect the different macrolevel framing forces such as the sociocultural norms and values in which social networks are shaped and function as well as individuals experiences and interpretations of these networks and hence the degree to which they can affect their health in addition especially when the analyses rely on selfreported information one may observe crosscultural differences in the disablement process at large and particularly the experience of disability might differ across different sociocultural contexts 125 apart from that the fact that in our study social network diversity had a stronger effect on the ability to perform iadl tasks than adl tasks could be due to several reasons first we analysed a relatively young sample thus more severe adl disability was less common than iadl disability further men suffered less often from adl limitations than women but reported more disabilities in the performance of iadl tasks which could to some degree explain the null findings in the ra models on adl limitations for the male sample the same observation holds for upperand lowerbody functional limitations moreover the ability to perform each of the tasks independently may require very different aspects of ones social network for example adl tasks related to personal hygiene may require a less diverse network of intimate ties for example the instrumental help of a spouse while some iadl tasks can be performed independently through the provision of emotional support from a more distant discretionary network member therefore while our findings grasp the overall positive impact of social network diversity on both functional limitations and disability among older indonesian adults they also raise some important questions about the underlying mechanisms and pathways behind these associations particularly with regard to functional health and disability outcomes numerous studies have emphasized the need to move beyond crude indicators and further dissect summary measures and discriminate between different types of networks andor the resources emanating from them that is in the form of structural and functional support 35126 it has also been noted that the failure to do so has possibly led to a number of null findings showing that social networks were not related to disability outcomes 127 previous studies have shown that familybased networks that is relationships with the spouse and adult children are the most frequent network types in which older adults are embedded 128 family members are the first ones to turn to in need of immediate assistance and should therefore play an important role when it comes to influencing functional limitations or disability outcomes in old age studies have shown that familybased networks are protective against the onset of disability and promote recovery 129130 however the evidence on spousal and parentchild relationships offers very heterogeneous results some studies have found that childlessness can have positive effects on oldage mobility but that relationships with coresiding children can increase the risk of future disability 131 additionally more nuanced analyses of spousal relationships have differential effects on mobility impairment and disability depending on whether the spouse provides emotional support which facilitates improvement or instrumental support which obviates the overcoming of limitations 131 again using a crude indicator we cannot draw any definite conclusions about which network types or which structural or functional aspects of older adults social network play a more important role in functional limitations and disability outcomes overall though the sni in this study had a strong familybased focus and five out of seven indicators were related to family members our results show that particularly women receive a better health impact from a more diverse social network than men and there are indications in the data that the marital dyad and ties to adult children seem to play an important role in older womens health in fact when replacing the crude sni post hoc with single social network indicators for women the presence of a spouse had a protective effect on functional limitations and disability while support from or to children in our study was negatively associated with reduced lowerbody functions recent censuses and surveys have shown that many widowed older adults are women and that remarriage seems to be a more common practice among widowed men than among women 41 due to the countrys demographic and economic transitions women in indonesia are facing a host of challenges that inter alia contribute to holes in older womens social networks for example having a longer life expectancy many women outlive their husband and many continue to live in lowincome singleperson households in predominantly rural areas in addition due to fertility declines and increasing ruraltourban labour migration fewer adult children are available to elderly relatives as caregivers in indonesia but also in other lmics undergoing similar developments such transitions are putting immense pressure on the traditional informal support systems of older adults and policies should be responsive to these trends and find ways to fill these network holes as they have strong implications for health particularly among vulnerable segments of society such as women especially women who intersect with other macrocontexts such as poverty or rurality because they have the fewest opportunities to counterbalance the effects of small and less diverse networks on their health greater network diversity benefits older adults cognitive health our last finding to be discussed relates to the results from the iv models showing a strong association of the sni with cognitive performance after instrumenting for residential instability a factor that webased on the review of the literature appraised as a potential barrier to social network development strong associations between social network diversity and cognitive outcomes remained that is men and women with a higher sni reported better episodic memory and visuospatial abilities respectively from a theoretical perspective there are clear reasons to expect an association between social networks and cognitive performance outcomes the cognitive reserve hypothesis the vascular hypothesis and the stress hypothesis are three major aetiological hypotheses that have been proposed to be the most relevant to the preservation of cognitive abilities 34 a systematic review evaluating the association between different aspects of social relationships with the cognitive functioning of healthy older adults has summarized evidence from 39 studies and suggested relationships between social activity participation and processing speed and visuospatial abilities and between social support and composite measures of social relationships and episodic memory 18 in our study we had limited capacity to identify the psychosocial mechanisms or pathways that eventually associated the instrumental probability of a high sni with better outcomes in episodic memory and visuospatial abilities among men and women respectively one could suspectfollowing berkmans frameworkthat more diverse networks provide more opportunities for social interactions and higher social engagement enhances cognitive reserves such a buildup of cognitive reserves allows for more efficient use of neural networks and thus enables better visuospatial abilities the stress hypothesis however may be more useful for explaining the results relating to episodic memory many studies have outlined the stressreducing benefits of social support and lower levels of stress have been shown to benefit memory performance of theoretical interest is also that the degree of association between social network diversity and cognitive performance decreased along the continuum from fluid to crystallized intelligence the opposite has been observed in a swedish study 133 to the best of our knowledge this is the first study to report results on fluid and crystallized intelligence in relation to social networks for an older lmic population further we again observed distinct gender differences that could be interpreted vis à vis the role of the instrument in the indonesian context censuses have shown that in indonesia many older adults migrate that is change their residency due to mortality or work 41 in many cases women after the death of their husband move to be near their adult children and may face a range of challenges stemming from social network changes namely the disruption of the old network and building up of new ties adapting to a new physical environment and possibly new duties for example taking care of grandchildren labour migration and job mobility on the other hand seem to be the prime reason for men to change their place of living in many cases in fact in our study men moved more often than women and increasingly before reaching retirement age further among those who changed their residency in our study more women than men reported being single and thus were most likely to be widowed another issue to be discussed in regard to the iv models is the large number of null findings for the other health outcomes we believe that this can likewise be explained by the role of residential stability in the indonesian setting rather than by potential model misspecifications a common assumption in iv analyses is deterministic monotonicity meaning that while the instrument may have no effect on some people all those who are affected are affected in the same way 134 such an assumption however sometimes does not prove to be realistic we assumed that any move within the past 7 years would represent a disruption in peoples social network however the opposite may be true in some cases in this study we did not consider motivations for moving how far or to where ifls respondents moved between the years 2000 and 200708 in addition the ifls data do not contain the reasons for moving or information about to whom people moved it could have been the case that participants moved only a short distance which enabled them to stay in touch with their old network while at the same time building up a new one even a longdistance move might not have a negative effect if the participants returned to a familiar setting or reconnected with family friends or other acquaintances who already resided in the new location possibly the new location could also offer a better network support than the old one during the first half of 2000 social media expanded in indonesia and sustaining access to previous social networks through social media can attenuate the effects of migration recent surveys have shown that in 2018 50 of all adults over 50 years of age owned a mobile phone smartphone ownership increased from 3 in 2013 to 13 in 2018 135 furthermore labour migration is increasingly common in indonesia following the asian economic crisis moving to a new place for economic reasons such as a prospective job may have benefits by itself that outweigh the potential harmful effect of disconnecting from old network members further in a very collectivist society like indonesia one move within 7 years may not have the same effects as in a lesscollectivist western society methodological considerations strengths and limitations in this study we used a comprehensive and large panel data which allowed us to employ multiple analytical strategies to address potential treatment biases however performing ra psm and iv techniques led to discrepant resultsa situation which overall demonstrates the difficulty of determining causal inference in observational studies our results show that the estimated associations between social network diversity and various adult health outcomes are sensitive to the choice of analytical method there was general concordance between the ra and psm models which is also commonly observed in other studies 136 however between the rapsm and iv models there was no concordance and the benefits of social network diversity on physical health disappeared in the iv adjusted models but yielded effects for two cognitive health outcomes with a rising number of studies simultaneously applying multiple methods such discrepancies between ps and iv analyses are not infrequent in medical and public health research 137 still the question remains why the iv models did not yield the same picture as the ra and psm models when results are conflicting many tend to take the iv results as the true estimations because of the ability of iv analyses to account for unmeasured or unkown confounders in addition to the measured ones here we do not unquestioningly consider the iv estimates as our true results but instead argue that both psm and iv estimates despite yielding differences are also simultaneously correct as outlined further above both psm and iv techniques were systematically implemented and relied on reliable propensity scores with a good support scenario and an iv which has been theoretically and statistically validated wuhauser instrument strengths f 1958 see fig 2c considering the conceptual differences between the two methods may aid in interpreting the discrepant results while the psm technique produces average treatment effects the iv results should be interpreted in terms of local average treatment effects restricted to a group of marginal respondents these marginal respondents are a subset of respondents whose exposure choices are affected by variations in the iv measured by residential stability 73 under the assumption that treatmentexposure effects are heterogeneous and the exposure assignment is related to this heterogeneity the ate and the late are different estimations thus despite yielding discrepant results both estimates are simultaneously correct 137 as mentioned earlier by applying both confounder control and instrumentbased approaches we are able to draw conclusions both on individual and population level since these techniques produce effect estimates which apply to different populations 7273 while the ra and psm models provide insights into the specific effects of social network diversity on various health outcomes for individual respondents the iv models measure effects for a marginal population which excludes those respondents who would always or never have a diverse network independently of their residential stability and focuses on respondents whose likelihood of having a high sni depends on their state of residential stability since many decisions with regards to changing residence in old age are less bound to individuallevel characteristics but more often contextrelated the iv results can guide social and health policies that relate to latelife moving relocations geographic mobility and migration among aging populations and more broadly to issues relating to aging in place and the effects of social network changes and network turnover on older adults cognitive health this study advances the prior literature in several ways first we took an outcomewide analytic approach to provide a comprehensive picture of the role of social network diversity across the disablement process this is the first study to present such evidence for an indonesian sample and it helps in synthesizing the previously scattered evidence on single outcomes from other studies second the application of multiple causal inference methods on a longitudinal panel data which established the temporal order of exposure and outcome and extensive covariate and baseline health control to reduce the option of reverse causation altogether permitted more evidence for a robust causal interpretation of our results the present study is however still subject to certain limitations some of which may be dealt with in future research many outcomes and the exposure in this study are based on selfreported information and thus might be subject to social desirability or common method bias while most outcomes were measured for all the respondents the biomarkers crp and hba1c were only measured for a subsample which could reduce the precision of those models further biomarkers are based on dbs testing and may therefore not be comparable to studies using assay results from venous blood while we took guidance from established approaches in the calculation of the sni we also performed some modifications to it in our study which may make it difficult to compare our findings directly with other studies employing a measure of social network diversity one limitation of our sni may derive from the inclusion of household size as one of the seven sni indicators this leads to potential double counts of existing networks in the sni and makes the different types of networks nonexclusive while this approach entails some limitations we still deemed it valuable to include the household size measure into our sni in order to account for the multiethnic and customary diverse setting of indonesia where various living and cohabitation combinations exist the maleheaded nuclear household is not the default setting across the indonesian setting and we thus believe there is added value in incorporating houshold size into our sni to account for networks that go beyond the spousal dyad or other coresiding close kin further selfselection bias may be a concern in our study as mentioned above we do not account for any details of mobility patters between ifls3 and ifls4 nor do we account for the reasons for changing residence or perform comparisons between characteristics of the old and new area of residence it might be possible that health status or healthrelated attitudes and behaviors predict the decision to change residence and the choice of destination in our study estimating the magnitude of selfselection bias in observational studies remains a methodological challenge and it has been noted that selfselecion may potentially inflate the observed associations 138 future studies should more closely examine the role of selfselection particularly residential selfselection in healthrelated social network studies lastly our findings also need to be interpreted in the light of the vast ethnic diversity in indonesia which may have different patterns of social networks and a varied structural significance of gender on the other hand the fact that we tested the relationships between network diversity and health in a large socioculturally diverse sample strengthens the generalizability of our findings across populations despite these limitations our findings offer a better understanding of the role of social networks and network diversity in the disablement and aging process in indonesia and offer an opportunity for future studies to investigate additional aspects of social networks in relation to adult health and aging processes conclusions this study considered the social networks of older indonesian adults a population for which to the best of our knowledge only a few prior studies have been conducted we examined the effect of social network diversity on a large battery of 19 health outcomes representing disablement and aging processes and our findings suggest that the ability to call on a diverse set of social networks confers strong heterogeneous longterm health effects particularly for older women due to its outcomewide approach this study can convey useful information to different groups of policy audiences for instance the findings on social networks role in shaping chronic disease outcomes including the potential role for smoking interventions as well as results pertaining to various impairments will be useful for policy makers who are involved with primary and secondary prevention efforts there should be room in future health polices to provide a framework to integrate patients social network members into disease treatment and particularly ncd management schemes particularly among older populations and for diseases that require more thorough monitoring and selfmanagement on the other hand the results concerning functional limitations and disability will be useful for decision makers who hold responsibilities for tertiary prevention such as shaping social and health policies related to the promotion of aging in place the provision of chronic longterm care disability rehabilitation and future health care and geriatric care management the crucial role of social networks in shaping adult health outcomes should arguably be considered in various health promotion programmes and translated into multilevel interventions and intersectoral health and welfare policies overall our study highlights the need for genderspecific policies because women gain greater health protection from their social networks than men interventions should particularly be designed to strengthen that is mobilize or optimize older adults social networks at times of certain elbow points specifically retirement widowhood or the onset of disease or disability besides gender particularly in an lmic setting policies should have sensitive intersections with poverty and rurality as these are contexts in which formal structures that is health care services are relatively weak and in which informal structures that is personal social networks are relatively strong appendix 1 fig 4 balance plots showing the distribution of the propensity scores for the exposed and control groups before and after matching source ifls appendix 2 fig 5 coefficient plots displaying the results from regression adjustment b propensity score matching and instrumental variable analysis models for effects of baseline sni on various subsequent adult health outcomes for the total sample source ifls appendix 3 competing interests the authors declare that they have no competing interests

background social networks sn have been proven to be instrumental for healthy aging and function as important safety nets particular for older adults in low and middleincome countries lmics despite the importance of interpreting health outcomes in terms of sn in many lmicsincluding indonesiaepidemiological studies and policy responses on the health effects of sn for aging populations are still uncommon using outcomewide multimethod approaches to longitudinal panel data this study aims to outline more clearly the role of sn diversity in the aging process in indonesia we explore whether and to what degree there is an association of sn diversity with adult health outcomes and investigate potential gender differences heterogeneous treatment effects and effect gradients along disablement processes methods data came from the fourth and fifth waves of the indonesian family life survey fielded in 200708 and 201415 the analytic sample consisted of 3060 adults aged 50 years the primary exposure variable was the diversity of respondents sn at baseline this was measured through a social network index sni conjoining information about household size together with a range of social ties with whom respondents had active contact across six different types of role relationships guided by the disablement process model a battery of 19 outcomes 8 pathologies 5 impairments 4 functional limitations 2 disabilities were included into analyses evidence for causal effects of sn diversity on health was evaluated using outcomewide multivariable regression adjustment ra propensity score matching psm and instrumental variable iv analyses results at baseline 60 of respondents had a low sni results from the ra and psm models showed greatest concordance and that among women a diverse sn was positively associated with pulmonary outcomes and upper and lower body functions both men and women with a high sni reported less limitations in performing activities of daily living adl and instrumental adl iadl tasks a high sni was negatively associated with creactive protein levels in women the iv analyses yielded positive associations with cognitive functions for both men and women

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introduction are there few or many people like me here is a question that becomes salient to a person almost immediately upon entering a space or place although all collective and intergroup behavior occurs within place the study of the place of intergroup relations has historically received relatively little empirical attention within the intergroup relations literature recent work however has begun to interrogate the role of place in shaping intergroup relations 12 in the present work i argue that level of group representation within place shapes perceptions of the groupbased nature of place and sense of belonging which in turn inform numerous and a diverse set of collective and intergroup outcomes taken together the evidence supports the notion that there are distinct psychological orientations as a function of low versus high group representation within place more broadly i introduce a social identity paradigm for contextualized experience that provides a framework for understanding how the characteristics of place inform social identitybased contextualized experience as manifested by three social identity constructs selfcategorization placeprototypicality and placeidentification thus the present work is concerned with one specific characteristic of place theorized to be central to shaping group members contextualized experience composition of place composition of place as a determinant of social identitybased contextualized experience why does group representation matter as a starting point demographic composition of place or viewing a place as having low or high group representation relative to the total social makeup of a place is expected to shape ones propensity to view the respective place in groupbased terms and sense of belonging a variety of characteristics within place likely account for a persons contextualized experience thus it is expected that numerous physical and social characteristics of a place or local context can shape group members experience in social identitybased terms however level of numeric group representation is theorized to be a foundational characteristic of place because of its capacity to affect numerous collective and intergroup outcomes there is a large diverse and interdisciplinary literature devoted to defining place andor space 3 4 5 6 7 which includes a long and nuanced debate on the difference between space and place 8 9 10 consistent with recent work that utilizes a more expansive classification of place 2 i use a holistic definition of place defined as the psychologically salient environment which can take the form of a geographic social or physical place this definition is in line with a social identity perspective such that psychologically salient environment is connected to frame of reference and suggests a place definition that is established in the most applicable or relevant social identity for a set of specified intergroup relations more generally in the present work i use the terms composition of place and level of group representation interchangeably or in an analogoussimilar manner composition of place entails level of group representation but also explicitly acknowledges the representation of other group within place which is an integral aspect of the factor under study thus composition of place is meant to denote total demographic composition of a respective place the current work is concerned with the degree to which ones group is represented in place relative to the total composition of people within the respective place places are filled with grouprelevant meaning that affect how social identity informs collective behavior in the physical environment indeed social identity is directly shaped by the context and place of collective or intergroup behavior including symbols 1112 objects of place and sense of belonging 1314 affecting perceptions of threat 15 and evaluative judgment of outgroups 11617 the present work seeks to complement these findings by explicitly linking how one characteristic of place the social makeup in terms of numeric group representation changes the way a person experiences the context in social identitybased terms and their collective and intergroup behavioral tendencies to start a central thesis of the present work is that degree of ingroup representation of a context gives a place grouprelevant meaning by shaping propensity to view the respective place in groupbased terms one way a person can view a place in groupbased terms is via perceptions of the group prototypicality of place a groupbased approach to place viewing place in groupbased terms placeprototypicality at the heart of the present work is a contrast between two distinct ways of understanding place group neutral versus groupbased a variety of places are either assumed or implicitly designed to be groupneutralmeaning the place is not identified characteristic representative or necessarily for any particular group these places include classrooms doctors office or hospitals organizations police precincts and locker rooms whereas a groupneutral approach to place starts with an assumption that places are not of a particular group or groups a groupbased approach to place assumes that places are full of characteristics that provide grouprelevant meaning the two approaches differ not only regarding the notion that people can and do view places in groupbased terms but also with respect to the starting point for approaching and understanding behavior of place importantly a groupbased approach to place suggests that even places designed to be groupneutral may not necessarily be perceived as groupneutral by all groups there are a variety of ways to view place in groupbased terms but the present work is concerned with how level of group representation affects a group members perceptions regarding the groupprototypicality of place prototypes and more specifically perceptions of prototypicality are central to the social identity perspective and therefore integral to understanding collective behavior prototypes are fuzzy sets of attributes that capture the features that characterize a group and distinguish the group from other groups 18 there is evidence not only that targets vary in perceived prototypicality eg leaders 18 but also that members of groups are often more likely to be responsive to targets that are viewed as relatively more prototypical of their group compared to targets viewed as less prototypical of their group 19 more specifically the extent to which leaders share groupdefining qualities 20 emphasize goals that are characteristic of the group 21 or are representative of the typical demographics of the group 22 all directly influence perceptions of the prototypicality of a leader moreover perceived groupprototypicality has a direct influence on how group members respond to leaders indeed variance in perceived prototypicality of a leader explains perceptions of fairness 20 trust 23 endorsement of leaders 24 and overall leader effectiveness 25 whereas prior theorizing on prototypicality has focused primarily on leader prototypicality see 2627 for reviews the current work extends the study of groupprototypicality to place in the present work i extend prototypicality to place and introduce the construct of placeprototypicality just as people can be viewed in terms of degree of group prototypicality such that some people are viewed are more prototypical of ones group compared to others eg leaders 27 it is expected that places can be viewed in terms of group prototypicality such that group members perceive places as varying in degree of group prototypicality for their own group drawing on past empirical work 2829 placeprototypicality is defined as the extent to which a given place is perceived as being characteristic of a group representing the unique values of the group and exemplifying the beliefs that define the group thus a central assumption of this work is that people perceive places as holding a predominant set of groupbased characteristics beliefs or values accordingly groupmembers make judgements about the groupprototypicality of place or the extent to which a place is characteristic of their own group consistent with work on leadership 27 it is expected that characteristics of a place should inform perceptions of placeprototypicality but also that group members will respond more positively to places perceived as high in placeprototypicality compared to places low in placeprototypicality rather than ignoring context to rely on individualistic and interpersonal frameworksdevoid of contextualized experience the present work starts with the assumption that collective phenomena are best understood by factoring in characteristics of the situated context 30 in seeking to examine how the social makeup of place shapes behavior it is expected that perceptions of placeprototypicality are just one facet of a broader social identitybased contextualized experience that shapes collective and intergroup behavior integrating placeprototypicality into socialidentity based contextualized experience to best understand a group members behavior it is integral to account for the group members contextualized experiencesituated and embedded within the respective place of relevant intergroup relations for the purposes of the current work there are three questions at the forefront of peoples experience within a given social context how do i think of myself in this context or place is this place characteristic of my group and do i identify with this place that is that the way one defines oneself ones perception of whether a place is representative of the characteristics that make their group unique from other groups and ones sense of belonging are critical to what could be termed a persons social identitybased contextualized experience more broadly the present work seeks to link characteristics of place social identitybased contextualized experience and collective behavior a social identity paradigm for contextualized experience provides a framework for understanding how the characteristics of place inform social identitybased contextualized experience which organize how group members approach understand and behave within the respective place a social identity paradigm for contextualized experience in line with the social identity perspective 3132 and work rooted in situational cues of context 1433 a space framework suggests that characteristics of a place and three facets socialidentity based contextualized experience shape collective and intergroup behavior more specifically the three basic tenets of a space approach are as follows 1 characteristics of place determine selfcategorization placeprototypicality and placeidentification 2 placeprototypicality and placeidentification are positively associated 3 the effects of characteristics of place on collective and intergroup behaviors will be explained by one of the three facets of social identitybased contextualized experience from a space perspective group members should demonstrate distinct collective and intergroup behaviors as a function of characteristics of place and the three facets of socialidentity based contextualized experience moreover it is expected that viewing place in groupbased terms directly shapes sense of belonging thus the effects of characteristics of place on collective behavior is expected to be function of perceptions of placeprototypicality and placeidentification a number of characteristics of place likely shape perceptions of the prototypicality of place and sense of belonging but the present work explores one specific component of local place level of group representation first consistent with a basic tenets of a space framework there is evidence that numeric group representation can affect selfcategorization 34 perceptions of prototypicality 22 and sense of belonging 14 second there is evidence of a positive association between placeprototypicality and placeidentification perceived prototypicality of a leader for example often partially explains identification with the respective leader 21 consistent with past work on prototypicality in the leadership domain 35 36 37 it would be expected then that there is a positive association between perceptions of prototypicality of place and identification with place finally numeric group representation directly affects collective and intergroup outcomes such as trust 14 and intergroup integration preferences 38 taken together there are distinct lines of work illustrating that relative level of group representation affects social identitybased experience on the one hand but also evidence that it affects collective outcomes on the other hand integrating these separate lines of work the present studies explore the notion that level of group representation within place is associated with distinct contextualized experience that is associated with unique collective and intergroup behavioral tendencies overview of studies in line with the social identity perspective 3132 and work rooted in situational cues of context 1433 the present studies investigate how one component of local place numeric group representation affect propensity to view place in groupbased terms and also sense of belonging which shape collective and intergroup behavior first the present work provides evidence that composition of place or level of group representation shape sense of belonging which is explained by perceptions of the groupprototypicality of place in addition the results illustrate that level of group representation of place affects group members comfort and willingness to stay in place via perceptions of group prototypicality of place and sense of belonging the remaining studies were designed to provide evidence for how differing levels of numeric group representation of place is associated with distinct collective and intergroup outcomes as a function of perceptions of groupprototypicality of place and sense of belonging more specifically perceptions of the degree of prototypicality of place and sense of belonging help to explain the way group members approach understand and behave as a function of level of group representation of place a large number of studies were included to not only demonstrate generalizability across a variety of conditions but also to provide strong evidence of the diverse set of outcomes shaped by composition of place participants were recruited from amazon mechanical turk for the equivalent of between 7 15 per hour or from university courses for partial course credit participants for all studies with the exception of study 5a were preselected based on necessary participant demographic characteristics for the respective study using preselection procedures none of the participants knew why they were selected for the respective study all manipulation checks confirmed the expected differences among or between conditions at the p 001 level study 3a is the only study in which some participants were dropped as a result of failing the manipulationcheck the city university of new york integrated institutional review board approved all studies all participants were over the age of 18 and the studies contain written or internetbased informed consentas approved by the irb all data were not personally linked to participants to reduce demand characteristics some studies included filler items for ease and clarity of presentation i have excluded reporting the specifics of these filler items for each of the respective studies i can send the specifics of these filler items for any of the studies upon request in addition for tests for indirect effects hayes 3940 procedures were followed using the process macro with 5000 bootstrapped samples finally the recommendations for power of a minimum of 50 participants per cell were followed for all experimental studies see 41 a study 1a ranged from 1 to 7 study 1a included three conditions low equal and high representation with thus also included an equal representation condition and there was an effect of experimental condition f 24530 η 2 p 76 and also followup comparisons were in the expected directionwith a reliable difference between low and equal representation condition b study 3b included two manipulation check items for studies 3b 5b and 5c q1 refers to manipulation check question 1 and q2 refers to manipulation check question 2 c study 4a manipulation check found an effect of experimental condition between the commonality and control condition means reflect scores for the control and commonality conditions respectively f 946 p 002 η 2 p 03 studies 1a1e level of group representation within place likelihood of perceiving place in groupbased terms studies 1a1e provide an experimental test of whether perceiving divergent levels of group representation within place has a direct effect on perceptions of placeprototypicality and placeidentification in addition these studies were designed to explore whether perceptions of the group prototypicality of a place explain the effects of group representation on identification with place thus studies 1a through 1e provide an experimental test of the effect of composition of place on two facets of social identitybased contextualized experience placeprototypicality and placeidentification study 1a method one hundred and fifty selfidentified white participants participated in the study first participants were instructed to assume you were in the market for a job and that the purpose of the study was to evaluate the attractiveness of an organization next all participants were given one page describing a hypothetical organization called ccg the information included a number of characteristics about the organization including the culture benefits opportunity for high salary philosophy and finally commitment to improving employees opportunities thus participants were provided with extensive information regarding the organization a second page provided information about the demographic composition of the organization with respect to raceethnicity in a piechart the piechart served as the composition of place manipulation the pie chart varied demographic composition of place such that there was either a low representation equivalent representation with another group or a high group representation within space although an equal grouprepresentation condition is not necessarily ecologically valid the condition was included as a comparison controlcondition to allow for an assessment of the direction of effects for the low and highgroup representation conditions the method and format for the manipulation was adapted from past work investigating representation and social identity 14 for all conditions a third page provided some additional information about the culture of the organization next a manipulationcheck assessed whether participants viewed the place as being low or high in representation of their group specifically participants were asked what is the racialethnic composition of ccg and answered on a 1 to 7 scale using the stem thinking in terms of your racialethnic group overall i would say ccg placeprototypicality was measured using three items among other filler items represents what is characteristic about my racialethnic group is representative of the unique values of my racialethnic group and exemplifies the beliefs that define my racial ethnic group the items were adapted from past work measuring perceptions of prototypicality 2829 placeidentification was measured using three items using the stem thinking as a member of your racialethnic group about how connected you feel to ccg i would feel at home at ccg i feel i belong at ccg and i identify with ccg these items were derived from past work on place identity 642 participants responded on 1 to 7 scales for both constructs items for both scales were randomized by computer for each individual participant results and discussion a confirmatory factor analysis with oblique rotation was performed to explore whether the placeprototypicality and placeidentification items tapped two distinct constructs bartletts test of sphericity was significant and the kaisermeyerolkin measure was using the joliffe criteria 43 and a scree test procedure 44 see 45 for guidelines two factors emerged items were considered to load if they had a factor loading of at least 30 the component matrix revealed as expected the three placeprototypicality items loaded on one factor and the three placeidentification items loaded on the other factor the factors explained 7918 of the common variance among the items an anova testing for differences in placeprototypicality revealed an effect of representation condition f 4635 p 001 η 2 p 38 followup pairwise comparisons revealed that participants in the high representation condition viewed the place as more prototypical of their group compared to those in the equal and low representation conditions respectively placeprototypicality was lower in the low representation condition compared to the equal representation condition p 001 similarly an anova revealed a significant effect of experimental condition on placeidentification f 3162 p 001 η 2 p 30 followup pairwise comparisons revealed that participants in the high representation condition reported greater identification with the place compared to those in the equal and low representation conditions respectively placeidentification was lower in the low representation condition compared to the equal representation condition p 001 to investigate the hypothesized mediating role of placeprototypicality in explaining the relation between level of group representation within place and sense of belonging a mediation analysis with a multicategorical independent variable was conducted 46 as the present work is concerned with relative effects of the experimental conditions as compared to control a mediation analysis was selected that allows for a test of the relative effects of low and high representation as compared to control on placeidentification thus following guidelines for analyses with multicategorical independent variables this mediation test not only retains all information about how the respective groups differ from one another but also allows for simultaneous hypothesis testing 46 to test the significance of the relative indirect effect a bootstrapping procedure was used and obtained 95 confidence intervals for indirect effects based on 5000 bootstrap samples as shown in fig 1 for the lowgroup representation condition there was support for an indirect effect of placeprototypicality on placeidentification similarly for the highgroup representation condition there was support for an indirect effect of placeprototypicality on placeidentification as zero falls outside the interval for both the indirect effect of level of group representation within place on placeidentification via placeprototypicality is significant demonstrating that increases decreases in representation of a group in place directly affect group members identification with place which is explained by variance in perceptions of the groupprototypicality of place study 1a provides initial evidence that level of group representation has a direct effect on social identitybased contextualized experience more specifically the results demonstrate that degree of representation within place shapes identification with place which is explained by perceptions of placeprototypicality studies 1b1e were designed to replicate the observed findings generalize the effects to new target groups and explore the implications of perceptions of the groupbased nature of place and sense of belonging for expectations of comfort and willingness to stay in a respective place more specifically white blackafricanamerican female and male participants received a variety of information about an organization including composition of placeindicating either low or high representation of the respective group membership within placeand perceptions of prototypicality sense of belonging and perceived comfort of being in the respective place were assessed studies 1b 1c method one hundred and one white participants participated in study1b and one hundred blackafricanamerican participants participated in study 1c all procedures and materials were identical to study 1a with the exception that the study 1b group representation manipulation only varied representation of the group as either low or high for study 1c the characteristics of the organization indicated there was either a high or low level of grouprepresentation for blackafricanamerican participants at the organization after the manipulationcheck placeprototypicality and placeidentification were assessed using measures identical to study1a finally among several filler items perceived comfort working at the ccg organization was assessed using three items α 76 1b α 76 1c 14 i could be myself at a company like ccg my colleagues at ccg would become my close personal friends and i would expect to be treated fairly based on my raceethnicity participants responded on a 1 to 7 scale and items for each of the respective scales were randomized for each participant studies 1b 1c results and discussion replicating the results of study 1a level of group representation within place had direct effects on perceptions of placeprototypicality placeidentification and comfort in addition as table 3 shows composition of place or holding minority or majoritygroup status had a direct effect on perceptions of placeprototypicality placeidentification and comfort to test the hypothesis that perceptions of group prototypicality of place mediates the relation between level of group representation within place and placeidentification a bootstrapping procedure was used to estimate the indirect effect of composition of place on placeidentification through placeprototypicality the effects of composition of place on placeidentification via placeprototypicality was significant for study 1b and study 1c for study 1b the point of estimate for the indirect effect was 132 1b with a 95 biascorrected confidence interval of 195 to 78 similarly a test of the indirect effect of placeprototypicality on the relation between group representation within place and identification with place was significant a critical hypothesis of the present work is that the characteristics of a given place directly shape groupbased perceptions of the respective place which is associated with sense of belonging sense of belonging then directly affects collective and intergroup behavior to test the hypothesis that perceptions of group prototypicality of space and sense of belonging mediate the relation composition of place and comfort a bootstrapping procedure was used to estimate the indirect effect of composition of place on comfort through placeprototypicality and placeidentification for study 1b composition of place had a reliable effect on comfort when the mediators were included in the analysis this coefficient was not reliable moreover the point estimate of the indirect effect of composition of place on comfort via a progression of placeprototypicality and then placeidentification was 079 with 95 biascorrected confidence interval of 0 thus across two different racialethnic groups the results provide clear and similar pattern of effects regarding the effects of level of group representation on social identitybased contextualized experience in the form of placeprototypicality and placeidentification studies 1d and 1e were designed to replicate the observed findings within a new intergroup context and space as well as add a new outcome measure studies 1d 1e method studies 1d and 1e were designed to examine the effects of group representation for two additional target groups women and men one hundred twelve selfidentified women participated in study 1d and one hundred selfidentified men participated in study 1e all participants were given one page describing a hypothetical restaurant called sams diner and told to assume that they were looking for a place to eat based on the menu as well as online reviews the restaurant seemed very very good an additional paragraph described general practices of the restaurant including reservation requirements seating capacity and commitment to extraordinary customer service on the next page participants were told to assume they decided to go to the restaurant for dinner and when they entered the restaurant it was almost completely full more specifically participants were informed that when you arrive to the restaurant it is almost completely full the next page informed participants that the restaurant had a specific gender composition more specifically the page said as you look around the restaurant you notice it is mostly filled with malesfemales for study 1d a graph depicted composition of place varied representation of the group such that there was either a low or high number of women in the respective place for study 1e the graph indicated there was a high or a low representation of men in the place on the next page a manipulationcheck assessed whether participants viewed the place as being low or high in representation of their group specifically participants were asked what is the gender composition of the restaurant and answered on a 1 to 7 scale for study 1d and on a 1 to 7 scale for study 1e on the following page placeprototypicality and placeidentification 90 1e were measured using items identical to study 1b comfort was assessed using three items i could be myself at this restaurant i could relax and be me at this restaurant and i would feel comfortable being myself at this restaurant finally one item assessed participants intentions to stay in place i would decide to stay and eat at this restaurant both comfort and decision to stay in space were assessed with participants responding on a 1 to 7 scale studies 1d 1e results and discussion providing further evidence of the implications of level of group representation of place for perceptions of placeprototypicality placeidentification and comfort studies 1d and 1e replicated the findings of studies 1a1c for both study 1d and 1e a test of the indirect effect of perceptions of group prototypicality of place on the relation between group representation within place and placeidentification was significant shape collective outcomes study 1d also found that placeprototypicality and placeidentification explained the effect of representation within place on intentions to stay in place to obtain a better estimate of the true effect size of composition of place on the proposed outcomes a minimetaanalysis was conducted 47 for studies 1b 1c 1d and 1e the averaged corrected standardized mean difference for the effect of composition of place on the outcomes was as follows on placeprototypicality was d 126 95 ci 104 147 z 1156 p 001 on placeidentification was d 91 95 ci 71 112 z 869 p 001 and on comfort was 74 95 ci 54 94 z 727 p 001 finally the indirect effect of composition of place on placeidentification via placeprototypicality was b 133 95 ci 157109 z 1098 p 001 taken together across two intergroup contexts and settings the results of studies 1a through 1e provide experimental support for the role of degree of group representation in shaping propensity to view places in groupbased terms in particular perceptions of placeprototypicality moreover the studies illustrate that the extent to which a group member views a place as being prototypical of their group directly affects the persons sense of belonging and collective outcomes that is consistent with a groupbased approach to place the findings illustrate that perceptions of prototypicality serve as an antecedent to sense of belonging and groupbased behavioral tendencies more generally the findings further support a contextdriven account of collective behavior which would suggest distinct and dissimilar patterns of behavior as a function of characteristics of place and socialidentity based contextualized experience collective preferences were a function of level of group representation within place and not group membership per se men and whites with minoritygroup status in the local context showed the same pattern of collective preferences as women and blackafricanamericans thus expecting or having minority vs majoritygroup statusas a function of composition of placeis associated with distinct groupbased perceptions and perceived sense of belonging in the respective place therefore the findings provide evidence for distinct psychological orientations as a function of groupbased status within local contextrooted in groupbased perceptions of place and sense of belonging the remaining studies were designed to explore how level of group representation or composition of place in a local context shape a wide range of collective and intergroup outcomes encompassing how a group member approaches understands and behaves as a start studies 2a2c examine how composition of place affects expectations for groupbased treatment and interpretation of groupbased events studies 2a2c level of group representation within place expectations of groupbased treatment and attribution for groupbased events studies 2a2c explore how diverging levels of representation affects expectations of negative groupbased treatment and propensity to make groupbased attributions as well as minoritygroup expectations of procedural justice and willingness to partner with law enforcement organizations studies 2a2c also extend the present work by testing how composition of place affects the third facet of socialidentity based contextualized experience the way one conceives of oneself and as such the lens in which a person interprets groupbased events the social identity perspective suggests that people can define themselves at differing levels of abstraction ranging for example from a subordinate level as a unique individual to an intermediate level as a member of a group ie social identity we vs they 3132 selfcategorization is rooted in context and to the extent that the others present in a context varies it would be expected that the way a person conceives of themselves in these respective contexts would also differ ie category salience varies 32 one implication of viewing the world through the lens of ones group membership is a person may be especially likely to make groupbased attributions there are two types of perception bias with respect to discrimination 48 a tendency to see less discrimination and a tendency to see more discrimination anticipating differing levels of group representation within place was expected to have a direct effect on expectations of groupbased treatment and attribution which would be explained by shifts in selfcategorization more specifically it was hypothesized that degree of group representation within place should directly affect selfcategorization such that under conditions of low grouprepresentation participants should be more likely to view themselves in terms of their social identity compared to under conditions of high grouprepresentation in addition to the extent that a person views themselves in terms of social identity it would be expected that they should be more likely to interpret the world at the level of social identity and as such be more likely to make groupbased attributions during grouprelevant events studies 2a 2b method ninetyeight selfidentified white participants participated in study 2a and ninetyfour selfidentified blackafricanamerican participants participated in study 2b participants were instructed to imagine they had been accepted to a university and told the purpose of the study was to understand how people respond to everyday events on campus they were then given a one page describing background information about the university the page included a variety of characteristics of the university including the studentfaculty ratio commitment to small classrooms building a closeknit community and providing students with handson experience in the lab and in the field the next page provided information about the demographic composition of the entire university with respect to raceethnicity for study 2a a pie chart varied representation of the group within place such that there was either a low representation of whites or a high representation of whites for study 2b the manipulation indicated there was either a low representation of blacks or a high representation of blacks in the respective place on the next page a manipulationcheck assessed whether participants viewed the place as being low or high in representation of their group specifically participants were asked what is the racialethnic composition of the university and answered on a 1 to 7 scale for study 2a or on a 1 to 7 scale for study 2b on the following page participants were instructed to consider living on campus walking around the university and interacting with other students selfcategorization at the level of social identity was assessed using three items adapted from past work 49 to what extent would you think about your own racialethnic group identity i would see myself in terms of my racialethnic group identity and i would probably be more likely to than usual to think about myself in terms of my racialethnic identity next to assess expectations of groupbased treatment participants were asked how concerned they would be about others treating them negatively based on their racialethnic group membership using the stem because of my racialethnic group membership i would be concerned about four items assessed expectations for negative groupbased treatment α 95 50 being ignored overlooked or not given service being treated rudely or disrespectfully feeling excluded from social events and being insulted called a name or harassed participants responded on a 1 to 7 scale to assess propensity to make groupbased attributions participants were asked to make a judgement regarding perceived discrimination based on racialethnic group membership specifically on the next page participants imagined the following situation derived from past work 5152 suppose that its the beginning of the semester and you need an add code for a course required for your major you stop by the professors office and politely ask to be let into the class to your disappointment the professor turns you down and says sorry but i just cant give you an add code later that day you talk to a friend and heshe is surprised the professor didnt let you into the class because she heard that the professor let another student in after you met with the professor perceived groupdiscrimination was measured using three items α 86 2a 92 2b 51 to what extent was the professors behavior due to racialethnic discrimination the professors behavior was biased against my racialethnic group and the professors actions regarding the add code were due to racialethnic discrimination finally two items assessed the extent to which participants viewed the professors actions as a result of external factors the professors decision was about the situation and what was the relative importance of situational factors in determining the professors decision studies 2a 2b results and discussion as table 4 demonstrates across both study 2a and 2b composition of place had a direct effect on selfcategorization expectations of negative groupbased treatment and perceived group discrimination but not situational attribution across both study 2a and study 2b a test to explore whether selfcategorization explained the effects of levels of group representation within place on expectations of negative groupbased treatment was significant similarly results demonstrated that selfcategorization explained the effect of group representation within place on perceptions of discrimination across two different racialethnic groups the findings of studies 2a and 2b demonstrate that level of group representation within place has a direct effect on not only expectations of groupbased treatment but also attributions of groupbased events thus these studies provide initial evidence that even before entering a place composition of place can set a foundation for the way a group member approaches the respective place by shaping expectations of how they will be treated based on their group membership beyond shaping expectations composition of place also influences attributions made within the respective place such that differing levels of group representation are associated with distinct patterns of propensity to make groupbased attributions the literature on perceptions of discrimination has moved toward a framework that seeks to identify the personal situational and structural factors that shape individuals likelihood of viewing themselves as victims of discrimination 48 a sociostructural framework suggests that situational cues and societal group status can shape perceptions of bias 48 the current findings contribute and compliment this work by suggesting that selfcategorization may also help to explain why group members make groupbased discriminatory attributions beyond expectations of negative groupbased treatment level of group representation of place was also hypothesized to affect expectations of fair treatment and willingness to partner or work with law enforcement or authority organizations study 2c method one hundred and seven selfidentified latinx participants participated to fulfill one option of an introductory psychology course participants were informed that the researchers were interested in impressions about police departments in all conditions participants were then given one page of information focused on the mission of the police department which included text on the departments commitment to enhancing quality of life partnering with the community preserving peace reducing fear maintaining order as well as treating every citizen with courtesy professionalism and respect a second page provided information about the general demographic makeup of the police department the composition of place manipulation varied representation of the group such that there was either a low representation of latinx or a high representation of latinx on the next page a manipulationcheck assessed whether participants viewed the police department as being low or high in representation of their group specifically participants were asked what is the racialethnic composition of the police department and answered on a 1 to 7 scale on the following page placeprototypicality and placeidentification were measured using items identical to previous studies next participants were asked to consider how you would be treated by the police department and four items assessed expectations of procedural justice using the i would expect stem the four items were as follows the procedures used by this police department in dealing with my racialethnic group to be fair the policies of this police department to be just this police department to develop policies that treat my racialethnic group in an unbiased way participants responded on a 1 to 7 scale in addition willingness to partner with the police department was measured using five items more specifically participants were asked to consider the police department they read about earlier and asked if the situation arose how likely would you be to call the police to report a crime that was occurring report suspicious activity by the police attend meetings with police to build communitypolice partnerships talk to an individual police officer on the street and cooperate with the police department participants responded on a 1 to 7 scale the items and response format were adapted from past work exploring procedural justice and willingness to partner with law enforcement 53 results and discussion as table 4 demonstrates composition of place had a direct effect on perceptions of placeprototypicality placeidentification expectations of procedural justice and willingness to partner with law enforcement in addition replicating the findings of the previous studies perceptions of the groupprototypicality of place explained the effect of composition of place on sense of belonging moreover consistent with a groupbased approach to place and replicating the results of previous studies the results demonstrate that perceptions of placeprototypicality and placeidentification explained the effect of level of representation of place on expectations of procedural justice in the respective place in addition the findings suggest that level of group representation of law enforcement agencies may be an initial antecedent associated with racialethnic minority group members willingness to partner with law enforcement the results speak to the importance of diversity within law enforcement indeed minority representation or diversity within law enforcement not only can have positive implications for officer behavior eg reduce groupthreat and office deadly use of force 54 it can shape the way minoritygroup citizens engage with police 55 the larger program of results suggest that diversity and proportionate representation is an integral aspect of bolstering the perceived legitimacy of criminal justice entities relative to a majority majoritygroup police force vast and diverse representation of many groups should increase expectations of procedural justice which is especially important for minority groups that often report less trust in authoritieslaw enforcement compared to majority group members 56 study 2a2c focused on individual approaching place but it is expected that placeidentification can also shape administrators of criminal justice eg police officers and neighborhood identification 57 studies 3a and 3b move beyond expectations to examine how placeidentification and perceptions of prototypicality can impact the treatment of individual and group targets one potential implication of the present work and more specifically the notion that there is variance in the degree to which people identify with places is that it might be expected that people would show favoritism toward certain places over other places from a social identity perspective under conditions of salient social identity group members often seek out strategies to achieve positive group differentiation 58 including showing favoritism toward those that share an inclusive identity eg helping behavior 59 thus there is evidence to suggest that group members should show favoritism toward places in which they have higher placeidentification compared to places with relatively lower identification study 3a tests whether people demonstrate favoritism toward individual targets from places high in ingroup representation compared to those low in ingroup representation which was expected to be explained by placeidentification study 3a method ninetyeight participants were originally recruited for the study but five participants were dropped for failing the manipulationcheck the final sample was ninetythree selfidentified white participants the purpose of study 3a was to put participants in the position to make evaluative and hiring judgements of an applicant therefore the study was described as focused on business decisionmaking and designed to explore how people make business evaluations regarding students all participants were given a twopage overview that described their position the position that the company is hiring for and the selection process all of the descriptions were adapted from actual business internship programs online next participants were informed they would be evaluating one applicant named conner adams participants were instructed to assume they personally had knowledge about the general demographics of the university conor adams attended that is that based on your knowledge of the university the demographics of the university were described as either predominantly white or blackafricanamerican more specifically a pie chart varied racial ethnic demographic composition of the university such that university was either predominantly white or predominantly blackafricanamerican on the next page a manipulationcheck assessed whether participants viewed the place as being low or high in representation of their group specifically participants were asked what is the racialethnic composition of the university and answered on a 1 to 7 scale on the following page placeprototypicality was assessed and on a subsequent page placeidentification with the university was measured next all participants were given basic demographic information about the applicant under evaluation including name gender age and raceethnicity as well as a resume for the applicant conner adams resume indicated an average gpa with both leadership and business experience thus all participants were asked to evaluate the same white applicant but what differed was the demographic composition of his university drawing on past work exploring evaluation of job applicants 60 the present research measured perceived competence warmth general work abilities criteria for evaluation hiring decision and standards for promotion more specifically participants responded on 1 to 7 for two fiveitem scales assessing perceived competence and warmth goodnatured sincere warm understanding and kind α 89 61 next participants were asked about the job applicants general work abilities using five items on a 1 to 7 scale motivation willingness to put in extra work problemsolving writing ability and ability to accept instruction on the next page criteria for evaluation assessed information needed to make a final decision on the applicant more specifically criteria for evaluation assessed participants standards of evaluation and was designed to examine whether participants would utilize the same criteria for evaluation based on level of group representation participants were asked if they might need additional information to evaluate the applicant using three items additional letters of recommendation additional inperson interviews and additional inperson performance tests using 1 to 7 scales decision to hire was assessed using two items the applicant would make a very strong candidate for the position and i would hire conner adams for the entrylevel position on 1 to 7 scales finally participants were asked to assume they hired the applicant and told that one common practice among managers was to assign weaker applicants to more hoursdays to get more information to help make a promotion decision standards for promotion was assessed using three items hours per week days per week and days per month results and discussion composition of place had a direct effect on perceptions of placeprototypicality placeidentification and most of the applicant evaluation variables for example the applicant was perceived as having more competence under conditions in which the applicant came from a place with high group representation similarly a test of the indirect effect of placeidentification on the relation between composition of place and ratings of competence of the applicant was reliable the mediation tests for the effect of composition of place on the other outcome variables were not significant or reliable the findings of study 3a extend the present work by illustrating how composition of place can affect the treatment of targets of respective places participants used less stringent evaluation criteria were more likely to view the applicant as competent evaluated the target as having higher work abilities and subsequently were more likely to hire the applicant under conditions when an applicant came from a highgroup representation place compared to when the applicant came from a place with low group representation although study 3a provides evidence that placeidentification explains the effects of composition of place on evaluative judgments of individual targets the results did not find support that placeidentification explained the effects of composition of place on perceptions of work abilities evaluation criteria or hiring decision recent work suggests that whites view spaces predominantly composed of blackafricanamerican people as embodying stereotypes ie spacefocused stereotypes 62 the failure of placeidentification to explain the effects of composition of place on these respective outcomes may therefore be a function of spacefocused stereotypes the findings of study 3a though complement and contribute to an emerging body of work on placefocused prejudice whereas past work suggests that places can embody the stereotypes of the dominant demographic group of the space ie spacefocused stereotypes 62 the present work suggests that people may differentially evaluate objects and people derived from place as a function of identification with place more broadly while it is expected that all group members should show a bias in favor of high grouprepresentation places the current findings are relevant for the maintenance of groupbased inequality indeed the findings suggest that majority group members may show an evaluative bias in favor of applicants from majority majoritygroup contexts thus whether in the domain of evaluating applicants from schools or universities or from different neighborhoods the findings of study 3a suggest that majoritygroup members may implicitly favor targets from majoritygroup places whereas study 3a focused on how composition of place shapes bias toward individuallevel targets study 3b examines how feeling threatened about the predominant values of place can explain grouplevel prejudice study 3b examines responses to shifts in groupbased perceptions of place with a focus on threat to placeprototypicality the feeling elicited from events that challenge the perceived predominant values or characteristics of a respective place more specifically the study examined minority group representation are associated with increased prejudice among minority groups 63 64 65 but also that threat to perceived values increases bias against minority groups 6667 indeed concerns about shifts in cultural values has been shown to explain majority group members prejudice toward muslims eg in the netherlands 67 and immigrant groups 68 to the extent that there is a direct relation between representation of ones group and perceptions that a place is representative of ones group unique values increases in minority group representationdecreases in majority group representation should elicit threat to placeprototypicality study 3b investigates whether shifts in composition of place are associated with increased majoritygroup prejudice toward a minority group which was expected to be explained by perceived threat to the prototypicality of the respective place study 3b method one hundred and two selfidentified white christiancatholic participants a racialethnic and religious majority group in the united states participated in the study the purpose of the study was described as exploring social attitudes and an investigation of perceptions of the people of the united states and policy attitudes participants were randomly assigned to a condition that emphasized that the religious makeup of the united states would either stay the same or change by 2027 more specifically all participants were given a pie chart reporting the 2017 religious demographics of the united states 72 catholicchristian 22 atheistunaffiliated 3 jewish 2 other and 1 muslim directly under the 2017 information a second pie chart provided estimates regarding the expected religious makeup of the country in 2027 in the nochange in composition condition the second pie chart indicated no change in the religious composition of the united states in 2027 72 catholicchristian 22 atheistunaffiliated 3 jewish 2 other and 1 muslim in addition a short message under the chart read the religious makeup of the country is expected to stay the same in the change in composition condition the second pie chart indicated there would be a simultaneous decrease of christianscatholics and increase of muslims in the united states by 2027 51 catholicchristian 24 atheistunaffiliated 20 muslim 3 jewish and 2 other in addition a short message under the chart read there will be a decrease in catholics christians and an increase in muslims thus participants in both conditions were given information about the religious makeup of the united states in 2017 and 2027 but only in the change in composition condition did majority group participants receive information of a decrease in majoritygroup representation the format for this manipulation was adapted from past work exploring demographic change and groupbased prejudice 63 on the next page two questions served as a manipulationcheck assessing participants perception of religious composition change in 2027 what is the expected religious composition of the united states in 2027 answered on a 1 4 and 7 scale and what is the expected religious composition of the united states in 2027 answered on a 1 4 and 7 scale on the following page participants were asked to think about the expected religious makeup of the united states in 2027 threat to placeprototypicality was assessed by asking participants if they perceived that changes in the religious makeup of the country would make the country less representative of the unique values and beliefs that define their religious group or orientation more specifically participants were asked how worried would you be that the united states would not represent what is characteristic of christianscatholics be representative of the unique values of christianscatholics and exemplify the beliefs that define christianscatholics finally on the last page among a variety of filler items participants indicated support for a number of policies targeting the minority group the muslim community that is participants were asked whether the united states should adopt more aggressive policies regarding muslims and limit the number of muslims in the country more specifically participants were asked given the projections you read about earlier how supportive would you be of the united states implementing the following policies now four items assessed support for antimuslim policies 69 create a muslim ban for immigration for all people from muslimmajority countries limit the number of people the united states accepts from muslim countries create a muslim registration list requiring that all muslims register with the us government create a muslim enhanced interrogation technique policy such that law enforcement would be allowed to use enhanced interrogation techniques on muslims participants responded on a 1 to 7 scale results and discussion consistent with hypotheses change in composition was associated with increases in threat to placeprototypicality and support for aggressive or discriminatory policies targeting the minority group more specifically there was an effect of experimental condition on threat to placeprototypicality t the findings are especially poignant the findings of study 3b demonstrate that majority group behavior toward minority groups may be dependent on composition of place of the respective context and illustrate the need to acknowledge or prioritize the social context of intergroup relations in analyzing and understanding the expression of prejudice more generally studies 3a and 3b complement a growing body of work that provides a contextdriven account of prejudice emerging research suggests that rather than conceiving of prejudice as a universal it is much more accurate to view prejudice and bias as a dynamic outcomeoften dependent on context for example prejudice in the form of automatic evaluative responses is often dependent on social context 7374 similarly several studies illustrate that data derived from weird western educated industrialized rich democratic 75 samples do not always generalize to other cultures demonstrating the role of cultural context in the expression of prejudice 76 thus the findings of study 3a and 3b suggest that composition of place is one such contextual factor that may shape motivation and expression of prejudice the program of research thus far suggests that composition of place perceptions of placeprototypicality and sense of belonging have direct implications for expectations of treatment within place attributions for groupbased events and bias or prejudice toward both individual and group targets providing further evidence that composition of place shapes a variety of collective behavioral tendencies the remaining studies examine how composition of place shapes outcomes relevant to social justice and the amelioration of inequality studies 4a4c level of group representation within place and the efficacy of prejudicereduction interventions solidarity and collective action the final set of studies were designed to demonstrate the role of composition of place in shaping the efficacy prejudicereduction intervention political solidarity among minority groups and collective action study 4a explores whether the efficacy of interventions to improve intergroup attitudes may be dependent on composition of place a large and robust literature demonstrates that emphasizing commonality or altering the perception of group boundaries is associated with more positive intergroup attitudes greater empathy toward outgroup targets and greater propensity to engage in prosocial behaviors toward outgroups 77 however past work demonstrates that context can moderate the efficacy of commonalitybased biasreduction interventions such that shared context 78 outgroup characteristics expressed in context 79 or intergroup contact with other groups 80 shape the efficacy of biasreduction interventions it is more effective to emphasize commonality for example under conditions where groups share a context compared to under conditions of separate context 78 in line with these findings it was hypothesized that composition of place would moderate the effect of a commonalityfocused bias reduction intervention on outgroup attitudes such that as level of group representation increases the efficacy of the intervention would improve which would be explained by identification with place study 4a method two hundred and fiftysix participants selfidentified latinx participated to fulfill one option of an introductory psychology course participants individually completed questionnaires in a group setting the design for the study was a 2 x 3 factorial design participants were informed that the researchers were interested in forming discussion groups between people of different racialethnic groups to help groups understand one another and build bridges across racialethnic divides for the initial commonality identityemphasis condition participants were randomly assigned to one of two conditions commonality or control method for manipulation adapted from 81 in both conditions participants were asked to consider the following information when considering the discussion group and read a general paragraph describing diversity in america including the following passages the population of the united states includes many different racialethnic groups as our country becomes more diverse and begins to include many groups it becomes critical to understand how group think about and relate to one another this initial generic paragraph served as the baseline comparison condition in the commonality condition participants read an additional paragraph designed to blur intergroup boundaries between latinx and white racialethnic groups in the commonality condition the paragraph read in part experts from different fields have recognized that latinas and nonhispanic whites share a common identity in the sense that they both share basic values rooted in a common national identity it is agreed that each group could benefit from thinking more in terms of common national identity thus social scientists have confirmed the existence of a common group identity on the following page all participants were then given a biased responseformat which further emphasized the goal of each condition 8082 more specifically in the commonality condition participants were asked to complete three tasks write down five reasons why latinoas and whites share a common identity choose a statement from four options that best summarized the news report from the previous page and finally choose a pictorial representation from two pictures depicting the relations between latinoas and whites each pictorial representation had two circles along a continuum of distance latinoas represented by a circle on one side and the other circle representing whites on the other end of the continuum 83 in the commonality condition the biased choice was between two representations that depicted latinos and whites as semioverlapping each of the circles overlapped with each other suggesting commonality in the control condition participants completed the following three tasks write down five reasons why there are a number of groups in america choose a statement from four options that best summarized the news report from the previous page and finally choose a pictorial representation from two pictures depicting the relations between latinoas and whites in the control condition the pictorial representation depicted two circles far apart with only slight overlap between circles in all conditions participants responded to a manipulation check item on the next page i view latinoashispanics and whites as a part of one group on a 1 to 7 scale next composition of place was manipulated by varying the expected composition of place for the discussion group specifically participants again informed that the researchers of the study were conducting discussion groups between different racialethnic groups focused on positive relations and building bridges that the discussion group would occur offcampus but within walking distance and that based on signups and spaceconstraints the composition of these discussion groups would likely vary for the composition of place factor participants were randomly assigned to one of three space conditions majoritywhite integratedmixed and majoritylatinx in the majoritywhite condition participants read a short paragraph informing them of the composition of place for the discussion group based on the number of people that have already signed up it is expected the discussion group will occur in a space composed of predominantly nonhispanic white people and that the majority of people at the discussion group will be white such that there will be significantly more white people at the discussion group compared to hispaniclatino people in the mixedintegrated condition participants were informed that it was expected that there would a mix of racesethnicities likely about half latinoahispanic people and half whitecaucasian people in the majoritylatinx condition participants read a short paragraph informed that based on the number of people that have already signed up it is expected the discussion group will occur in a place composed of predominantly latinoahispanic people and that the majority of people at the discussion group will be latinoahispanic such that there will be significantly more hispaniclatinoa people at the discussion group compared to whitecaucasian people thus study 4a provides a test of the effect of composition of place utilizing an alternative means of manipulating level of group representation on the next page placeidentification was assessed for the discussion group in addition participants were also asked to report the level of anxiety for the upcoming discussion using three items adapted from 84 uneasy anxious uncomfortable α 88 on a 1 to 7 scale next attitudes toward whites was assessed via a standard thermometer scale eg 85 in which participants were asked to describe their feelings toward whites at the moment ranging from 0 to 100 finally two items assessed participants decision to attend the discussion group with participants responding on a 1 to 7 scale if i had the choice i would go to the discussion group and i would like to go to the discussion group results and discussion a 2 x 3 twoway factorial anova was conducted for each of the outcome variables table 7 and table 8 report the results for all outcome variables for placeidentification posthoc tests to compute pairwise comparisons for the two main effects of identity emphasis and composition of place in which bonferroni adjustment was applied revealed that all pairwise comparisons were significant p 001 for anxiety the two main effects were qualified by a significant interaction posthoc tests were performed to analyzed the simple main effects of identity emphasis for each condition of composition of place with statistical significance receiving bonferroni adjustment which revealed that only the lowrepresentation condition was statistically significant f 1120 p 001 η 2 p 04 thus under conditions of low representation the commonality intervention reduced anxiety relative to the control for intergroup attitudes the two main effects were also qualified by a marginal twoway interaction posthoc tests to analyze the simple main effects revealed significant difference only in the high grouprepresentation condition f 1230 p 001 η 2 p 05 under conditions of highgroup representation participants reported more positive outgroup attitudes in the commonality condition compared to the control neither of the main effects were significant but the interaction was reliable posthoc tests to analyze the simple main effects for identity emphasis for each composition of place condition with statistical significance receiving bonferroni adjustment were conducted which revealed significance for both the lowrepresentation condition f 571 p 05 η 2 p 02 and the high grouprepresentation condition f 885 p 01 η 2 p 03 under conditions of highgroup representation participants for example were more likely to decide to attend the discussion group in the commonality condition compared to the control conversely under low representation conditions participants were less likely to decide to attend the discussion group in the commonality condition compared to the control the findings of study 4a provide initial evidence of the role of composition of place in shaping the efficacy of prejudicereduction interventions indeed the efficacy of emphasizing commonality was dependent on level of group representation of place for anxiety outgroup attitudes and decision to join a discussion group the findings suggest that relative level of group representation of place may shape prejudicereduction outcomes but also may have implications for explaining the divergent effects of prejudicereduction interventions on minority and majoritygroup members respectively a large body of work demonstrates that prejudicereduction interventions such as contact and common identity are often less effective at improving attitudes for minority group members compared to majority group members 86 87 88 much of the work explaining divergent outcomes of prejudicereduction interventions between minority and majority group members has focused on personal or intergroup factors such as the content of discussion 89 differences in the potential for positive contact outcomes 88 or distinct affective experiences 90 the results of study 4a however suggest that the efficacy of prejudicereduction interventions may also be dependent on composition of place or intergroup context indeed to the extent that most prejudicereduction interventions occur in majority majoritygroup contexts the divergent outcomes of majority and minoritygroup members may be partially a function of distinct responses to respective level of grouprepresentation within place and the role of place in moderating the efficacy of prejudicereduction intervention on factors relevant to outgroup attitudes one intriguing pattern of findings is how composition of place placeidentification and anxiety manifest under conditions of commonality for example across all conditions there was a negative association between placeidentification and anxiety but under conditions of commonality with a highlevel of ingroup representation there was less strong association between the two constructs generally it would be expected that placeidentification is associated with less anxiety but if some of the anxiety associated with prejudicereduction interventions for minority group members is rooted in the experience of being in a majoritygroup context there may be less anxiety and less variance to be explained under conditions of relative highgroup representation the present findings though suggest that one fruitful avenue for future work concerns the interrelation among composition of place placeidentification anxiety and the efficacy of prejudicereduction interventions whereas study 4a was designed to explore intergroup attitudes study 4b examines how level of group representation within place affects another construct relevant to social justice and the amelioration of group inequality study 4b investigates the implications of composition of place for solidarity among minority groups studies 2a and 2b provide evidence that level of group representation has a direct effect on the selfcategorization at the level of social identity such that group members are more likely to categorize in terms of a social identity under conditions of low grouprepresentation past work finds that the extent to which minority group members think in terms of racialethnic group membership is associated with support and solidarity on behalf of another minority group 91 it was expected that under conditions of low group representation minority group members would report higher solidarity with another minority group compared to under less group representation which would be explained by increased tendency to selfcategorize in terms of their racialethnic minority group membership study 4b method one hundred selfidentified blackafricanamerican participants participated in study 4b participants were instructed to imagine they had been accepted to a university and told the purpose of the study was to understand how people respond to everyday events on campus all participants were given one page of information describing a number of characteristics of the university including studentfaculty ratio commitment to small classrooms desire to build a closeknit community and provide students with handson experience in the lab and in the field a second page provided information about the demographic composition of the entire university with respect to raceethnicity in a pie chart and varied representation of the group such that there was either a low or a high representation of blacksafricanamericans thus the manipulation was designed to imply relatively greater group representation but not necessarily majoritygroup status for blacksafricanamericans in the high representation condition on the next page two manipulationcheck items assessed participants perceptions of the representation of place specifically participants were asked what is the racialethnic composition of the university and answered on a 1 to 7 scale in addition participants were asked consider the university would you expect there to be many blackafricanamerican students on campus and answered on a 1 to 7 scale on the following page participants were instructed to consider living on campus walking around the university and interacting with others students selfcategorization was assessed using the same items as study 2a to provide an additional more nuanced evidence of shift in selfcategorization from subordinate level to intermediate level study 4b also included an additional item assessing selfcategorization 92 how would you think about yourself on campus on the next page perceptions of commonality with latinas were assessed using three items 80 blacks and latinoas would have similar experiences on campus blacks and latinoas would likely share common experiences on campus and blacks and latinoas would be likely to have common values on this particular campus participants responded on a 1 to 7 scale next motivation for contact with the other minority group was assessed using three items i would be motivated to make friends with latinoshispanics on campus i would seek out latinoshispanics on campus to become friends and i would be especially likely to make friends with latinoshispanics on campus participants responded on a 1 to 7 scale finally on the last set of pages assessed political solidarity finally preference for political solidarity was assessed participants were asked to imagine that there had been several incidents of anthispaniclatino discrimination on campus many of which likely came from groups outside of the campus participants were asked how likely they would be to engage in collective action on behalf of latinoshispanics using three items 93 if given the opportunity i would participate in a protest on behalf of latinoshispanics on campus i would participate in events to raise awareness about injustices faced by latinoshispanics on campus if given the opportunity i would sign a petition to improve security to help protect latinohispanic students participants responded on a 1 to 7 scale results and discussion there was a direct effect of composition of place on selfcategorization using the original measure of selfcategorization t 304 p 01 d 063 95 ci 29 142 as well as the more nuanced measure of selfcategorization t 215 p 05 d 044 95 ci 06 146 consistent with previous results participants were more likely to selfcategorize in terms of their racialethnic group membership under conditions of low grouprepresentation compared to under conditions of relatively greater grouprepresentation level of group representation within place also had an effect on perceptions of commonality and motivation for contact with another minority group specifically under conditions of low grouprepresentation participants were more likely to perceive commonalities with another minority group t 352 p 001 d 072 95 ci 39 141 and report a higher motivation for contact with another minority group t 304 p 01 d 061 95 ci 26 125 compared to under conditions of relatively greater grouprepresentation however there were no differences between the representation conditions for collective action on behalf of another minority group t 96 p 33 a test to explore whether selfcategorization explained the effects of composition of place on perceptions of commonality was reliable these effects were replicated using the second measure of selfcategorization which assessed shift from subordinate level to intermediate level the test of the indirect effect of selfcategorization on motivation for contact however was not significant study 4b suggests that composition of place can shape solidarity among minority groups much of the work on relations among minority groups suggests that perception of a shared experience of disadvantage can improve relations among minority or stigmatized groups 94 the findings of study 4b suggest however the place or context of intergroup relations may moderate the efficacy of a shared disadvantage approach the manipulation of study 4b suggested relative greater representation but not necessarily majoritygroup status providing additional evidence that level of group representation and not majoritygroup status per se is associated with collective outcomes indeed under conditions of relatively greater grouprepresentation minority group members were less likely to categorize in terms of their specific minority social identity and less likely to view commonalities with another minority group the findings have implications for a shared disadvantage approach to minority solidarity 94 it is possible that the meaning of shared interest or shared disadvantage changes under differing conditions of composition of place such numbers increase for a specific minoritygroup relative to the total composition group members may advocate for more numerous diverse or nuanced interests for their own groupat the expense of shared interest with other disadvantage groups future work is of course needed to more fully explore the way demographic composition may influence relations among minority groups but the present work provides clear evidence of the effects of composition of place as well as selfcategorization on shaping perceptions of commonality more broadly the findings of study 4b point to the importance of acknowledging context in the study of minorityminority relations the default assumption of many studies is a majoritygroup context but changing the composition of context can lead to a change in patterns of intergroup dynamics thus it should not be assumed that findings regarding interminority relations that have been studied within predominantly majoritygroup contexts will necessarily generalize to other groupcomposition contexts moreover it seems reasonable to note that studying interminority relations within predominantly majoritygroup contexts may also produce narratives of solidarity that may not exist in alternative contexts indeed the current findings would suggest that as demographics change within a context eg in the united states 63 potential for conflict among minority groups may also increase thus consistent with calls to move beyond the twogroup paradigm within intergroup relations empirical studies 95 the findings of study 4b illustrate that data collection that assumes a predominantgroup context may lead to a narrow set of conclusions that do not necessarily generalize to all contexts having demonstrated that the implications of composition of place for two outcomes relevant to amelioration of inequality study 4c examined the effect of level of group representation of place on willingness to work on behalf of ones own group study 4c tests whether level of group representation within place affects minority group collective action tendencies past work demonstrates that there is a positive association between social support and groupefficacy such that to the extent that group members perceive they have social support they are more likely to report groupefficacy 96 group efficacy in turn is often associated with collective action tendencies 97 taken together these findings suggest that level of group representation should have a direct effect on collective action tendencies which should be explained by groupefficacy study 4c method one hundred and fifty participants selfidentified blackafricanamerican participants participated in study 4c participants were instructed to imagine they had been accepted to a university and told the purpose of the study was to understand how people respond to everyday events on campus all participants were given a one page of background information about the university a second page provided information about the demographic composition of the entire university in a pie chart and varied representation of the group such that there was either low representation or relatively greater representation of blacksafricanamericans thus in both conditions the manipulation suggested blacks were a minoritygroup but one condition suggested greater relative group representation of the minority group on the next page two manipulationcheck items assessed perceptions of grouprepresentation specifically the first manipulationcheck item asked participants what is the racialethnic composition of the university and respondents answered on a 1 to 7 scale in addition a second manipulationcheck item asked participants consider the university would you expect there to be many blackafricanamerican students on campus and answered on a 1 to 7 scale on the following page participants were instructed to consider living on campus walking around the university and interacting with others students perceptions of placeprototypicality and placeidentification were assessed using identical items to past studies on the next page participants were asked to imagine a group had invited a speaker that some students on campus viewed as controversial or threatening for his views on blacks africanamericans participants were provided with a list of quotes from recent speeches and books including the following its difficult for black people to submit to white leadership if you look at history black people are so violent they havent evolved yet if you think about the future i think white people need to be careful with intermarriage with blacks i call on white volunteers to rise up and be prepared for violence in the face of threat of black people and anything negative that comes to black people they deserve it participants were then informed that because of the invitation of this speaker blackafricanamerican students on campus had organized to advocate that the university review policies and procedures regarding speaker invitations on the following page perceived groupefficacy regarding blackafricanamerican students ability to successfully change university policy was assessed participants were asked to what extent could you working with other blackafricanamerican students on campus advocate to successfully change the speakerinvitation policies of the university groupefficacy was measured using four items working with other blackafricanamerican students i think we could change the speakerinvitation policies of the university i think working together we could change this situation blackafricanamerican students working together could successfully stand up for their rights on campus and blackafricanamerican students could influence the decision of the university officials regarding speakerinvitation policies participants answers on a 1 to 7 scale and the items were adapted from past work 98 finally willingness to engage in collective action was assessed using four items i would sign a petition advocating to review speakerinvitation policies if i had the opportunity i would take time out of my day to participate in a demonstration against discrimination against blacksafricanamericans on campus in support of blacksafricanamericans i would engage in direct action to pressure the university to review speakerinvitation policies and participate in a panel discussion to promote change in speakerpolicies on campus participants responded on a 1 to 7 scale results and discussion consistent with the previous studies composition of place had a direct effect on perceptions of placeprototypicality t 865 p 001 d 150 95 ci 131 172 and collective action tendencies t 605 p 05 d 089 95 ci 68 113 under conditions of higher grouprepresentation participants reported higher groupbased efficacy and willingness to act on behalf of their group compared to under conditions of relatively lower grouprepresentation consistent with the notion that social support is associated with group efficacy 96 results demonstrate that sense of belonging and group efficacy explained the effect of composition of place on collective action tendencies may serve as an antecedent to groupefficacy one of the core motivations for collective action 99 whereas much of the work on the antecedents to collective action has focused on individualand grouplevel factors such as groupidentification anger and moral conviction 99 the current work suggests how these antecedents manifest may be dependent on level of group representation and placeidentification the final study was designed to extend the current work by examining whether composition of place affects an additional indicator of propensity to view place in groupbased terms study 5a level of group representation within place and labeling place in terms of social identity to provide evidence with greater external validity regarding the effect of composition of place on propensity to view place in groupbased terms study 5a used a quasiexperimental design in a classroom setting more specifically data was collected in a classroom and included a new measure of viewing place in groupbased terms study 5a method one hundred and fortysix participants were recruited from two large sections of introductory psychology courses in the first week of each course the sample consisted individuals that selfidentified with a variety of racialethnic groups white hispaniclatinx blackafricanamerican asianasianamerican and biracialmixed consistent with national trends in the field of psychology both sections had a clear majority of selfidentified women compared to men thus for the purposes of this study women were the numerical majority group and men were the numerical minority group all participants were asked to consider the physical space of the classroom including the look of the class people in the room and objects around the room thus all participants completed the survey in the actual place of the classroom next utilizing the same items as the previous studies adapted to gender placeprototypicality and placeidentification were measured in addition two separate items assessed propensity to view the classroom in terms of social identity specially the items asked participants the extent to which they would label the classroom as male space versus female space on a 1 to 7 scale results and discussion composition of place had a direct effect on group members perceptions of the groupprototypicality of place t compared to men that had low group representation in the classroom there were no differences between men and women in their likelihood to label the classroom as male space t 191 p 05 men were more likely to label the class as female space compared to women t 448 p 001 d 088 95 ci 98 61 the results provide additional evidence within an ecologically valid place of how level of group representation shapes propensity to view place in groupbased terms using two indicators as well as sense of belonging general discussion why does group representation matter the present work speaks to this fundamental question by providing robust evidence linking the social makeup of a local place perceptions of the groupbased nature of place sense of belonging and collective behavioral tendencies across a diverse set of groups and placescontexts the findings provide support not only for the integral role of composition of place for understanding collective behavior but also for a groupbased approach to place first composition of place is directly associated with propensity to view places in groupbased terms via perceptions of placeprototypicality and labeling place in terms of social identity a groupneutral approach to place assumes that people perceive approach and understand places as being not representative or characteristic of a particular group the current findings suggest however one should not assume all people or groups in a local place view the respective place in groupneutral terms nor that similar places are perceived the same in terms of groupbased perceptions second the present work illustrates that perceptions of placeprototypicality is an antecedent to sense of belonging third the social makeup of place in terms of numeric group representation shapes a comprehensive set of collective and intergroup outcomes rooted in distinct psychological contextualized experience as a function of minority versus majoritygroup status level of group representation shapes a group members expectations understanding and behavioral tendencies indeed the effects of composition of place on numerous and a diverse set of outcomes speak to the comprehensive way in which composition of place shapes a group members experience the present work extends the literature in three central ways first the findings illustrate the direct effect of level of group representation within place on numerous and a diverse set of outcomes these findings contribute to an emerging literature on the effects of numerical group representation and bolster the case for a minoritymajority distinction in the study of group behavior within specific contexts second whereas much of the work within the social identity literature exploring prototypicality has focused on leaders and leadership 18 the current work introduces the construct of placeprototypicality and demonstrates its potential for explaining collective and intergroup outcomes third a space approach provides an organizing framework for the study of how characteristics of place shape groupmember behavior i elaborate on these contributions in the next sections level of grouprepresentation a distinct psychology of numerical groupstatus within place across several studies the current work provides clear evidence that group members with differing levels of representation within place have distinct contextualized experience within the respective place which explains unique patterns of collective and intergroup behavior indeed moving from low to high group representation within place shapes how a person defines themselves their propensity to view place as representing the unique beliefs or values of their respective group and a persons sense of psychological connection to the respective place importantly the effects of numerical status in place were consistent and reliable for both socionational minority and majority groups that is the findings generalized across groups of differing national numericalgroup status for both raceethnicity and gender demonstrating the effects are contextdriven and fundamentally about the social makeup of local place of course national numerical group status and group status within local place often cooccur but the evidence suggests that groupstatus within place and not membership in a particular sociodemographic group per se explain the distinct collective behavioral tendencies the results contribute to a wealth of empirical evidence that points to the conclusion that minority and majoritygroup status within place is associated with distinct psychological orientations indeed numerical group representation within place as manifested by minority or majoritygroup status directly affects sense of belonging 100 cognitive orientation 101 anxiety 102 propensity to feel under a spotlight 103 academic motivation 104 sense of threat in performance situations eg stereotype threat 33 trust 14 and stereotyping 105 to name just a few taken together with the findings in the present work there is a wealth of evidence illustrating distinct psychological experience and dissimilar realities based on numerical minority and majoritygroup status within place this conclusion is bolstered by replication across a diverse set of literatures such as neuroscience 106107 social cognition 108 persuasion 109 healthwellbeing 110 education 111 and business 112 the large body of work suggests that the minoritymajority groupstatus classification is an important necessary and meaningful distinction for studying and understanding psychological experience within social contexts and a useful means to organize and explain findings from across psychology importantly the present work suggests not just that minority and majority group members have distinct experience in place but that there a host of benefits associated with majoritygroup status within a respective place one of the most distinct differences between minority and majoritygroup members everyday experiences is the salience of place communicating this place is for younot for you and who is supposed to be in a respective place given the large degree of segregation across most social educational and professional settings eg raceethnicity religion class 113 the benefits of majoritygroup status are not merely theoretical but have very real practical implications based on the current data the results demonstrate that holding majoritygroup status within a respective place is associated with more positive expectations regarding groupbased treatment increased sense of belonging less propensity to make attributions to discrimination and greater expectation that fair procedures will be utilized to resolve disputes beyond the benefits associated with everyday experience study 5a suggests that composition of place also shapes conception of places designed to be groupneutral what does it mean to have systematic differences between minority and majority group members sense that public institutions are prototypical of their group one additional benefit of majoritygroup status therefore is the general expectation that many public service entities predominantly composed of majoritygroup members are for you in sum the luxury of majoritygroup status whether based on national numerical status or contextdriven is that holding majoritygroup status fundamentally shapes the way one experiences social reality with a variety of benefits the benefits of majoritygroup status however start with social identitybased contextualized experience more generally a critical piece of divergent experiences of place is associated with perceptions of group prototypicality placeprototypicality perceiving place as prototypical of your group placeprototypicality is defined as the extent to which a given place is perceived as being characteristic of a group representing the unique values of the group and exemplifying the beliefs that define the group that is the extent to which a place is representative of the factors that make the group distinct from other groups whereas prior theorizing on prototypicality has focused primarily on leader prototypicality see 2627 for reviews the current work extends the study of groupprototypicality to place conceptually it is expected that many of the positive benefits of leader prototypicality should translate to placeprototypicality but also that placeprototypicality may help to explain a variety of other intergroup relations outcomes consistent with work on leader prototypicality 27 places viewed as high in groupprototypicality should also be viewed as fairer more trustworthy and also lead to greater productivity thus this work speaks to approaching the study of collective behavior by not only acknowledging that people can view places in groupbased terms but seeking to understand the implications of divergent understandings of the groupbased nature of place more broadly the current findings provide robust evidence that perceptions of placeprototypicality are an antecedent to sense of belonging but also that both placeprototypicality and sense of belonging shape collective behavioral tendencies including comfort intentions to stay in place expectations of procedural justice willingness to partner with law enforcement and collective action tendencies beyond the investigation of placeprototypicality as an antecedent to sense of belonging and other positive outcomes one intriguing avenue for future work is the exploration of placeprototypicality as a mediating construct the findings of study 3b for example provide initial evidence that concerns about groupprototypicality of place partially explain majoritygroup bias against a minority groups more generally these findings seem to suggest that placeprototypicality may be especially useful construct because group members have concerns about the ideas or values of space or place that is there is often a struggle for the predominant values of place and some intergroup conflict may be a result of groups vying for the ideas of space or place to the extent that conflict between liberals and conservatives for example is rooted in distinct moral values 114 it seems that some intergroup disagreements between the two political groups eg political correctness 115 is explained by each groups desire to have their groups unique beliefs or values represented in spaces places and contexts across the national landscape thus beyond the benefits of studying placeprototypicality as an antecedent to sense of belonging the ideas of place and the battle for who or which group should represent place is a compelling topic of future study placeidentification and collective behavior whereas much of the work on attachment to place or sense of belonging has been rooted in a sociological perspective 6 relatively little work has explored the implications of variation in identification with place as a function of group membership or social identity cf 116 one of the central practical contributions of this work involves the evidence for the way identification with place can play a role in explaining collective behavior just as a wealth of empirical work demonstrates that high group identification can impact motivation 117 performance 118 or commitment to the group under threat 119 it would be expected that identification with place would play a similar role in shaping a variety of outcomes indeed placeidentification had a direct role in explaining several outcomes including comfort perceptions of competence of a target expectations of procedural justice and groupefficacy importantly placeidentification is pertinent to a variety of contexts including education eg classroom academic performance 120 health eg a doctors office or hospital patient health outcomes 121 business eg office employee organizational commitment 118 marketing eg locationspecific franchises consumer behavior 122 neighborhoods eg town or city as space gentrification 123 or even sports eg lockerroom teambuilding 124 as others have noted identification with place is central to the nature of ones experience in place and peoples understandings of who belongs who has rights and who one feels a sense of commonality with 116 thus one contribution of the present work is illuminating the role of identification with place in explaining collective and intergroup relations phenomena more broadly a space framework provides a means for linking characteristics of place social identitybased contextualized experience and collective or intergroup behavior social identity paradigm for contextualized experience as an organizing framework for studying collective and intergroup behavior a social identity paradigm for contextualized experience provides a framework for understanding how the characteristics of place inform social identitybased contextualized experience which organize how group members approach understand and behave within the respective place the present work focused on one characteristic of place composition or level of group representation but there are variety of characteristics of place that cumulatively shape contextualized experience and collective behavior moreover although the present work primarily focused on racialethnic gender and religious group memberships it would be expected to be relevant to any social identity or group membership within a given context a space framework and groupbased approach to place opens up opportunities to study a variety of collective and intergroup behaviors each place could be conceived as an ecosystem of characteristics that determine group members likelihood of viewing place in groupbased terms as well as their socialidentity based contextualized experience for example demographic characteristics of leader 125 leadership style 126 norms 127 ideological climate 128 or physical objects in place 13 all likely play a role in shaping perceptions of the groupbased nature of place and group member behavior thus one potentially fruitful area of work is to explore how other characteristics of place directly shape collective and intergroup behavior as explained by perceptions of placeprototypicality and sense of belonging the collection of findings also demonstrate the need to prioritize context and the place of collective and intergroup behavior in the development of theory empirical methods and interpretation of findings place as a unit of analysis the present studies complement recent work that seeks to shift away from a decontextualized individualindividual approach to collective behavior toward an approach that is rooted in specific context of intergroup relations eg prejudice 129130 indeed this approach suggests that to change individual group or intergroup relations behavior interventions should focus on changing macrolevel social factors related to the situation or context consistent with this approach a space framework implies the need to devote much greater attention to situational affordances and constraints as a function of contextualized experience indeed utilizing place as a unit of analysis would suggest a shift away from examining group differences based solely on individualcharacteristics eg perseverance 131 to a framework that examines the advantages and disadvantages of place for the individuals group members and groups within the respective place thus a groupbased approach to place would suggest that research more fully explore how grouplevel differences in individuallevel behavior may emerge because of affordances and constraints of a respective place conceiving of place as a unit of analysis also has implications for the way practitioners make comparisons and the interpretation of findings scientists and practitioners often have a goal of objective comparison between individual targets but individuallevel comparison requires equivalence of contextlevel factors integrating place and contextualized experience in comparative analysis therefore challenges the logic of using individuallevel comparisons for example with respect to the study of educational outcomes the present results would suggest distinct social identitybased contextualized experience for people as a function of level of group representation in a class or school thus students in different classes but also students in the same class likely have very dissimilar social identitybased contextualized experiences which likely affects their performance see sense of belonging work 120 an individuallevel analysis would fail to account for the potential role of composition of place and social identitybased contextualized experience on educational outcomes for these respective students indeed the collection of results suggest acknowledging or incorporating the place or context of a study in analyses and interpretation of findings will produce more nuanced findings and better science thus it seems incomplete for example to say blackafricanamerican andor white people act in a particular ways more accurately particularly if the goal of the research concerns making more generalizable comparisons which replicate across contexts ie moving beyond the replication crisis 132 klein ratliff vianello adams et al 2014 one might say blackafricanamerican and white individuals within predominantly white contexts blackafricanamerican and white individuals within predominantly blackafricanamerican contexts or blackafricanamerican and white individuals within integrated contexts in sum rather than divorcing ourselves from the social context of the participants and study of our work the results clearly demonstrate the need to more fully engage in the social of the social psychology of intergroup relations 133 especially relative level of group representation which will allow for a more nuanced study of human behavior the strong effect of composition of place on a variety of outcomes also has implications for diversity science diversity science a contextualizedexperience driven account of how to create inclusive space as nations become more diverse many citiesneighborhoods businesses and universities are concerned with the question of how to create an inclusive environment in the context of diverse populations the findings of the present work have implications for diversity science and speak to the need for a more nuanced understanding of what constitutes a diverse place or space much of the focus on diversity initiatives emphasizes representation 134 complimenting this work the current findings clearly speak to the importance of groupbased representation however the collection of studies also reveal that the underlying mechanism of the effects of representation is the sense that a place is characteristic of the unique characteristics that define ones group and sense of belonging or identification with place thus the mechanisms explaining the effects of group representation on collective outcomes clearly suggests there is an importance in exploring group members subjective contextualized experience as demographic composition of nations change 135 and majority groups begin to act more explicitly in terms of racialethnic group membership or identity 136 a dynamic approach to diversity is necessary 137 indeed a definition of diverse space or place should not only be rooted in numeric representation but also be attuned to the social identitybased contextualized experiences of different groups do all people feel the place represents their group do all people feel connected to the place defining diverse space based on social identitybased contextualized experience of all group members suggests there is not one solution to issues related to diversity but solution linked to the specific challenges and opportunities of respective contexts thus a groupbased approach to place would suggest that the goal of creating diverse or inclusive space explicitly for improving intergroup relations should not necessarily be to create places that benefit one group over another group but to create places that are responsive to both minority and majority perspectives and rooted in identitysafety 138 to the extent that one might expect that any group that assumes majoritygroup status would likely show ingroup favoritism and an assimilative orientation toward minority groups in the respective context 38 it becomes integral for those interested in diverse spaces to strive for a functional equilibrium indeed much like the tragedy of the commons 139 as each group vies for majoritygroup status it diminishes the capacity of all other groups to connect to the respective place thus this diversity equilibrium would suggest that truly diverse spaces with no group holding a majority require a sacrifice or a diversity bargain if you willin which no one group feels maximally connected to the place but no group feel disconnected from the place of course any diversity bargain would also require integrating power status and history of the respective groups in the local place a diversity science though should be attuned to the groupbased nature of place and explore the characteristics of place that maximally benefit the most groups to achieve healthy outcomes relevant to diversity equity and inclusion limitations future directions it is worth noting limitations and areas for further investigation first the present work was concerned with numeric group representation of local place but does not factor how other characteristics of local setting might shape socialidentity based contextualized experience thus it is theorized that the socialmake up of a place in terms of numeric group representation is a foundational characteristic but a variety of social and physical features or cues may be associated with distinct social identitybased contextualized experience eg 16 second the present work primarily utilized mturk samples and a crosssectional design which limit the conclusions that can be drawn regarding causal direction relatedly these studies utilized a surveydesign to examine place additional evidence replicating the current results within naturalistic settings or via longitudinal data would help strengthen the evidence in support of the specified hypotheses nevertheless a large body of work suggests the quality of data obtained from online data collection is comparable to student and professional samples 140 in addition numerous studies in organizational psychology conducted in the fieldincluding field studies in the present workprovide evidence complimenting the general pattern of results 141 third the current studies used an expansive definition of placeencompassing a variety of geographiesbut additional work is needed to further generalize this work to specific places there is a large diverse and interdisciplinary literature on place or space 4 5 6 7 142 such that there are different notions of the way place is connected to space and dissimilar ways to operationalize place whereas the consistent pattern of findings across the respective places in the current work can be viewed as strengthfuture work should seek to replicate these findings in specific places fourth several of the studies used manipulationchecks that may raise concerns about demand characteristics that is the studies included multifaceted descriptions of place in the respective studies but the manipulationcheck items may have cued participants to the purpose of the studies therefore additional work is needed to examine the effects of composition of place using alternative methods fifth the present work primarily focused on three facets of socialidentity based contextualized experience but there is room for further investigation around the interrelation between the three facets of contextualized experience as well as potential moderators of the effects of composition of place on collective behaviors thus although i would theorize that selfcategorization is the proximal construct which shapes the relevant social identity for perceptions of placeprototypicality and identification with place the present work did not explore the interrelation among all three facets of social identitybased contextualized experience moreover there is also a need to examine factors that moderate the effects of composition of place on group behavior at both the individual eg groupidentification 143 and structural eg perceived permeability of group boundaries 144 level sixth the current studies focused on numerical group representation but failed to explore power although status and power can be positively associated they are distinct constructs and thus one should avoid confounding the two constructs 145 indeed numerical representation does not necessarily equate to power such that if you put unequal parties within place outcomes derived in the respective place often reflect the fundamental inequality of asymmetrical power relations outside of the place 146 thus one avenue for future work concerns the extent to which power dynamics can moderate the effects of level of group representation within place on collective outcomes finally for ease of investigation the present studies used broad racialethnic categories collapsing across different types of racialethnic groups to classify both majority and minority group status but additional work should explore nuances associated with distinct racialethnic groups for example although there is certainly a common experience rooted in minority status there are important experiential distinctions not only among groups identifying in a single category but also between different racialethnic religious minority groups similarly majority groups differ based on a variety of demographic cultural and ideological factors suggesting distinct behavioral patterns as a function of these potential moderators therefore a more nuanced approach to the study of contextualized experience would not only explore the unique experience of multiple groups and multiidentity groups but also dimensions of intersectionality conclusion the present research provides evidence for the integral role of composition of place or level of group representation in shaping propensity to view place in groupbased terms sense of belonging and a host of collective and intergroup outcomes the relative level of group representation of place can shape our collective imaginations about a particular place the current work suggests who inhabits place implicitly communicates grouprelevant meaning particularly about a set of predominant beliefs and values as well as who belongs and who does not thus who is and isnt represented within place sets the foundation for the geography of social identity collective behavior and intergroup relations all data are contained within the paper andor supporting information files

the current studies n 1709 explore why demographic composition of place matters first this work demonstrates that relative level of group representation affects ones experience of place in the form of selfdefinition selfcategorization perceptions of place being representative or characteristic of factors that distinguish the group from others placeprototypicality and sense of belonging placeidentification studies 1a1e studies 2a 2b second the studies illustrate that group representation within place shapes the way group members approach ie expectations of groupbased treatment and procedural justice studies 2a2c understand ie attribution for groupbased events study 2b responsiveness to biasreduction intervention study 4a sense of solidarity study 4b and behave ie prejudice studies 3a 3b collective action study 4c more broadly i present a social identity paradigm for contextualized experience space that provides an organizing framework for the study of the impact of characteristics of place on social identitybased contextualized experience and in turn collective behavior taken together the findings provide evidence of distinct psychological experience and orientation as a function of minority versus majoritygroup status within place as well as for a groupbased approach to place implications for the study of collective and intergroup behavior are discussed

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background the most recent internationally accepted definition of household food and nutrition security has been defined by the food and agriculture organization as existing when all people at all times have physical social and economic access to food which is safe and consumed in sufficient quantity and quality to meet their dietary needs and food preferences … allowing for a healthy and active life 1 the definition is conceptualised as having a number of domains including availability access utilisation 2 for high income industrialised countries the availability of adequate quantities of food to meet caloric needs for a majority of the population is usually not an issue 3 however certain sectors of these populations still struggle to provide enough food of sufficient quality for an active and healthy life 4 in most high income countries the inability to put food on the table is largely due to neoliberal policies that result in low wages insecure and unstable employment minimal or inadequate social protection unaffordable housing and unaffordable food 5 consequently investigating the continuum of food security experiences is essential to evaluate both reduced quality and quantity of foods that individuals and households can access most data on household food insecurity in a highincome country context has emerged from the united states of america followed by canada and the united kingdom 67 more recently data is emerging from australia new zealand europe and the republic of korea 7 8 9 10 the usa and canada are the only two countries that have regular population monitoring the usa monitors hfi annually using the usda household food security survey module 11 while canada has biannual monitoring of some states using an adapted version of the same tool 12 the usda hfssm tool classifies food security based on severity which includes marginal low and very low when the quantity of food consumed is compromised 9 data from the usa and canada report similar prevalence rates of hfi in canada in 2021 the prevalence of hfi was estimated to be 116 of which 42 were identified as severe 13 the most recent prevalence estimate of hfi in the usa was 102 of which 38 had very low food security 11 in the uk use of foodbanks is taken as a proxy indicator of food insecurity in the absence of regular monitoring from 2015 to 2019 the trussell trust indicated a 73 increase in the use of food banks although the proportion of the population using food banks at either date is unknown 14 in europe again in the absence of regular monitoring analysis of the eurostat database indicated that 109 of participants in 2012 were not able to afford meat every second day a proxy for uncertain or insufficient food availability and access arising from resource constraints 15 in australia ad hoc national data relies on a singletwopart question which asks if in the last 12 months was there any time when they or members of their household ran out of food and could not afford to buy more for those who answered affirmatively the second questions asks if they or members of their household had gone without food 16 this question identifies the prevalence of food insecurity in 201112 to be around 4 17 this question has been demonstrated to underestimate hfi by between 58 percentage points 18 in japan there is no routine measurement of hfi and the national poverty line has been deployed as a proxy indicating 157 of the population are potentially food insecure 19 in korea the usda hffsm was deployed in 2012 and indicated a hfi prevalence of 113 20 with hunger 20 in denmark a representative sample of households using the 6 item usda hffsm revealed a prevalence of low and very low food security as 60 and 24 respectively 21 other countries have used different ad hoc measures or no measures at all 22 the disparity in measurement makes it difficult to undertake crosscountry comparisons this recognition across all countries led to the development of the fao food insecurity experience scale that enables comparison at an individual level across different levels of severity households and individuals with low economic resources and poor labour market attachment appear to be most at risk of food insecurity in hic 23 analysis of the fies data across 147 countries identified that although demographics factor into determining fi in hic social and economic variables are potentially more relevant 24 other analyses of the same data indicated that fi in hic was associated with age and number of child in the household being single separated having an elementary and secondary education residing in a rural area log household income and employment status 25 it appears that those at risk of hfi in more industrialised nations are households with children led by single parents 25 single person households 2425 low income households 232426 those receiving welfare payments 23 indigenous 27 28 29 refugees and migrants 3031 and people living with a disability or chronic conditions 32 other studies using the fies data either in hic or longitudinally include analyses of countries located in the middle east 33 in latin america 34 and in central and eastern europe omidvar et al 33 investigated rich and politically stable countries in the middle east finding that the odds of being food insecure were significantly elevated among individuals aged 13 to 25 years living in the poorest quintile and with low education attainment personal health social capital and not enough money for shelter were all found significantly associated with fi providing insights into changes in fi status from 20142017 de sousa et al 34 investigated rates of fi in latin american countries classifying them as improving worsening or stagnating finally in central and eastern europe the fies data were used to identify between country differences in prevalence and determinants 35 due to the relatively low numbers of households in hic experiencing fi most studies conflate the levels of severity typically dichotomising the sample to food secure and food insecure the fao data is the first opportunity to explore a pooled sample of households who are experiencing severe fi in hic that is where individuals are reducing the quantity of food they consume due to a lack of financial or other resources with similar developed social welfare employment agricultural food retail transport systems and policies such an exploration will allow elucidation of between and withincountry factors that may be impacting on the manifestation of severe fi to our knowledge there are no published studies investigating in depth fi across the levels of severity in hic over time thus the current analysis aims to describe the characteristics of individuals who were moderately or severely food insecure and to assess temporal trends in the prevalence of moderate and severe fi between 2014 and 2018 methods this study is a secondary data analysis of data obtained under licence from faovoh sample data were collected during the 20142018 gallup world polls each gwp is a nationally representative sample of approximately 1000 individuals aged ≥ 15 years the gwp is typically conducted annually in over 140 countries maintaining a core set of questions across surveys detailed sampling and data collection methodology along with data preparation has been previously reported 36 data weighting has been applied with weights adjusting for oversamples and household size as well as poststratification weighting using population statistics for gender age and potentially education or socioeconomic status where reliable data were available 36 geographic scope this study only considered data from highly developed wealthy countries the categorisation has been made based on a combination of the world bankss index of gross national income and the united nations human development index only countries with a gni above usd12500 37 and a hdi above 08 are included 38 thirtyfour countries from seven regions were included oceania western europe central europe eastern europe nordic region east and southeast asia and north america food insecurity measures food insecurity measures were derived by the faovoh based on responses to the eight questions in the fies the fies questions scales and how severity is calculated are all available at the fao voices of the hungry website to allow for multicountry analysis moderate severe fi and severe fi was defined using the probability of moderate or severe fi and the probability of severe fi respectively these probability measures take into account measurement error and are based on adjustment of respondent severity parameters to the voh global standard so are intended to be comparable between countries 39 the threshold of severe fi is specified at the severity level of the fies item did not eat for a whole day while moderatesevere fi is specified at the level of severity associated with the fies item ate less than should in both cases individuals with a probability of moderatesevere fi or severe fi ≥ 050 were classified as being moderately or severely or severely food insecure respectively social and demographic variables selected social and demographic variables collected during the gwp were included in this analysis including participant age gender income quintile per capita annual income in international dollars education level number of adults living in household number of children living in household and area of residence a new variable was created called household structure based on the number of adults and children living in the household single adult with no children single adult with children two adults with no children two adults with children three or more adults with no children and three or more adults with children statistical analysis the characteristics of individuals experiencing moderatesevere fi and severe fi were compared using anova welchs f pearsons chisquare and linearbylinear association dependent on the variable of interest where a significant association was indicated using pearsons chisquare the ztest with bonferroni correction was used to compare proportions the mean age was compared across income quintiles using welchs f with dunnetts t3 used for posthoc tests due to unequal variances between the groups hierarchical cluster analysis was used to group countries according to their prevalence of moderatesevere fi and severe fi exploratory analysis of the temporal trends in the proportion of individuals experiencing moderate severe fi and the proportion experiencing severe fi using generalized linear mixed models with a poisson link function indicated that country was an effect modifier of the temporal trend for both moderatesevere fi and severe fi as a result countrybycountry analyses were conducted using the linearbylinear statistic to assess linear trends and pearsons chisquare to detect any differences between individual years within each country association between the prevalence of moderate severe fi and severe fi within a country was tested using pearsons correlation coefficient all statistical analysis was conducted using spss version 27 results a total of 154704 individuals from 34 countries had a food insecurity classification and were included in the analysis data for all 34 countries were available for 20142017 while 22 countries had data for 20142018 the countries missing 2018 data were australia belgium cyprus finland germany italy luxembourg new zealand norway south korea sweden and united states for some variables 2018 data from the united kingdom was also missing overall the weighted sample was 516 female with mean age 466 years 320 610 years and median per capita annual income of intl 12266 approximately 16 were aged 25 years or less while 183 were aged over 65 years over 70 of the weighted sample lived in adultonly households with 149 living alone approximately 2 lived in single adult households with children the household structure varied across age groups with 299 of those aged 65 years living alone compared to 81 and 124 for ≤ 25 years and 2665 respectively almost 71 of those aged ≤ 25 years lived in households with 3 adults either with or without children moderate or severe food insecurity prevalence overall 65 of the weighted sample were moderately severely food insecure msfi individuals were present in all 34 countries in all years and across all education levels and income quintiles the prevalence of moderatesevere fi ranged from 25 in japan to 145 in greece and 155 in the united states hierarchical cluster analysis suggested that countries could be assigned to one of four groups based on the prevalence rate group 1 united states greece and cyprus group 2 portugal slovenia hungary canada belgium new zealand and australia group 3 spain south korea ireland croatia estonia united kingdom italy finland and poland and group 4 czech republic luxembourg slovakia austria norway sweden malta denmark israel netherlands france singapore germany switzerland and japan characteristics of individuals who were moderately or severely food insecure fiftysix percent of individuals experiencing moderate severe fi were female 52 were unemployed or out of the workforce and 47 were in the poorest income quintile one in five msfi individuals lived alone while 35 had children in the household for individuals aged 25 years or less a significantly higher proportion of msfi individuals lived in single or twoadult households with or without children compared to individuals who were not msfi this was offset by a lower proportion living in 3 adult households with no children for those aged 2665 years single adult households and households with 3 adults with children were overrepresented amongst the msfi group compared to those who were not msfi for those over 65 years single adult households with no children were significantly overrepresented in the msfi group while those in twoadult households were underrepresented countryspecific age prevalence rates across the 34 countries the prevalence rate for moderate severe fi was 65 72 and 42 for individuals aged 25 years or less 2665 years and 65 years respectively age prevalence rates and patterns varied between countries 1 in additional file 1 the prevalence for those aged 25 years or less was generally lower or similar to the prevalence for the 2665 year age group but there were three clear exceptions canada finland and norway temporal trends the proportion of individuals experiencing moderate severe fi varied between years from 74 to 54 overall there was a significant linear trend for declining prevalence of moderatesevere fi but the temporal trends differed between countries twelve of the 34 countries demonstrated no significant trend or difference in the prevalence of moderatesevere fi between years while 15 countries showed a significant linear trend for decreasing prevalence of the remaining countries three showed a significant trend for increasing prevalence and four had significant differences detected between years without a consistent trend for the 15 countries with an overall decreasing trend this trend was significant within each age group in contrast the increasing trend identified for canada new zealand and sweden was restricted to those aged 25 years or less and 2665 years with no trend for those aged 65 years this result did not change when 2018 data was excluded from the analysis notably the prevalence of moderatesevere fi in countries with a decreasing trend was similar between the three age groups whereas countries with an increasing trend showed higher prevalence of moderatesevere fi in those aged 65 years or less severe food insecurity prevalence almost 2 of individuals were classified as severely food insecure these individuals were distributed across 31 of the 34 countries with no severely food insecure individuals identified in croatia czech republic or slovenia there was a strong significant linear correlation between the prevalence of moderatesevere fi and the prevalence of severe fi within a country countries could be grouped into four categories based on the prevalence of severe fi using hierarchical cluster analysis these groups were group 1 portugal united kingdom belgium united states new zealand and cyprus group 2 greece group 3 malta poland ireland netherlands singapore italy japan austria luxembourg hungary slovakia switzerland germany sweden estonia israel finland france norway denmark australia spain and canada and group 4 czech republic slovenia croatia and south korea characteristics of individuals who were severely food insecure approximately half of the severely food insecure individuals were female lived in urbansuburban areas and were in the lowest income quintile for their country approximately 55 of severely food insecure individuals were single divorcedseparated or widowed countryspecific age prevalence rates the highest prevalence of severe fi was 49 in portugal agespecific prevalence rates for severe fi exceeded 5 for individuals aged 25 years or less in new zealand and united states and for individuals aged 2665 years in portugal and united states temporal trends overall there was a slight but significant decreasing linear trend in the prevalence of severe fi over the study period prevalence peaked at 18 in 2015 declining to 13 in 2018 analysis of the temporal trend in the prevalence of severe fi revealed no change over time for 18 countries a decreasing trend for five countries an increasing trend for four countries and sporadic differences between years in the remaining four countries comparison of moderately and severely fi individuals one quarter of the msfi individuals were classified as severely fi this value differed between countries ranging from 0 in croatia czech republic and slovenia to 46 in singapore and new zealand and 47 in united kingdom a higher proportion of males were severely fi compared to females with severely food insecure individuals slightly younger than moderately food insecure individuals over 30 of severely food insecure individuals lived in single adult households compared to 238 for moderately food insecure individuals while they were underrepresented in multiple adult households without children the annual household income for severely food insecure individuals was significantly lower than for moderately food insecure individuals discussion this analysis of the faovoh data has shown that 65 of individuals are estimated to be moderate or severely food insecure and 16 severely food insecure in hic globally moderatesevere fi occurred across all ages income quintiles and education levels however those living in single adult households and those with lower household incomes were more likely to be severely food insecure preliminary analysis comparing moderate with severe fi indicated no statistically significant difference in per capita income this indicates that income needs to be contextualised to the individual households living arrangements and that fi severity in a hic context is highly sensitive to income in europe for example each 1 rise in unemployment was associated with a 029 percentage point rise in the prevalence of fi and each 1000 decrease in annual average wages was association with a 062 percentage point increase in fi 40 the country with the highest prevalence of severe fi in the current analysis was portugal where from 2011 social support and benefits were reduced as unemployment and poverty increased 41 given that income is critical for minimising fi population level measures to protect and ensure stable incomes including ensuring social protection and wages that support a decent standard of living are needed ensuring a living wage irrespective of social circumstances has the potential to ameliorate severe food insecurity that is going without food in this study three countries had no severely fi individuals and it is interesting to note that all operate under a postsocialist welfare model in the bismarckian tradition 42 in addition slovenia made changes to minimum wage legislation starting in 2007 in response to the increasing price of food electricity and other essential consumer goods leading to legislative changes in 2018 resulting in a true living wage 43 this corroborates the findings from reeves et al that indicated the probability of severe fi was dependent on how wages were established with little or no wage setting policy associated with higher odds of severe fi 44 for those who were unemployed the prevalence of severe fi did not change across the models indicating that reducing unemployment and ensuring a dignified social protection system all need to be considered 44 for 44 of the hic countries included in this analysis there was evidence of improvements in the prevalence of moderatesevere fi over time countries that experienced a linear increase in moderatesevere fi from 2014 to 2018 included canada new zealand and sweden while the usa and israel also had an increasing trend in the prevalence of severe fi it is unclear why this was the case but the observation of differences in prevalence of moderate severe fi between age groups in these countries contrasts the more uniform prevalence seen between age groups in countries with a decreasing trend in canada nz and sweden the burden of moderatesevere fi appears to fall on the younger age groups and it is an increasing prevalence in those younger than 65 years that is causing the overall increasing trend differences in trends between countries and age groups suggest complex intersections between social income and food policies all of which are subject to varying levels of political upheaval and change when looking at the sociodemographics of individuals more likely to report moderatesevere fi in hic these were female those living in single adult households and in the lowest income quintile this agrees with other previously published studies 2425 however within those reporting moderatesevere fi males were more likely than females to experience severe fi this result highlights the value of analysing moderate and severe fi separately using samples that are weighted to better reflect population characteristics such as those in the faovoh data a crosssectional study in australia indicated a higher proportion of men experienced severe fi were less likely to be fi as they got older but were more likely to be fi if they were single or lived alone with children 45 the drivers of these gender differences could relate to any number of factors such as social networks mental health gendered support services and income and warrant further investigation patterns in prevalence rates across age groups differed in some countries which may be an indicator of different social supports particularly in the oldest and youngest age groups of note are the higher rates of severe food insecurity in those aged over 65 years in greece croatia and south korea in other countries the old age pension appears to protect most seniors from financial food insecurity 4647 when looking at younger people and fi country variations on transitioning from secondary schooling to work or to further education and the associated costs and government support are likely to have an impact similarly the proximity of further education facilities and the social norms associated with living away from the family home could impact those under 25 years of age a recent review of fi among postsecondary school students in the usa canada australia and poland estimated prevalence rates between 989 26 much higher than the values in this study there is significant variability in how social protection and income policies are enacted across countries and this potentially contributes to food security status in australia those receiving welfare payments including jobseeker austudyabstudy disability support pension the carer payment and the parenting payment were all more likely to be fi 23 reeves et al 48 used the faovoh fies data across 142 countries to compare the family policy impact on fi they found that those countries that implement family policies have lower fi prevalence this was more prominent for families with children at the lower end of income distributions childspecific cash transfers were found to be more effective in reducing severe food insecurity 48 this analysis has several strengths and limitations it is to our knowledge the first to look at temporal and between country changes to fi in hic using a valid scalar equivalent measure the fies can estimate and monitor food insecurity experiences across countries irrespective of cultural and social differences 49 the data has some limitations in that variations between countries could be an artefact of cultural norms and perceptions associated with stigma and shame there is no measurement of hfi among those who may be at more risk for example first nations peoples those who are homeless or experiencing deep deprivation it should also be acknowledged that the analysis conducted used data predating the covid19 pandemic and that some of the trends reported may have subsequently been impacted by the sudden and significant social and economic impacts caused by the pandemic future research into the prevalence and trends during and after the covid19 pandemic would provide valuable information about the stability of food insecurity in hic conclusion the analysis of this data indicates that hic are not immune from experiencing moderate and severe food insecurity at the individual level individuals across all income education and age categories are affected but with prevalence of moderatesevere fi higher in those experiencing more disadvantage there were no statistically significant differences in per capita income between moderate and severely food insecure individuals meaning that income needs to be contextualised to the individual households living arrangements during the study period some countries experienced escalating while others demonstrated decreasing moderatesevere fi trends the complex sociopolitical drivers of these variable trajectories need further investigation fi severity in a hic context is highly sensitive to income this comparison of countries with similar economic and human development indices highlights an opportunity to investigate subtle variations in social economic and education policy that could have profound impacts on food insecurity abbreviations competing interests the authors declare no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready 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background due to the relatively low numbers of households in high income countries experiencing food insecurity most studies conflate the levels of severity which masks betweenand withincountry differences this study aims to describe the characteristics of individuals living in high income countries who were moderately or severely food insecure and investigates temporal trends in prevalence it assesses these characteristics in comparison to those who were food secure methods this is a secondary analysis of data collected by the fao voices of the hungry between 20142018 the data were collected during the annual gallup world polls of nationally representative samples using the food insecurity experience scale data from 34 highly developed wealthy countries were analysed the age gender income education area of residence and household structure of individuals experiencing moderatesevere food insecurity fi and severe fi were compared using anova welchs f pearsons chisquare and linearbylinear association dependent on the variable of interest hierarchical cluster analysis was used to group countries according to their prevalence of moderatesevere fi and severe fi results overall 65 of the weighted sample were moderatelyseverely food insecure msfi while 16 were severely food insecure msfi individuals were present in all 34 countries in all years and across all education levels and income quintiles the proportion of individuals experiencing moderatesevere fi varied between years and countries fifteen countries showed a significant downward temporal trend in prevalence of moderatesevere fi p 0001 while three countries demonstrated an increasing temporal trend driven by increasing prevalence in those aged 65 years or less p 0001 comparing individuals experiencing moderate versus severe fi showed overrepresentation of males single adult households and lower household income in the severe fi group conclusions individuals across all income education and age categories living in high income countries are experiencing moderatesevere food insecurity but with higher prevalence in those experiencing more disadvantage over the study period some countries experienced escalating while others demonstrated decreasing moderatesevere fi trends this comparison of countries with similar economic and human development indices highlights an opportunity to investigate subtle variations in social economic and education policy that could have profound impacts on food insecurity

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introduction it is well established that regular moderate physical activity such as walking has many health benefits but that most americans especially lowincome and ethnic minority groups do not meet the national recommendations of 150 minutes of moderate pa per week in line with an ecological perspective of health current theory and a growing body of literature indicate that environmental factors and perceptions may influence the decision to walk since most walking occurs outdoors in neighborhood streets environmental variables may be of particular relevance to walking versus other types of pa health promotion interventions are needed especially in african american and other minority communities which are at greater risk for physical inactivity and related illness understanding the environmental correlates of walking may inform health promotion interventions many of which focus on walking given its desirability ease and positive impact on chronic disease environmental approaches are particularly important for promoting physical activity in minority populations because they directly address barriers such as access and safety that are known to limit walking in addition the american heart association specifically recommends that interventions in minority populations assess and address environmental barriers to behavior change the purpose of the present study was to investigate the relationship of walking for pleasure with environmental variables consistent with an ecological framework safety access to places for walking access to services aesthetics and neighborhood satisfaction moreover because sex differences in environmental predictors of walking in underserved communities are not well understood this study examined sex as a moderator of the relationship between environmental perceptions and walking finally this study extends the current literature by targeting a lowincome ethnic minority sample a population known to be at greater risk for physical inactivity and related chronic disease theoretical framework conceptualizations of the influence of environment on walking have generally been broad and a lack of theorybased research has led to an abundance of descriptive data looking only at main effects of environmental factors indeed a range of variables have been studied with the most common being residential density sidewalk and street connectivity access to or convenience of places or facilities for walking safety from crime safety from traffic access to services or destinations aesthetics and composite indices of neighborhood quality other theoretical frameworks have been more specific in defining the relationship between environmental factors and walking in a key article saelens sallis frank emphasized the use of an ecological approach endorsing the use of measures of perceptions of the environment the inclusion of psychosocial and demographic variables and the examination of interactions between environmental and intrapersonal variables in empirical models alfonzo further built upon the ecological framework proposing a theory that might enable an understanding and testing of the complex relationship between the built environment and walking across different populations and settings alfonzo suggested that the individuals perception of the satisfaction of a walking need more proximally predicts walking than objective reality alfonzo also suggested that perceptions are shaped by intrapersonal characteristics such as sex furthermore needs may be satisfied on different levels simultaneously may be satisfied partially or foregone altogether before moving up the hierarchy and may be satisfied in variable order sociodemographic and psychosocial characteristics moderate satisfaction thresholds and how an individual relates to the hierarchy together these conceptualizations of environmental determinants of walking emphasize three important ideas access safety aesthetics and overall neighborhood quality are four key factors related to walking intrapersonal factors moderate the impact of environmental perceptions on walking and perceptions rather than objective measures of the environment influence behavior as such the present study focused on perceptions of access safety aesthetics and overall neighborhood satisfaction as predictors of walking and sex as a moderator of these relationships environmental perceptions and walking in lowincome minority communities while it is well established conceptually and empirically that both objective and subjective measures of the environment are related to walking attention to subjective measures is growing although geographical information system data enable estimates of walkability based on density pedestrian infrastructure and land use diversity these indicators miss the psychological experience of walking an important determinant subjective ratings provide a richer picture of what environmental features are most salient to pedestrians moreover ecological theory emphasizes an individuals phenomenological experience and thus places them more proximally to intrapersonal factors and behavior given the more proximal relationship to walking and intrapersonal determinants of walking perceptions of the environment may interact with psychosocial or demographic variables more directly than the objective environment to impact walking behavior likewise perceptions may be more relevant when examining sex differences in environmental impacts on walking perceptions of the environment may be particularly relevant for underserved individuals and the types of environmental factors that influence individuals in underserved communities may be unique for example lowincome ethnic minority communities tend to have similar accessibility than those of higher ses but residents perceive less access to places for walking ethnic minorities and low ses individuals tend to also have poorer perceptions of safety comfort and pleasurability these perceptions directly impact walking behavior both qualitative and quantitative studies have highlighted poor perceptions of safety access and aesthetics as barriers to walking in lowincome and minority individuals for example wilson et al found that for low but not high ses individuals having access to walking trails predicted walking for 150 minutes per week likewise scott et al found that african american but not caucasian participants perception of safety was the strongest correlate of recreational walking miles and colleagues had a similar finding when comparing a lowincome african american neighborhood to a middleincome african american neighborhood indeed in underserved communities with high rates of poverty and violent crime environmental perceptions may be especially important and may explain the health disparities that persist in these communities however the evidence base to date is still limited with few studies specifically investigating environmental perceptions as correlates of walking in minority communities sex as a moderator of perceptions of the environment and its influence on walking while previous research suggests that men and women have different perceptions of safety access aesthetics and the overall neighborhood environment it is not clear how these perceptions may impact walking differentially by sex or whether these results generalize to low income minority populations in general sex does seem to impact perceptions of safety and safety concerns are reported as more of a barrier to walking in women than men but their impact on walking is unclear for example some investigators have found that lower perceptions of safety were significantly associated with less walking in women however others have shown the opposite pattern of results results from previous studies also suggest that perceived accessibility to destinations is more important for women than men similarly kondo et al found that access to places for walking was related to walking for both men and women others have shown this variable is more important for women or more important for men previous authors also found that aesthetics are more important for walking for men than women finally bopp et al using a composite score of environmental factors similar to neighborhood satisfaction found that environmental perceptions predicted walking for african american men but not african american women overall few of the studies of sex differences in environmental perceptions have been conducted with underserved minority populations leaving a gap in the current literature in understanding sex differences in environmental perceptions and their impact on walking in this atrisk population in summary the present study expanded on previous research by using an ecological framework to investigate sex differences in the impact of perceptions of the environment on walking in an underserved african american population the focus was on walking for pleasure previous literature suggests that walking for different purposes may have different environmental correlates therefore it is expect that walking for pleasure may have unique environmental perception correlates as well the first aim was to determine if perceptions of access to places for walking access to services safety from crime aesthetics and overall neighborhood satisfaction influence walking for pleasure in lowincome highcrime communities the second aim was to determine if sex differences moderated these relationships methods procedure baseline measurements were conducted simultaneously at health screenings in local community centers in the three communities to control for extraneous environmental and historical variability the procedures were approved by the university of south carolina irb and all participants gave informed consent prior to data collection trained and certified measurement staff collected anthropometric data and health outcome measures administered a psychosocial questionnaire and supplied forms for the four week history interview the fwh interviews were conducted by phone participants received a 10 gift for participating in the screening and 15 for completing the fwh call measures dependent variable four week historythe four week history recall is an interviewer administered survey assessing leisure time pa patterns it has been previously validated and was adapted from the minnesota leisure time pa questionnaire participants provide data on the number of times per week for the past four weeks and the average duration per occasion for several different physical activities this study focused on the walking for pleasure data these items were focused on walking for pleasure only and explicitly excluded transportation or other types of walking using the compendium for physical activities we found the metabolic equivalent intensity level for walking for pleasure the met is a standardized intensity estimate defined as the ratio of work metabolic rate to resting metabolic rate activities estimated as less than 3 mets are defined as light pa 36 mets as moderate pa and greater than 6 mets we then calculated estimates of intensity by frequency for walking this type of pa estimate is commonly used in the pa literature independent variables neighborhood environment walkability scaleseveral subscales from the neighborhood environment walkability scale were used to assess perceptions of the neighborhood environment the news has been previously validated as a multifactor scale and for use in ethnically diverse urban populations the news demonstrates acceptable testretest reliability and internal consistency similar to that reported below for the included subscales participants responded on a fourpoint likerttype scale ranging from strongly disagree to strongly agree except the neighborhood satisfaction subscale for which response options ranged from strongly dissatisfied to strongly satisfied on a fivepoint likerttype scale for all subscales items were coded so that higher scores reflected a more positive perception of the environment perceptions of safety from crime the news subscale h was used to assess perceptions of crime and neighborhood characteristics related to crime this is a six item scale and example items are my neighborhood streets have good lighting at night and there is a high crime rate in my neighborhood one item i see and speak to other people when i am walking in my neighborhood was dropped from the scale to improve reliability the remaining five items had an α 71 perceptions of access to places for walking the news subscale e assessed perceptions of places and the quality of those places for walking and cycling this is a five item scale and example items are there are sidewalks on most of the streets in my neighborhood and there are bicycle or walking trails in or near my neighborhood that are easy to get to perceptions of access to services three of the seven items from the news subscale c assessed perceptions of access to local places providing services such as shopping and transit the subscale was modified to more closely match key intervention elements and concerns most relevant to the communities the item related to parking for example was omitted based on the interventions focus on walking likewise items related to hills were omitted because the terrain in these suburban areas was flat one item it is easy to walk to a transit stop from my home was dropped to improve reliability the remaining two items stores are within easy walking distance of my home and there are many places to go within easy walking distance of my home had acceptable reliability perceptions of aesthetics three of the six items from the news subscale f assessed perceptions of neighborhood surroundings regarding trees and litter again the subscale was modified given the focus of the intervention on walking on neighborhood streets and sidewalks the items assessing more general aesthetic qualities were omitted and items related specifically to streets and sidewalks were used because it was a concern in all three communities one item related to litter my neighborhood is generally free from litter was also used however this item was omitted before statistical analyses to improve reliability the remaining two items there are trees along the streets in my neighborhood and trees give shade for the sidewalks in my neighborhood demonstrated good internal consistency neighborhood satisfaction the seventeen item news subscale i was used to assess satisfaction with the neighborhood in general these items included satisfaction with safety from crime access to places for pa access to services aesthetics as well as domains not measured separately such as social connectedness the scale demonstrated good reliability example items are how satisfied are you with the safety from threat of crime in your neighborhood and how satisfied are you with how easy and pleasant it is to walk in your neighborhood covariatesthe measures included in this study were body mass index and selfreported demographic variables sex age income education employment status and marital status statistical analyses analyses were conducted to test for sex differences on all demographic and baseline variables using independent ttests and chisquare tests it should be noted that the distribution of men and women was similar across the three communities 203 p 36 therefore the sex differences do not likely reflect community differences correlations of all variables were conducted to look for multicollinearity among variables logistic and ordinary least squares regressions were used to estimate the relationships between daily walking levels and perceptions of the environment missing data were handled by listwise deletion because the distribution of daily walking had a positively skewed distribution typical to count data a square root transformation was conducted to control for community of residence community was dummy coded and these two variables were included as covariates in the regression model bmi and income were included as covariates because previous studies and the current study indicate they are correlates of walking and interaction terms were included to test for sex differences income an ordinal variable was treated as a continuous variable given preceding analysis showing good model fit for income when categorized in this way and given that the variable was normally distributed and unlikely to significantly impact parameter estimates the environmental perception variables were centered before being entered into the models in the final model demographic covariates were entered in the first step to control for the variance associated with bmi and income before looking at the predictors of interest next sex and environmental perception variables the key variables of interest were entered in the second step within alfonzos theoretical framework the environmental variables contribute over and above feasibility but no specific order can be assumed for any individual or group therefore they were entered simultaneously into the model finally interaction terms were entered in the third step to test for a moderation effect by sex the assumptions of regression were tested and none were violated results participant characteristics demographic perception and pa data are presented in table 1 participants were 195 women and 95 men were mostly nonworking had a high school diploma or less and were making less than 25000 per year the majority were overweight or obese with 54 the sample exceeding bmi of 300 kgm 2 women had a significantly higher bmi than men and there were significantly fewer women than men with an income greater than 25000 perceptions of the neighborhood environment and walking by sex measures from the news confirm that women and men perceive the aspects of the environment differently on average women had significantly lower scores on neighborhood safety 245 p015 aesthetics 218 p030 and neighborhood satisfaction 202 p045 than men in contrast there were no significant differences between the womens and mens perceptions of access to walking places or access to services there were no sex differences in selfreported walking zeroorder correlations correlations between walking demographics and environmental perceptions are presented separately by sex in table 2 for men only bmi was negatively correlated with walking for pleasure 21 p 05 no environmental variables were correlated with walking for pleasure for women walking for pleasure was correlated with income 18 p 05 perceptions of access to places for walking 19 p 05 and perceptions of access to services 16 p 05 age education and employment were not correlated with walking for pleasure and were therefore dropped from subsequent regression models also of interest is the significant correlation between perceptions of safety from crime and neighborhood satisfaction for men 56 p 05 and women 36 p 05 neighborhood satisfaction was also associated with perceptions of access to places for walking similarly for men 21 p 05 and women 21 p 05 moderate correlations ranging from 28 to 47 were also observed across sex between perceptions of aesthetics and both perceptions of access to places for walking and access to services effects of environmental perceptions and sex on walking table 3 presents results of a hierarchical regression analysis for predicting fwh of walking for pleasure after controlling for covariates there was a main effect for perceptions of access to places for walking in model 2 perceptions of access were significantly related to daily walking levels accounting for 14 of the variance in daily walking levels sex and the other perception variables did not significantly contribute to the variance in the dependent variable overall model 2 accounted for 75 of the variance in daily walking levels r 2 075 f 209 p 05 after controlling for the effects of demographic variables and main effects of the perception variables there was a significant neighborhood satisfaction by sex interaction in model 3 the sex by neighborhood satisfaction interaction was such that the relationship between neighborhood satisfaction and walking for men was positive and the relationship between neighborhood satisfaction and walking for women was negative it should be noted that this relationship between neighborhood satisfaction and walking was not observed at the zeroorder level thus influence of neighborhood satisfaction on walking was observed holding constant the direct effects of bmi income community sex and environmental perceptions in other words sex moderated the effects of neighborhood satisfaction on walking over and above the effects of demographic variables and the perception variables overall model 3 accounted for 111 of the variance in daily walking for pleasure r 2 0111 f212 p 05 discussion this study builds on previous research by expanding our understanding of potential barriers to walking for underserved highcrime populations and by highlighting the differences between lowincome ethnic minority men and women in perceptions of the physical and social environment and their differential impact on walking the results indicated that women not only perceive their neighborhoods as less safe and less aesthetically pleasing than men they are also less satisfied with their neighborhoods overall than men furthermore after controlling for bmi income and community perceptions of access to places for pa predicted walking for both men and women and accounted for 14 of the variance in daily walking levels while this is a relatively small proportion of variance these results are in line with previous reported research others also note that although their direct influence on walking is smaller than psychosocial factors environmental factors can influence use of facilities for pa and thus contribute meaningfully to walking outcomes furthermore the small proportions of variance in walking accounted for by physical and social environmental variables can be substantial on a populationwide scale since environmental changes can complement interventions targeting individual psychosocial variables after controlling for demographics and environmental perceptions a sex by neighborhood satisfaction interaction was significantly related to walking this interaction suggested that over and above the effects of bmi income and specific environmental perceptions sex moderated the relationship between overall neighborhood satisfaction and walking for pleasure specifically among women walking for pleasure decreased with increased satisfaction while among men walking for pleasure increased with increased satisfaction previous studies have found that composite neighborhood ratings are related to walking and few have looked at gender differences in neighborhood satisfaction thus this finding adds to the literature by suggesting that overall satisfaction with the neighborhood may relate to more walking only in men however given that these data are crosssectional it could be that women who walk more have poorer overall perceptions of their neighborhoods but men who walk more have better overall perceptions of their neighborhoods perceptions of safety and aesthetics have been linked to neighborhood satisfaction and neighborhood satisfaction was correlated with the perception variables in this study moreover women in the current study had significantly poorer perceptions of safety and aesthetics than men neighborhood satisfaction also captures aspects of the social environment which tend to affect walking in underserved women it may be then that walking for women may increase awareness of the neighborhood and worsen their negative perceptions especially of safety from crime and aesthetics compared to men especially in underserved communities as such interventions targeting walking in underserved communities may benefit from social marketing or other methods for addressing womens concerns about the social environment of the neighborhood considering the highcrime rates in these communities it is interesting that perceptions of safety did not predict walking this finding is consistent with previous literature which generally suggests that the effects of safety on walking is mixed the nonsignificant result could be due to the restriction of range in perceptions of safety from crime given the homogeneity of the sample the perceptions of safety from crime in the current study were lower on average than other studies using the news in lowincome samples overall this study is in line with current theory suggesting that access to places for pa is a fundamental environmental determinant of walking and a growing body of research supporting that physical environments that provide access to places for physical activity are positively associated with walking much research has indicated specifically that sidewalks support walking given that most walking occurs in neighborhood streets and public facilities fostering accessibility to and awareness of sidewalks and trails for walking may be especially valuable especially in underserved communities on the other hand targeting perceptions of safety and aesthetics may be less beneficial unless the more fundamental psychological need of perceived access to walking places is met future research should also address this studys limitations these data are crosssectional therefore it is possible that walking changes perceptions of ones environment rather than perceptions causing walking the use of selfreport pa data and the exclusion of instrumental walking measures may have impacted our findings future research would benefit from objective pa measures and more comprehensive selfreport pa measures that assess both instrumental and pleasure walking while they were not completely redundant the neighborhood satisfaction scale correlated moderately with the safety subscale and the access to places for walking subscale therefore the results should be interpreted in light of this multicollinearity treatment status and community overlap in this study and mixedmodel analyses estimating random effects for community cannot be included in these analyses therefore inferences drawn from this study are limited to the difference between the communities participating in this trial finally we used perception of the physical environment rather than objective environmental measures however lowincome minority communities tend to have similar resources but perceive less accessibility to places for pa so perceptions may be particularly relevant to measure in these groups it should also be noted that we did not control for clustering effects given the small number of communities involved in this project walking is an important form of exercise for meeting pa recommendations because it can be free easy accessible and a pa behavior that is easy to change understanding environmental correlates for walking has the potential to inform interventions to increase pa that are relevant to underserved men and women in the present study women tended to perceive their neighborhoods as less safe and aesthetic and were less satisfied with their neighborhoods for women the relationship between neighborhood satisfaction and walking was negative however a main effect for access to places for walking suggested that walking for pleasure is important for both women and men despite sex differences in perceptions of safety and aesthetics interventions to simultaneously build accessibility to places for walking and address social environmental concerns of women may be especially valuable in lowincome minority communities

research indicates that people from low socioeconomic and ethnic minority backgrounds disproportionately fail to meet the weekly national recommendations for physical activity perceptions of environmental factors may be significant barriers to walking in communities experiencing high rates of crime and poverty and may impact women and men differently the present study investigated sex differences in the impact of perceptions of the environment and overall neighborhood quality on walking in an underserved population participants were 195 african american women and 95 african american men baseline data indicated that women reported greater concerns about safety poorer perceptions of aesthetics and lower neighborhood satisfaction than men regression analyses showed that perceptions of access to places for walking significantly predicted walking for both women and men and that sex moderated the effect of neighborhood satisfaction these results suggest that interventions focused on building accessibility to places for walking while also addressing social environmental concerns are needed in high crime communities

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introduction the utilization of health services represents the center of health systems operation comprising every direct or indirect contact with the services being considered the result of the interaction between the individual who is seeking care and the professional who will perform it and guide the patient within the system 1 it is also considered a complex health behavior determined by a wide variety of factors predisposing or restricting the use of these services by users 23 access to and use of dental services are considered essential factors for prevention and management of oral diseases 4 and it has been demonstrated that regular use of these services results in less tooth loss and dental caries 5 on the other hand obtaining access to dental care is often challenging this situation represents a public health problem in countries where the use of dental services is observed to be unequal among different social and demographic groups 46 childhood and adolescence are particularly relevant times for studying the use of oral health services in a way the ages of growth reflect the family context in the search for such services 7 thus understanding the use of dental services by children becomes even more complex as it reflects the interaction between psychosocial material cultural and behavioral factors as well as the perception of the individual or of their parentsguardians about their health condition and the need for care 89 among the psychosocial factors that may influence the use of dental services the sense of coherence has been shown to be a protective factor for the adoption of more favorable oral health behaviors 10 soc is the basis of the salutogenic theory developed by antonovsky which measures the individuals ability to deal with adverse situations without influencing hisher quality of life 11 the soc is composed of the following attributes understandability manageability and meaningfulness that is an individuals soc shows the degree to which heshe sees life as comprehensive manageable and meaningful 12 according to the salutogenic model it is important for people to focus on their resources and their ability to generate health rather than on the causes of their illness a stronger soc leads a person to perceive the environment as less stressful disruptive and chaotic it also facilitates the selection of more effective health behaviors 13 several studies that have worked with soc have shown that people with lower levels of education low income and weak soc tend to take their children to dental care less frequently 14 on the other hand parents or caregivers with a strong soc showed association with higher frequency and more favorable dental services utilization pattern reflecting directly in the oral health of their children 1516 such findings show that the level of parentguardian soc can be considered an important psychosocial determinant of childrens oral health status and practices 1017 added to this is the fact that children are dependent on their parents to have good general and oral health which points to the relevance of considering not only individual factors but also the psychological and sociodemographic factors of parentscaregivers in order to ensure comprehensive health in childhood therefore the aim of this study was to evaluate the association between soc of parentsguardians and the use of dental services by 12yearold children in the city of manausam materials and methods study design and population as part of a larger research project entitled socioenvironmental determinants clinical oral conditions healthrelated behaviors and psychosocial factors psychosocial factors of quality of life in children a longitudinal study the present study was a crosssectional conducted in the eastern zone of the city of manaus between september and december 2016 with 12yearold schoolage children and their parents andor guardians the eastern zone which is composed of 11 neighborhoods is the second most populous zone of the city characterized by being a socially deprived urban area children enrolled in the municipal public school network who were 12 years old at the initial research period were included in the study and those using orthodontic appliances and those with any syndrome andor requiring special care were excluded a representative sample of 12yearold children enrolled in the 7th grade in municipal public schools was then selected by stratified random sampling according to the size of the school population in the 11 neighborhoods of eastern manaus thus 25 schools were randomly selected proportionally to the number of schools per neighborhood the sample size was estimated at 528 children of these 86 did not return the consent form or their parents did not agree with their participation of the remaining 442 adolescents 27 were excluded due to the use of orthodontic appliances pilot study and instrument reliability prior to the main study a pilot study was carried out involving parentsguardians of 10 schoolchildren children who were not selected for the main study sample parents guardians were interviewed to verify the understanding of the questionnaire items on the sense of coherence data collection data collection was performed using selfadministered questionnaires sent to parents andor guardians containing questions about socioeconomic characteristics use of dental services and soc the socioeconomic characteristics included questions to the parents andor guardians about number of people in the household number of rooms in the house number of assets family income regarding the use of dental services we asked whether the child had dental insurance how many times they had visited the dentist during their life how long it had been since their last visit and for what reasons their parentsguardians had taken them to the dentist the soc of parentsguardians was measured using the antonovskys soc13 scale crossculturally adapted for the portuguese language 18 each question has five response options that follow a likerttype psychometric pattern always from the worst to the best condition the scores of the questions that are negative to the sense of coherence were inverted for the final composition of the scale score the minimum value of the scale is 13 and the maximum 65 18 the higher the sum of the items the higher the sense of coherence data analysis the data were analyzed by descriptive analysis including the distribution of variables by medians means and standard deviations the chisquare test was performed with a significance level of 5 to evaluate the association between the dependent variable and the independent variable all analyses were performed in spss version 220 software ethical aspects the study project was submitted to the municipal education secretary of the city of manaus and to the research ethics committee of the federal university of amazonas all eligible students including their parents signed the free and informed consent form and the minors consent form results the final sample consisted of 358 children due to the exclusion of 57 of them for lack of complete data in the questionnaire of these 149 children were male and 209 were female of the parentsguardians 754 declared themselves as brown 131 as white 59 as black 42 as indigenous and 14 as yellow regarding the number of years of schooling most parentscaregivers declared to have eight to eleven years of schooling equivalent to complete elementary school and complete high school most of the population studied had a family income of ½ to 1 minimum wage which at the time of data collection was brl 44100 to brl 88000 children with their respective parentsguardians lived predominantly in households with less than two residents per room and on average each family owned 662 assets in the household braz j oral sci 202322e230302 regarding the use of dental services by children 461 of parentsguardians said they took their children to the dental office less than 1 year ago and 159 answered that the children never had a dental appointment it was also evidenced that the main reasons for the last visit were revisionprevention followed by treatment and pain or extraction the public service was the most used and 894 of the children had no dental care plan when asked why the child had never been to the cd or had not been in the last year 81 answered there was no need on the other hand 68 children needed it were referred to the dental office but did not attended braz j oral sci 202322e230302 table 3 presents the chisquare test to analyze the association between the soc of parentsguardians categorized into weak soc and strong soc and the utilization of dental services no significant difference was found between strong and weak soc regarding the frequency in the use of dental services both groups showed a higher frequency for using dental services for less than 1 year followed by 1 to 2 years and 3 years or more similarly no significant difference was found between soc and the reason for the last dental visit discussion the present study investigated the possible role of parentguardian soc and the use of dental services by 12yearold children in the city of manausam the results showed that the frequency of use of dental services by children as well as their pattern of use showed no significant association with the soc score of parentsguardians in families with low socioeconomic status such results indicate that not all child oral healthrelated behaviors are related to parentsguardians soc corroborating the findings of qiu et al 19 and differing from those found in national studies 14 15 16 comparable results were also found in studies with adults 20 and adolescents 21 the reason for soc not being associated with all oral healthrelated behaviors has not yet been clarified a possible explanation for this would be that childrens oral health behaviors are mainly influenced by the oral health behaviors of parentsguardians and not necessarily by their soc or the analysis used was not able to detect the differences the mean score obtained by the responses of parentsguardians on the soc 13 scale was 4627 a mean similar to the studies of bonanato et al 17 14 which obtained 4750 and 472 points respectively the total score in the study ranged from 22 to 62 points similar to the study of bonanato et al 17 a significant percentage of children participating in this study used the dental service at least once in their lives and about 16 had never been to the dentist findings that are relatively lower than those reported by da silva et al 22 and those presented in the last national survey on oral health 23 which may express the increased access to and use of dental services by children as also identified in a previous study 24 the frequency of use of dental services proved to be regular since more than half of the children had an appointed with the dentist within 2 years despite this the use of dental services among children was more related to treatment than to prevention suggesting a need for change in the work process of oral health teams especially regarding the expansion of prevention and health education for a model of integral care to child and adolescent health 7 another worrying fact is the nonuse of dental services represented by children who sought care but were not seen this suggests failures in the organization of the local health system on the other hand a recent study conducted in brazil showed an association between greater coverage of oral health teams in the family health strategy greater use of dental services in the public network and the use of services for treatment by 12yearold children revealing the influence that contextual factors have on individual choices 7 in addition a very small proportion of children had dental insurance indicating that these families rely exclusively on the public system to ensure basic oral health care for their children this is particularly relevant for the use of dental services since brazilian individuals with private health insurance tend to use more dental services than those who do not have health insurance 25 these aspects are paramount to address inequalities in the use of dental services by underprivileged children 15 thus it is evident that considering the soc in isolation may not be enough to clarify the use of dental services in view of other factors that are involved in the complexity of the behavior or attitude of using or not using such services some limitations of the present study should be considered the crosssectional study design restricts the causal relationships between the variables it should also be recognized that the use of selfcompleted questionnaires may result in measurement bias to some extent however the use of validated questionnaires for the brazilian population potentially reduces reporting error finally only 12yearold children residing in socially disadvantaged areas were investigated therefore our findings should not be attributed to other age groups and children of other socioeconomic levels conclusion the results showed that the soc of parentsguardians and the use of dental services both in terms of frequency and pattern of use were not correlated suggesting that the soc of parentsguardians analyzed in isolation cannot explain the use of dental services for children data availability datasets related to this article will be available upon request to the corresponding author author contribution jmrv and mabr designed the study acg lnq vcs contributed to data collection and analysis acg vcs wrote the first draft of the article all authors read and approved the final manuscript and actively actively participated in the discussion of the manuscripts findings

the aim of this study was to evaluate the association between the sense of coherence soc of parentsguardians and the use of dental services by children who are 12 years old methods this is a crosssectional study conducted in the eastern zone of the city of manaus with 358 children enrolled in the 7th grade in the municipal public school system data collection was performed through selfadministered questionnaires sent to parentsguardians which contained questions about socioeconomic conditions use of dental services by children and antonovskys soc13 scale data were examined by descriptive and bivariate analysis using the chisquare test with a 5 significance level results of the 358 children 584 were female in addition 754 of the parentsguardians selfreported to be brown and 399 of them had a family income of ½ to 1 minimum wage soc was categorized as strong soc and weak soc by the median the association between strong or weak soc and the use of dental services in terms of frequency p 0839 and reason for last visit p 0384 was not significant conclusion it was concluded that soc of parentsguardians and utilization of dental services by children were not associated

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introduction adolescents constitute about 7 of the total number of individuals with hiv in nigeria 1 and young women are disproportionately affected by hiv compared to their male counterparts 2 hiv incidence per 1000 uninfected populations among male adolescents aged 1019 years was 053 compared to 13 among females 3 also females aged 2024 years had nearly four times the prevalence of hiv compared with males of the same age group 4 the drivers of the hiv epidemic among adolescents and young people in nigeria include low personal risk perception multiple concurrent sexual partnerships and transactional and intergenerational sex 256 entrenched gender inequalities and inequities chronic and debilitating poverty and persistence of hiv and aidsrelated stigma and discrimination also significantly contribute to the spread of the infection 2 the complex nature of the determinants of hiv among adolescent girls and young women requires intervention approaches that have a clear understanding of the diseases epidemiology despite the myriad programs and agencies offering hivrelated interventions in the country the level of knowledge of the infection among young people their uptake of counselling and testing services and access to other prevention and care services remain inadequate 7 some national programs developed specifically for young people include the family life hivaids education curriculum for junior secondary school in nigeria an abstinenceonly curriculum 89 and the national youth service corps peer education program for inschool youth 10 some of the gaps in these programs are that the young people were not adequately involved in developing implementing and evaluating the programs 7 ordinarily interventions that address the determinants of hiv infection among agyw ought to be grounded in the context of their vulnerabilities to hiv while proffering accessible and acceptable solutions with their participation the action research methodology can help in the development of such contextual interventions it offers a platform that allows young persons and other stakeholders to jointly identify a relevant problem act together to solve it cooperatively review to assess their efforts success and attempt other solutions if the present one was unsatisfactory 11 reason and bradbury 12 define action research as participatory democratic process concerned with developing practical knowing in the pursuit of worthwhile human purposes grounded in a participatory worldview it requires an active and iterative collaboration of researchers and participants in its design implementation and evaluation it offers an opportunity to develop tailored innovative and adaptive hiv prevention solutions for those affected by the problem action research has been used in different contexts in nigeria in a study among rural youths in nigeria action research was used to target the youths and their communities with hiv prevention programming that addressed the gendered nature of hiv vulnerability 13 the researchers focused on developing communities hivaids competence and schoolbased hiv interventions to improve a schoolbased sexual and reproductive health program fakoya et al 14 reported on the a360 intervention which integrated a humancentered design and youthled participatory action research as an innovative and replicable approach to reducing unmet need for contraception among adolescents and young people the four phases of the intervention included youthengaged formative research collaborative analysis to generate themes to inform intervention design prototyping of interventions and adaptive implementation important lessons from this study for using action research in global health research included forming transdisciplinary teams centering empathy by using methodologies that amplify the voice of participants eg qualitative data collection purposive selection of participants rapid prototyping of solutions and having tangible services or products action research intervention involves cycles of dialogue and action among stakeholders in the area of interest and it is a valuable approach for quality improvement in health programming complex persistent or unstructured problems cannot be tackled effectively by the more traditional research approaches that do not adequately address the problems underlying social political economic cultural and ethical aspects 15 the breakthrough series collaborative lends itself to the ideals of action research 16 17 breakthrough series is a learning collaborative approach that utilizes a quality improvement method designed to enable participating teams to make dramatic improvements in a focused practice topic over a short period 17 it is an improvement approach that relies on spreading and adapting existing knowledge to multiple settings simultaneously 18 the bts collaborative methodology was developed in 1995 by the institute for healthcare improvement and associates in process improvement 17 the bts collaborative allows researchers and potential research beneficiaries to use existing and available interventions to build custommade solutions to identify local problemschallenges test the solutions on a small scale and rapidly assess their viability the rapidity of the bts collaborative methodology allows for the development of several solutions while testing them on a small scale to identify the one with the most significant potential for success at scale more so learning collaborative is not intended to create an entirely new body of knowledge but provide what might be the missing link between best practice and actual practice 19 the method has been used extensively in health care delivery in highincome societies and much less so in low and middleincome settings 2021 the bts collaborative approach has been implemented in nigeria but mostly in clinical settings for example it was used for providing a sustainable framework for the role of community health workers in promoting retention in hiv care 22 improving prevention of mother to child transmission of hiv 2324 and improving childhood immunization rate 25 combination prevention is the recommended approach for comprehensive prevention of hiv according to the unaids prevention reference group 26 combination hiv prevention is defined as the strategic simultaneous use of different classes of prevention activities that operate on multiple levels to respond to the specific needs of particular audiences and modes of hiv transmission and to make efficient use of resources through prioritizing partnership and engagement of affected communities the nigerian national hivaids prevention plan 20102012 27 introduced the combination prevention approach as minimum prevention package of interventions to scaleup evidencebased programming using targeted interventions and standardized intervention packages at scale strategies under the behavioral components include outreach peer education and condom and lubricant programming strategies under the biochemical component include hiv counseling and testing prevention of mothertochild transmission and sexually transmitted infection control and treatment the structural component includes community mobilization and dialogue advocacy and individual empowerment incomegenerating activities the aim of this study was to use an innovative collaborative approach to develop a minimum hiv prevention package for agyw which is responsive to sociocultural settings and based on combination hiv prevention the country is still in the process of developing a scalable guide for the implementation of communitybased hiv programs focused on ayp in nigeria the package of care put forth in the nigerian npp 20102012 and the mppi are generic while the prevention package we present in this study are adaptive and contextualized this paper describes the intervention component and outcomes of the action research used to develop the package of prevention conceptual framework to provide a conceptualization for how multilevel interventions reduce hiv incidence the mechanisms at play and the implementation outcomes assessed in our study we adopted the conceptual framework used by chimbindi et al 28 in their intervention to reduce hiv incidence among agyw in south africa fig 1 include increased access to hiv and srh services and reduction in risky sexual behaviors ultimately these lead to reduction in hiv incidence our study provides insight into how the adolescent hiv response within the country based on the combination prevention can be particularized at subcountry levels methods and materials study design the institute of public health obafemi awolowo university nigeria collaborated with the society for family health a national nongovernmental organization to develop and implement the action research to reduce hiv vulnerability among agyw in nigeria from 2016 to 2017 this research has a mixedmethod design involving quantitative and qualitative data collection methods we carried out the study in akwaibom kaduna oyo states and the federal capital territory these states are located in different geopolitical zones hence represent the multicultural nature of the country we purposively selected two local government areas as implementation sites and one as the control site in each study location the selection of the states was based on states that had the highest hiv prevalence amongst the target population within their zones updated national survey shows that akwa ibom state has the highest hiv prevalence among persons aged 1549 years in the country at 56 this was 13 in the fct abuja 09 in kaduna and 08 in oyo 29 the selection of lgas in which interventions were implemented was based on the estimated youth population of the lgas and the absence of any youthfocused hiv prevention interventions in the area at the time of our intervention implementation approach the bts collaborative methodology drove the approach taken in this action research our bts collaborative objective was to develop a comprehensive change package we defined a change package as a collectioncombination of innovative interventions that have been tested on a small scale and found to give the desired change therefore having a good prospect for scaleup secondly the developed change package must align with the combination hiv prevention model the basis for mppi with behavioral biomedical and structural components on small scales we tested the potential intervention models to be included in the change package using the plandostudyact cycle desired change was contextual for each change idea implemented and was evaluated using the decision rule for implemented change ideas bts collaborative management learning session we developed intervention models by selecting problematic situationsissues derived from an objective assessment of the intervention target population this objective assessment was a baseline survey that identified vulnerability factors to hiv among agyw the findings from this baseline survey are published elsewhere 5 the problematic situations identified were called change topics the state bts teams worked with each of their local bts teams to explore the contextual factors unique to the change topics identified in each study location in a series of twoday meetings called learning sessions we developed a prioritization matrix for deciding on the change topics for which to focus intervention the prioritization matrix allowed for scoring each change topic on the prevalence of the change topic perceived public health importance ease of intervening and time interval to achieve results if there was an intervention scoring of the change topics using the prioritization matrix was conducted during the learning sessions by the local bts teams the two highestscoring change topics were selected to be intervened on at the study lgas each time during two rounds of intervention during the learning sessions also appropriate intervention models were developed to address the prioritized change topics by the state and the lga teams we held three sets of learning sessions in all separately in each study state the first set of learning sessions across the study locations were strictly for selecting the change topics for intervention and planning the interventions to deploy in the second learning session we reviewed interventions implemented so far and planned new change ideas the last learning session was for reviewing the whole implementation process using the monitoring and evaluation reports from each of the interventions implemented the first learning session was held in each intervention lga while the remaining two sessions were held at the state level to allow for crosspollination of ideas between the lga teams within a state members of the national bts team participated in the statelevel learning session to provide guidance and oversight the national bts team also held two nationallevel review meetings in the course of the project to which some members of the state and local bts teams were invited to participate learning sessions provided fora for sharing knowledge discussing methodology and planning action periods the learning sessions corresponded to the plan and act phases of the pdsa cycle during the learning sessions planning for the implementation of interventions is done during subsequent learning sessions the act phase of the pdsa cycle was included which entailed deciding whether to abandon test under different conditions adapt or adopt for this the bts teams used the decision rule in table 3 below change ideas scored 0 were abandoned while those scored 1 or 2 were adapted or tested under different conditions in the subsequent action period those scored 3 were adopted into the change package action period the action period was the time during which change ideas were implemented this study had two action periods the first period lasted for three months and the second lasted for two months the two were implemented between may and september 2017 action periods corresponded to the do and study phases of the pdsa cycle new change ideas were started or previously successful ones were continued or adoptedadapted from another location at the subsequent action period 1617 the study phase was each change ideas monitoring and evaluation component that captured data based on interventionspecific indicators developed during the planning phase for instance the indicators included uptake of services such as hiv testing service and condoms among those reached with the interventions teams identified the successes and challenges they experienced while implementing the change ideas and shared them at the subsequent learning session to enhance knowledge for the entire group local communitybased organizations were engaged in the implementation of some the change ideas for example they provided the youth facilitators for the facilitatordriven interventions cbos were engaged according to the need in each study site and the research provided sitespecific training and support as was necessary for the cbos that were engaged the change ideas each study location had its set of customized interventions that addressed specific vulnerability to hiv our assessment showed that the change ideas that had reasonable success could be grouped into five classes parental communication peer to peer youth facilitatordriven nontraditional outlets for condoms and social mediabased interventions each of the interventions developed was given names unique names by the respective bts teams nontraditional outlets for condom distribution traditionally condoms are accessed from pharmacies drug stores health facilities or similar places these places often present barriers to accessing condoms for agyw because of stigma shyness and cost this study explored some nontraditional outlets for condoms with some success such as betting shops football viewing centres and barbinghairdressing salons there were two such interventions in akwa ibom state in one condoms were stationed in selected publicly assessed locations the second one had condoms placed with selected young persons who could distribute them freely to their peers on request in kaduna the condom for us intervention incorporated some peerdirected condom distribution in fct abuja the peertopeer distribution of condoms was a flagship nontraditional condom outlet intervention also in fct abuja the social to health and stihts outreach interventions incorporated some peerdirected condom distribution social mediabased interventions this was carried out in akwa ibom and oyo state only specifically whatsapp groups were formed to engage agyw and those engaged were tasked to recruit other agyw to join the groups online meetings were carried on during which a facilitator creates conversation and passes across srh and hiv messages however this approach was only marginally influential in the higher socioeconomic areas where the agyw were more likely to afford internet access due to the low output in young people joining the groups the approach was abandoned after initial testing assessment of exposure to and uptake of the interventions household survey a quantitative household survey was conducted as part of the evaluation of this action research we used a standard normal deviate at 95 confidence level of 196 a precision margin of 5 a design effect of 15 and an estimate of true proportion of 27 to determine a minimum sample size of 302 we adjusted this minimum size for nonresponse to 360 and applied this sample at the lga level to allow robust data interpretation at the local government level the total sample size was 4308 a multistage sampling technique was employed to sample participants at enumeration area and at household levels respondents were asked if they had been exposed to any sexual and reproductive health intervention in the past six months the persons who introduced the intervention what services were introduced and what services they took up due to the exposure the instruments were pretested in a different population to refine the tools and adapt to the target populations realities without losing the contents validity the action research design we adopted did not fit a prepost assessment type of evaluation because the specific interventions implemented were designed as the study progressed in this study we only report data collected at the end of the intervention the specific outcomes of interest were if the respondents were reached with an hiv prevention intervention in the past six months what type of hiv prevention intervention it was who reached them with the intervention and if they took up the intervention only these outcomes are reported in this current study the study instruments were intervieweradministered using trained data collectors the data collectors were trained to describe the local intervention implemented in the different study locations to reduce misclassification bias focus group discussion indepth and key informant interviews in each lga studied agyw were recruited purposively to participate in the fgds also interviews were held with selected community gatekeepers health workers and hiv focal persons we designed appropriate study guides for the data collection all discussions and interviews were taperecorded transcribed and translated into english recruitment of research participants before commencement of the household survey we conducted advocacy visits with community leaders at the selected study locations to gain entry for each study lga a computerassisted simple random selection of 30 enumeration areas was made from a list of all eas in the lga a household listing exercise was done in each selected ea to generate a sampling frame of all eligible households eligible respondents were selected from households randomly selected from a household listing exercises for the qualitative research participants eligible respondents were purposively selected based on the various categories of participants in each lga five groups of participants were recruited purposively for fgd sessions including adolescent girls young women and young men aygw identified to be at higher risk of contracting hiv due to identified risk practices and a group of adult men 30 years or older each fgd session had 810 participants the research participants included both those were exposed and not exposed to the interventions we carried out indepth interviews were held with purposively selected community gate keepersinfluencers including at least one religious leader traditional leader youth leader media practitioner secondary school teacher in each study lga in addition four parents of ayp were interviewed key informant interviews were held with selected officials including officers from the primary healthcare department women affairs program hiv program and nonprofit organizations involved with ayp all fgd and idi participants received transportation reimbursement of ₦1000 each key informants were not reimbursed because interviews took place in their various offices data analysis quantitative data we conducted tests of the equality of proportions comparing the interventions uptake among respondents in the intervention and control lgas all relevant data are within the manuscript and its supporting information files qualitative data we developed codes from an initial run of a few transcripts these were refined in a group session and shared among coders who subsequently coded all transcripts from the fgds idi and kiis applying thematic content analysis a generic codebook was used across all transcripts four coders used the atlasti 8 software for organizing the codes and the units of meaning or concepts they represented the codes were organized into themes and subthemes coding discrepancies were resolved during plenary meetings and final decision when discrepancies remained was made by the lead qualitative researcher on the project this study reports aspects of the qualitative data relevant to understanding the interventions dynamics and perceived impact we viewed acceptability of the interventions as the extent to which our target population considered them appropriate based on their cognitive and emotional responses to the interventions 30 on the other hand we viewed accessibility of the interventions as the relative ease the interventions could be reached in a given location including the suitability of location confidentialityanonymity and cost of services 3132 ethical approval ethical approval was obtained for this study from the national health and research ethics committee of the federal ministry of health nigeria with approval number nhrec0101 200713092016 written informed consent was obtained from each study participant after an adequate explanation of the study objectives for participants younger than 18 years assent to participate in the study was obtained from them after obtaining written informed consent from their parents or guardians results to evaluate the reach and uptake of interventions in this study we interviewed females aged 15 to 24 years old in a household survey 4308 agyw were interviewed across the four study states we also conducted 53 fgds 22 idi and 18 kiis for the fgds 36 agyw were recruited in each lga and categorized into the following groups adolescent girls young women and young men we had a group of females identified as at higher risk of contracting hiv due to identified risk practices and their work nature such risk factors included those engaging in transactional sex and multiple partnering females whose occupations put them at risk including female hawkers around highrisk locations barmaids food vendors and domestic hands we also conducted fgds with mothers who had female children in the 1524year age group as well as men in the 3040year age group the latter were included because of the role this age group plays concerning girls and young womens vulnerability to hiv infection and stis we held indepth interviews with 22 selected traditional leaders religious leaders and youth leaders across the study states we also held key informant interviews with 18 health workers and focal persons from the lga primary health care department and the state ministry of health across the study states parental communication intervention in the intervention areas the proportion of agyw who indicated that their parents communicated with them on hivsrh in the past six months ranged from 232 to 406 compared to 39 to 189 in control lgas among all respondents in the intervention lgas hiv testing was the most frequently used service due to exposure to parental communication in comparison those who reported using hiv testing services following parental communication were fewer in control lgas and the difference in proportion was statistically significant at p 0001 the least used service following parental communication was family planning services all services assessed had a higher proportion of uptake in the intervention lga than the control lga and all the differences were statistically significant some of the participants of fgd sessions indicated ongoing discussions on reproductive health issues between mothers and their children in the intervention sites for instance a 21yearold young woman said the woman was talking to the daughter the daughter poured out her mind told the mother everything the mother advised her on some area she needed another 19yearold girl similarly said mothers are now friendly with adolescent girls rather than giving them threatening words unlike before further evidence from other stakeholders in the intervention sites confirmed that some parents were now better informed on giving srh information to their agyw wards than before the interventions were carried out in their communities a female community leader in fct abuja reiterated this by saying we now know that we should nurture them we tell them what they should do since we know that they are mature if you think that you cannot hold yourself that you cannot maintain yourself use a condom because of the sickness a state ministry of health hiv desk officer from kaduna state said knowledge on hiv has increased before our women dont sit with their daughters to talk on sexual issues but with this program mothers now discuss with their daughters on sexual issues similarly a 39yearold youth leader in chikun lga kaduna state said the following the benefits of the program are many one there is information now two the mothers too are informed and this will go a long way to help the girl child because every child you see comes from a home and if the mother is adequately informed she will also pass the information to her child parental communication on reproductive health was less evident in control lgas as seen in the comment of a respondent who said some of the parents are afraid of mentoring their children you know our local names for male and female sex organsits not good to hear a participant in the fgd for older men in fct revealed that parents in abaji were generally not favourably disposed to discussing reproductive health issues with their agyw he said our people are still looking at it as a taboo for a mother to sit her daughter down or a father sits his son down and tell him this is how to go about a woman that is to say the knowledge is still lacking peer to peer interventions across the intervention lgas 471 to 600 of respondents in the household survey reported that they were spoken to by a young person or friend about hivaids or sex education in the last six months compared to 61 to 189 across all the control lgas among all respondents in the intervention lgas hiv testing was the most frequently reported service used following peertopeer communication on srh followed by getting condoms sti treatment and family planning services all services assessed had a statistically significantly higher proportion of uptake comparing the intervention lgas to the control lgas the respondents in the fgd sessions affirmed the intervention programs for agyw where adolescents were recruited to give sex education to their peers for instance a 19yearold girl from oyo state said we get information from our friends too some young girls were educated and they also educated many young girls on hiv prevention and treatments so that we dont spread the virus again another agyw participant from oyo state said i introduced my friend to the agyw program she in turn introduced her friends many of my friends attended the program it was very educative how i wish it continues similarly a 22yearold participant from kaduna state said in recent times there are lots of information we get from our friends about infections contracted through sex stakeholders interviewed affirmed the benefit of the peertopeer communication for instance a 40yearold health worker from kaduna state said honestly it has so many benefits especially the tellafriend as i have said earlier these agyw believe in themselves whenever their peers are telling them something they take it more seriously than when another person is doing that so tell a friend has helped many of them youth facilitator driven interventions across the intervention lgas 405 to 481 of respondents in the household survey reported being told about hivaids in the last six months by a health workeryouth facilitator interpersonal communication agents compared to 08 to 139 across all the control lgas among all respondents in the intervention lgas hiv testing was the most frequently used service following the exposure to the information followed by getting condoms sti treatment and family planning services similarly the respondents in the intervention lgas had a higher proportion of uptake of all services and all the differences in proportions were statistically significant we found some evidence for the reach of the facilitatorled intervention from the fgds and stakeholder interview sessions for instance a 42yearold mother of an agyw in fct abuja said yes some people came to educate the young people in the community on hiv and many adolescents attended the program similarly a female adolescent in fct abuja said i was personally at the program they started with a skill acquisition program and also educated us on how to prevent infections and later conducted tests for some of us who agreed to the request a 22yearold female from akwa ibom said on my street they gathered some girls in one place and talked to them about this hiv and most girls that were not aware got to know about it they talked about ways of preventing it and how to protect yourself as a girl child a 60yearold community leader in oyo state said we have some communitybased organizations who came to our communities to educate young people on hiv prevention in the last few months many of them attended some agyw participants reported behavioral changes as a result of the intervention a female participant from akwa ibom state said benefit is that the project has helped us a lot it has made us understand that if you have hiv your life does not end there it had helped me personally before i never liked condoms now i am proud of using it nontraditional condom distributionbased interventions awareness of where condoms could be obtained apart from a health facility and chemist pharmacy shop was higher in the intervention lgas compared with the control lgas among all respondents in the intervention lgas 121 collected condoms at locations apart from a health facility similarly 333 heard of or attended a program within their communities where condoms were distributed also 318 were aware of condom distribution by friends or youths in their communities and 148 collected free condoms from their friends or youths in their communities in the last six months these proportions were smaller for those reporting similar experiences in control lgas and the differences in proportions were statistically significant according to participants in the fgd sessions some of the condom outlets they were aware of included barbing salons sports betting centres tailoring shops and sports viewing centres some adolescents distributed condoms to their peers a 20yearold girl from akwaibom said recently when i went to retouch my hair ive seen condoms in the salon and in the barbing area so those things are very common a 23yearold male from akwa ibom state equally said my brother showed me the condom he took from the bet naija centre social mediabased interventions the reach of the social media approach was shallow the social media intervention exposure was not very common across all the study sites as a result of the reported low reach among the respondents we did not further explore the uptake of services discussion in this study we explored an innovative approach to developing and testing tailored hiv prevention interventions we successfully developed a basket of intervention models with reasonable acceptability that can be scaled up to tackle the vulnerability to hiv among agyw in different settings these interventions were grounded in the combination hiv prevention approach combination hiv prevention continues to be the strategic approach to the national response to hivaids in nigeria 3334 the mppi operationalizes the combination prevention framework in nigeria using information about the drivers of the epidemic relating to various target populations emphasizing dosage and intensity on interventions and recognizing the processes of behavior change and structural and environmental influencers of behavior 35 several authors have successfully implemented hiv prevention interventions based on the mppi strategy among inschool and outofschool adolescents including community mobilization outreach advocacy and monitoring 36 37 38 a report from kogi state nigeria demonstrated significant success and achievement in using mppi in an hiv prevention program according to the study outofschool youths comprising male and female were recruited and trained as peer educators who carried out activities which included community dialogue peer educators recruitment and training distribution of condoms and hct 37 similarly in another report from an intervention among inschool youths in kwara state nigeria the authors reported the effectiveness of mppi programming which addressed behavioral change through the combination of prevention interventions targeted at individuals and communities 36 we found that communication of hiv prevention messages through parents is an efficient channel for delivering sexuality and hiv messages to their childrenwards studies have shown that parentsguardians are vital in hiv prevention education of their childrenwards 3940 however cultural barriers often prevent many parents from discussing matters relating to sex with their daughters 41 and many do not have the correct information to pass 42 they tend to be vague authoritarian and indirect about sexual matters 43 therefore programs that target agyw should look for opportunities to engage parents especially mothers such programs should give parents correct information on hiv and sexuality and help them acquire the necessary communication skills to engage their adolescent children previous intervention studies corroborate the findings of our study a randomized control study in the bahamas showed improved parentadolescent communication on sexrelated issues perceived parental monitoring and the youths condom use skills and selfefficacy 44 further parental communication interventions have been shown to improve multiple communication domains including the frequency quality intentions comfort and selfefficacy for communicating with adolescents 45 concerning parentadolescent srh communication interventions that are likely to work are those that specifically train parents in soft communications skills such as talking less listening more being less judgmental and asking more questions in interactions with adolescents about srh 45 efforts should be directed at boosting the selfefficacy of parents by increasing their knowledge about adolescent srh 4647 also interventions that will increase the motivation of parents to communicate with their adolescents including both males and females as well as on all appropriate srh topics are likely to be effective 48 an important consideration for program design is to create programs that target parentcaregiveradolescent pairs as there is some evidence that they are effective 49 the interventions that mediate the intergenerational gaps between parents and adolescents by finding a common ground for them are likely to be effective interventions as such gaps have been implicated in poor parentadolescent communications 50 some interventions may be presented via traditional and social media in order to bring them to scale for example the use of radio drama has a good history of success in social behavior communication change 5152 sociocultural norms impede open sexuality communication and they are a major impedance to parentadolescent communication about srh yet interventions must be sensitive to local cultural and linguistic norms and beliefs for them to gain any traction adopting cocreation approaches from the ground up with the people for whom the interventions are targeted as we did in this study can help to navigate the norms that are peculiar to different groups peer education is one of the mainstays of behavior communication change in mppi 35 young people are more likely to accept information from their peers based on the peer education approach in hiv prevention strategies 53 interventions that address the gap in knowledge and poor perception about hiv need to employ suitable and sufficient channels to deliver messages 54 we adopted two approaches to engaging peers one involved agyw delivering interventions directly to their peers such as acting as nontraditional outlets for condoms or being mentors and growing their mentoring networks through snowballing the other involved training selected agyw to facilitate some programs such as agyw cell meetings there were opportunities to acquire incomegenerating skills and receive hts and sti counseling as part of the meetings these approaches are candidates for testing at scale to further demonstrate their effectiveness biomedical approaches usually require trained professionals to conduct preand posttest hiv counseling followup counseling and referrals and sti syndromic management adolescents and young people have often faced cultural structural personal or health workerrelated barriers to access these services at health facilities on sexual and reproductive health matters 55 in this study all our peertopeer interventions and youth facilitatordriven interventions that targeted agyw directly had biomedical components here we used the proverbial one stone to kill two birds underlining the combination prevention approach we adopted while demonstrating the importance of differential approaches to hiv prevention programming among agyw some other option currently being explored in hts with some success is testing at nonhospital communitybased services such as proprietary and patent medicine vendors 56 also nwaozuru et al 57 showed that adolescents and young people have pronounced heterogeneity in hiv testing preferences including a preference for hiv selftesting structural interventions we adopted included economic empowerment through creating platforms for acquiring incomegenerating skill sets economic empowering of young women can potentially reduce risky sexual behaviors such as transactional and intergenerational sex 5859 we also addressed structural barriers to accessing condoms through the use of nontraditional outlets for condoms we sought to address gender norms and genderbased violence by engaging local power structures in some locations such as traditional leaders fathers and partners of agyw in line with the local context our structural approach also included means of bringing hts and sti services to youthfriendly locations buttressing the point that one size does not fit all this viewpoint is supported by the fact that hiv prevention programming for agyw needs to consider the underlying contextual issues that shape risks and vulnerabilities and must be tackled through a combination of approaches 60 we also found that hiv testing was the commonest service used following exposure to the various interventions while family planning was the least it may be because of the more substantial emphasis on hts further focused research might show if these approaches can be equally valuable for promoting family planning among agyw in all what is most critical is the combination of intervention approaches we recommend that interventions brought to scale should have at least a parental communication component a peertopeer component and innovative ways of removing barriers to accessing condoms some of these interventions are easily deployable by local organizations and are not very capital intensive challenges may include getting access to testing kits since it is preferable to provide testing services for free using empowerment activities that can lead to acquiring skills for income generation is also very important we used this approach to attract agyw to meetings where they were offered hiv testing sti counseling and referral for sti treatment services social media intervention ordinarily would be promising but such approaches are greatly hampered by internet accessibility and affordability especially among agyw of lower socioeconomic status further studies are needed to test their effectiveness among young people from higher socioeconomic statuses this action research presented an excellent opportunity for true collaboration between the community and academia the research framework ensured that the local priorities and context are taken into account when developing and implementing interventions to reduce the risk of hiv in agyw including the potential beneficiaries of the interventions during intervention model refining processes is an improvement over earlier models that were less collaborative in their approach this study was not without limitations the main limitation of this study was the short duration of the action period or intervention the duration of intervention did not allow for long enough time to observe attributable impact at population levels however the interventions developed through a participatory approach with young people and welltailored to local realities seem to aid the acceptability and accessibility of programs for reducing hiv vulnerability also given that we didnt have a baseline probability of receiving services nor controlled for confounders or possible contamination effects we are more restrained about the significant differences found in services used between respondents in the intervention and control lgas finally we had multiple and varying interventions across the study sites therefore we were not able to attribute impact to individual interventions conclusion this study used local contextual issues impacting the hiv infection to design customized interventions to reduce hiv vulnerability among agyw we demonstrated that young people could participate in developing interventions targeting them we showed that a combination of behavioral biomedical and structural interventions delivered through strategies such as parental communication peertopeer interventions facilitatordriven interventions and utilization of nontraditional services for the distribution of condoms have good acceptability among agyw these interventions can be locationspecific within broader interventions the locationspecific approach allows for more program reachpenetration amongst the target audience pursuing approaches developed in participation of adolescents and young people themselves fills the gap of the noninvolvement of adolescents and young people in developing implementing and evaluating hiv programs targeting them future implementation research is required to assess the individual and community contextual factors that can affect the scalability of the interventions to reduce vulnerabilities to hiv infection among agyw

adolescent girls and young women agyw in nigeria are especially at risk of hiv in nigeria their vulnerability to hiv is linked to multiple concurrent sexual relationships transgenerational sex and transactional sex amongst other factors these factors have sociocultural contexts that vary across a multicultural country like nigeria the aim of this study was to use an innovative collaborative approach to develop a minimum hiv prevention package for agyw which is responsive to sociocultural settings and based on combination hiv preventionwe conducted action research to develop and implement actionable hiv prevention intervention models that address agyws vulnerabilities to hiv in three nigerian states and the federal capital territory fct abuja the action research adopted the breakthrough series bts collaborative which accelerates improvement through mutual learning the bts implementation involved rapid plandostudyact pdsa cycles an iterative process to plan and implement a basket of interventions problems or problematic situations termed change topics for which interventions could be carried out were identified in each study location using participatory approaches during a series of meetings called learning sessions specific and innovative interventions termed change ideas were developed these learning sessions were conducted with young women groups and other stakeholders the change ideas were tested studied adapted adopted or discarded at each participating site exposure to and uptake of the implemented interventions was assessed in the study areas using a household survey with 4308 respondents 53 focus group discussions and 40 oneonone interviews in intervention and control study sites

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background go austinvamos austin is a placebased crosssector initiative to improve the health of residents living in south austin through improved access to healthy food and safe physical activity gava was launched in 2012 by the michael susan dell foundation in partnership with community organizations schools and residents implementation efforts began in the south austin zip code of 78744 and expanded to the neighboring zip code of 78745 2 years later although austin is considered one of the healthiest cities in america zip codes 78744 and 78745 face systemic issues that pose barriers to healthy living they are the most populous zip codes in the city but lack basic amenities parks in both zip codes lack basic features such as playscapes water fountains park benches and have gone years without sufficient lighting to keep the neighborhoods safe fifty percent of adults in the community and 80 of the children in area elementary schools are overweight or obese in 2012 a collective of nonprofit and governmental agencies came together to address the health needs of these communities through the placebased gava initiative informed by socialecological theory gava holds that health is strongly influenced by the built environment and that organized communities are key to creating and sustaining demand for healthy opportunities and social norms supportive of healthy behaviors gava seeks to both harness and improve existing built and social environments through a defined set of change strategies viz • increase access to built environment assets such as parks and healthy food and couple these with demand building strategies in order to influence healthy behavior changes • facilitate residents capacity to lead these efforts to increase relevancy community ownership and community use of such infrastructure go austinvamos austin was designed as a model for sustainable community change that could be translated to other communities in need the sustainability strategy focused on coalition building both within the community and across implementing organizations thus an important precondition was that communities had an existing reservoir of social capital that was necessary to facilitate and disseminate change strategies gava is not merely communityplaced it is explicitly communitybased prioritizing the building of social capital reserves over making changes to the built environment in addition while the work in 78744 and 78745 was specific to the assets and needs in those individual communities and responsive to the emergent and evolving needs of those who live work learn and worship in the neighborhoods the overall design of the gava project was informed by theory and created according to identifiable strategies that allowed it to maintain sufficient fidelity for evidenceinformed strategies to be impactful and replicable in other urban communities we hypothesized that over a 5year period this theorydriven communitybased intervention simultaneously targeting both built environment assets and resident capacity to utilize them would lead to measurable changes at the individual level as well as the community level building sustainability selecting communities with social and financial resources to support intervention in identifying potential sites for the gava partnership the aim from the beginning was to capture information that would not just illustrate the needs of the neighborhood but also its assets need was defined as a combination of socioeconomic characteristics of residents lack of environmental assets promoting healthy eating and physical activity and childhood obesity prevalence rates given the placebased approach it made sense to curate these numbers with a geographic focus to that end gis maps of zipcode level demographics and of community infrastructure for food access physical activity and transportation were constructed these were supplemented with fitnessgram data collected in schools to identify obesity hotspots across the city together this compilation of data presented a comprehensive picture of which zip codes had the highest need relative to available infrastructure and access points an equally important precondition for selecting the community was the presence of assets that would be critical in supporting the intervention to address these needs to assess community assets an inventory of communitybased organizations that were located in or served each specific zip code was undertaken focusing on those with strong leadership those emphasizing partnership with their clients and those with healthy diversified funding streams community residents were engaged to determine their priorities and willingness to work on raised issues and to begin to build relationships ground truthing through visits to the neighborhood with resident guides allowed us to validate the community relevance of data that we had obtained from the needs assessment for example whether green spaces were actually viable physical activity destinations funding coming into the zip code from other sources was identified as a priority asset that would help sustain intervention activity it was clear that larger more durable infrastructure investments requiring an array of public partnerships and funding were outside the capacity of gava to deliver as part of the initial intervention the city of austin was queried to determine priority sites for infrastructure projects and what they had observed with regard to community characteristics that would maximize potential success such as community cohesion and leaders who were able to successfully engage with the city this neighborhood analysis resulted in the foundation narrowing the focus to two specific zip codes to invest in with a population of about 43000 the 78744 zip code had the highest obesity prevalence at close to 30 among middle school children the national average is 17 and also had the highest percent of the population under 18 years of the communities investigated predominantly hispanic the median income was among the lowest at 38000 and more than half of the population were renters based on previous gis studies the community had very limited infrastructure with respect to healthy food and physical activity access however the zip code had a long history of community organizing to mitigate safety concerns and a number of established neighborhood watch teams they already had relationships with the city of austin including the parks recreation department and city council based primarily on these issues given their work to bring resources and increased public safety efforts to their neighborhood they had established community leaders a sense of community cohesion and an established community agenda the analysis also revealed significant need and capacity in the neighboring community of 78745 but with a few notable differences from 78744 with a population of about 55000 78745 had a slightly higher median income than 78744 and fewer children on free and reduced lunch the community also had a slightly lower obesity prevalence among students what was lacking in 78745 was the community cohesion and leadership that was the hallmark of 78744 the community was larger in its geography with a wide range of demographics fewer longterm residents with more renters and an upwardly mobile community that seemed to pass through more than established roots building community cohesion and identifying resident leaders was identified as the most promising engagement model for this neighborhood however differences across these communities were of smaller magnitude than the commonalities both communities had significantly higher poverty and obesity prevalence than the national average significant mobility had been documented in both these communities choosing two especially geographically contiguous communities across austins i35 corridor created the opportunity for zip codebased efforts and messaging to reinforce each other with the recognition that a mix of engagement models that made the most of foundation staff and funding capacity would be needed building community trust trust was a vital component to launching the work and remains a critical component to continuing efforts particularly in dove springs the community had been selected for a wide array of previous assessments and interventions residents were used to being in studies asked their opinions and then left to wonder what happened as researchers wrote a thesis or a needs assessment and moved on this made many key stakeholders wary of a new partnership the foundation was from the beginning transparent about what was in scope of the initiative and what wasnt dove springs had a number of community priorities beyond those considered in scope these included healthcare access affordable housing economic development and others while there was tremendous interest in hearing all the barriers to wellness only some would be addressed directly and residents would need to be connected to partners for others the foundation was prepared to listen and to show evidence that residents were being heard when resident leaders were approached with a plan for engagement following the neighborhood analysis they signaled dissatisfaction with the organizations selected to lead the work primarily because these organizations were not located in the neighborhood and did not have an established relationship with the residents a 1h meeting scheduled to share the implementation plan turned into a 4h meeting to devise a new one the foundation continued this strategyresponding to resident input with changes that reflected feedback even if it meant significant changes in the way the foundation did work internally to accommodate what residents thought would work in the field and built in mutual accountability for results efforts were also directed toward building trust with the entities that were already known and familiar to the community knowing that it would take significant time to build trust within the neighborhood particularly given the long history of failed relationships with interventionists evaluators academicians and others the foundation worked to gain the trust of trusted entities it was not an easy path but it was a clear one with nonnegotiables and a strong desire to approach the work as equals building a leadership structure within the community because gava is a coalitionbased initiative and not an independent 5013 organization there is no board of directors the leadership structure of the initiative has been created to allow the space for resident leadership and organizational partnership and guidance it consists of the following core components • coalitiona group of community decision makers who represent the various sectors community based and service organizations and residents and leaders of the community coalition meetings are attended by institutional partners funded implementation partners local policy makers and most importantly residents in the community the agenda of the coalition meetings is centered around providing updates of progress made on gava goals using data and maps identifying priority areas of work based on resident feedback and providing for capacity building opportunities such as leadership training • advisory councilto guide the coalitions decisionmaking and maintain accountability to the partner communities the gava coalition created an advisory council comprised of directorlevel representatives from partnership organizations and leaders from the residentstakeholder teams a simple majority of residents and community stakeholders is maintained on the advisory council votes are taken to endorse various decisions that affect the coalition • executive directorthe director functions as the key strategist to lead the work within the neighborhoods this key leader with an organizing background has a strong history with neighborhood residents and a deep understanding of community challenges and opportunities structured implementation and evaluation models the specificity and thus the limited generalizability of placebased interventions has generally been accepted as given in the field of health promotion utilization of a sectoral approach one of the first decisions regarding the organization of gava activities was that it would follow a sectorbased framework for delivery five sectors of activity were identified consistent with the goals of the overall project physical activity access through assets like parks and greenspaces healthy food access through farm stands and corner stores early childhood coordinated school health and neighborhood safety addressing pedestrian safety and crime challenges selection of these sectors informed by the focus on children and their families and the goal of meeting them where they were was facilitated by community leaders of these five sectors schools were assigned a central role schools have always been a central hub for foundation obesity prevention efforts but data from district wide implementations of the coordinated approach to childhood health and healthy schools program demonstrated the importance of an engaged surrounding community especially parents and organized coordinated school health teams gavas goal was to effectively activate the power of parent advocacy which had proven elusive in many past implementations and to integrate coordinated school health efforts into a more activated community working toward similar goals elementary schools in the community were selected based on feeder pattern to the middle school in the neighborhood and relationships were established with principals and parent leaders to get buyin from the start of the intervention the single middle school in the zip code was included for continuity of messaging and strategies as families moved across the educational spectrum in dove springs one of our implementing partners and a core trusted neighborhood resource was located at the zip codes middle school some of our other strategies including those focused on food access and access to physical activity utilized the locational advantages of schools thus farm stands were set up at schools jointuse agreements were set up with school playgrounds and parks in schools were among early physical activity facilities targeted for improvements the sectoral implementation strategy while guided by local needs and the availability of local resources to address these sectors is easy to adapt to other settings it has the advantages of being relatively modular so that the implementation strategy mix within each sector is complimentary and coordinated with but not entirely dependent upon the activities in other sectors further it leverages different community strengths and funding resources as and when these become available utilization of evidencebased strategies a menu or master list of evidencebased strategies and tools was developed to identify the implementation strategies to be implemented by gava teams in each of the sectors this menu was initially developed by conducting an extensive literature search for evidencebased strategies for each sector and informed by the foundations previous investments in the space the menu was further informed by stated community preferences as well as by anticipated availability of funds for particular implementation strategies over time the menu has evolved to include a finite set of gold standard strategies organized by site type that are researchbased as well as applicable to the community the use of the term gold standards is idiosyncratic to gava and was utilized to emphasize to community residents that ultimately all strategies that they chose to implement would need to be connected in some way to the master list because the strategies were sourced from both the literature and community members the evidencebasis for these strategies was not always available or defined nevertheless all strategies were scored by a team of implementation and universitybased evaluation experts according to the following rubric scores were developed for effectiveness based on literature review reach based on the anticipated numbers of people directly impacted within the community setting and frequency depending on the length of time for which the strategy is implemented the product of these three scores gives a total impact rating or dose the impact score was calculated for each strategy the entire goldstandard document of strategies with impact rating for each forms the basis for the suite of strategies any given sitebased team is undertaking further details describing the identification of strategies and development of a usable menu are available online while dosage is monitored to encourage implementation of highest impact strategies action planning is based on community input with implementation driven by resident and neighborhood team leaders whose lived experience provides the context and approach for strategies to be more specific and effective the rubric we created is an elaboration of the dose of interventions rubric advocated by kaiser permanente leveraging geographic teams for sector activities organizing the implementation through teams in each sector kept the funding mechanisms and initial workplans streamlined because we had subject matter experts in the form of communitybased nonprofit partners in each sector however when 78745 became active one of these partners an affordable housing nonprofit provided an opportunity to engage resident teams in multisector efforts that affected their own family and immediate community this new model of microneighborhood or geographic teams was replicated in other small parts of the zip code and encompassed relevant access points for that area in each of the sectors two geo team organizing positions were created within gavas headquarters and strong crosssector teams began to develop within other local housing complexes and around schools parks and stores this strategy of geo team organizing was so effective that after 2 years of engagement with 78745 the neighborhood had achieved the same level of community readiness as had been developed in many years of organizing in 78744 structured ongoing evaluation a key goal of evaluating strategies was that results from evaluation be available and transparent to residents and stakeholders at all times so as to usefully inform the direction of their implementation efforts this required then that evaluation be an ongoing activity rather than a onetime exercise at the end of the intervention this applies to impact evaluation but even more to process evaluation which contains more actionable information in most cases process evaluation because the process evaluation directly guides implementation efforts investment was made in collecting and reporting activities and key outputs to implementation teams on an ongoing basis there are two key sources of process data available to inform implementation sitebased teams produce site plans at the beginning of each year or at the start of a new team updated quarterly these plans are based on the gold standard list of strategies described earlier ie comprised of evidence based and evidence informed strategies curated for each type of siteschools early childhood education sites parks and greenspace food retail outlets and so on in addition key wins data are collected from teams monthly and organized by categories under the three themes of sustainability access and utilization examples of key wins include leveraged funding policy progress resident leadership development building of organizational networks and implementation wins like infrastructure improvements safety improvements creation of new healthy food access points and health educationoutreach key wins and site plan data are summarized in a monthly dashboard to provide insights into implementation progress as well as to ensure strategic alignment across all levels of gava stakeholders this allowed the dashboards to be presented at meetings comprised of the executive director the funders the impact evaluation team the communications team and core gava personnel findings from the dashboard were often used to discuss implementation priorities with the funder as well as discuss gaps that may need attention from the operations staff highlights from the dashboard as well the highlights of the discussion were then summarized and presented periodically at operations staff meetings to ensure alignment among implementation team key wins data were also shared with community residents in the form of maps to generate interest among neighborhood residents on gava priorities site plans and key wins data served as progress reporting for the funder as well as the broader gava coalition the monthly implementation dashboards were also used by gavas executive director to display active versus emerging teams with their geolocation current active implementation strategies along with their impact score categorization of the type of intervention and expected outcome category the dashboard also displays the number of active individuals and accumulating key wins for the teams the dashboard view allowed the community director and the gava implementation teams to monitor activity of a multicomponent intervention with clarity map visualizations of process and impact data have been essential to the coalition enabling partners to see what types of barriers residents are identifying around particular sites what those same residents might be looking for with regard to improved access and more recently where utilization rates of healthy access points have increased an example of the kind of map visualization that is used is presented in figure 1 being able to see results at the street level helps the implementation to maintain its micro neighborhood focus allowing for the nuances of what can make placebased efforts so successful however the structure of this visibility evidencebased gold standards and outcomes analysis provide the standard structure that can make placebased efforts more replicable for example residents around one corner store reported that availability of healthy fruits and vegetables was a barrier to access for healthy food while residents around another corner store reported that fruits and vegetables were available but too costly or of poor quality implementation plans for the teams focused on these two retail outlets were variable despite their proximity impact evaluation the impact evaluation for gava is being conducted independently by an evaluation team at the university of texas health science center at houston school of public health austin campus as is the case with gava implementation activities the evaluation plan was designed to be comprehensive and flexible to accommodate changing ground realities but also follow the structure of the implementation as a result the evaluation plan consists of several substudies and uses mixed methodology the cohort substudy is a 5year longitudinal study in which the research team follows 150 families living in the gava community and 150 families living in socioeconomically similar communities outside the gava community respondents report their awareness attitudes perceptions and behaviors in regard to use of physical activity and healthy eating opportunities provided in their community as well as physical activity and dietary behaviors of an index child in addition the evaluation team tracks objectively measured bmi data from study participants and from the index child over the 5year period data from the cohort study will allow us to determine the impact of gava on child and parent outcomes by comparing intervention versus control families the cohort study is supplemented by a serial crosssectional survey the doortodoor study that collects data from approximately 300 individuals living in the gava communities each year the d2d participants selfreport many of the same constructs as the cohort participants but is limited to adult data addresses of both cohort and d2d participants are obtained and geocoded to allow examination of placebased intervention effects in addition to these two quantitative studies the evaluation team conducts yearly interviews with school principals and with key stakeholders and community residents finally the evaluation team conducts observations of community assets to determine changes in quality of these assets over the evaluation period data from the cohort and d2d surveys are compiled annually and summarized as feedback for implementation team both to allow monitoring of progress as well as to provide information that serves to redirect resources to areas of high need or low impact identify specific actions to strengthen fidelity of implementation and address access and quality gaps with regard to healthy food and physical activity figure 2 shows how interim evaluation data feeds into process data these interim data summaries from the cohort and d2d teams have also proven useful to the gava leaders as advocacy tools and in pursuing funding to maintain viability and sustainability of gava gava outcomes at the community and organizational level go austinvamos austin is now in year 5 of a planned fiveyear implementation in the first zip code and year 4 of implementation in our second at this time the gava coalition is comprised of six funded nonprofitcity agencies over 122 organizations and over a thousand residents of the 98420 individuals living in both zip codes 86 have geographic access to gava assets over 1600 residents have been mobilized as part of gava outreach efforts and over 800 residents are active leaders in gava implementation across both zip codes currently 35 implementation teams comprised of residents community in areas with high residential leadership key wins include a 30 reduction in perceptions of barriers to physical activity reduction in access barriers are geographically correlated with increased usage of the neighborhood assets and improvements in physical activity utilization behaviors by 20 similarly mobilization of resident activity around awareness building and outreach is correlated with a 20 increased awareness of barriers to healthy food access positive trends in nutrition have also been observed with increased utilization of local food retail outlets last year the foundation funded the work at 50 of operational costs this year at 33 and next year at 33 in only the second neighborhood launched this trajectory has required identification of supportive funding from private and public sources for operational activities additionally organizations that participate in gava and see the increased value in having engaged client advocates have pledged to support key staff who benefit their organization and gava overall through current or raised operational funds the gava implementation team is now spinning off independently as an organization to best maintain and deepen core operational functions while serving as partners to other institutions and initiatives in the execution of community agendas for population health conclusion given the way gava is organized the tools used to monitor process and gaps and the measurement that has been put in place there are strong indications as to what structures and strategies are working and can be replicated the building of partnerships and networks far outstretch the geography of the current implementing neighborhoods and further support an effort aimed at replication with fidelity we are also considering a broader set of social determinants to begin addressing in more established gava neighborhoods with the capacity and will to do so the gava team has often been asked whether funding resident leadership or capacity building within people is actually sustainable indeed gava makes the case that the investment in people is the key to sustaining these efforts gava communities are among the most mobile of austin residentsgava works because it does not depend on a small cadre of leaders rather capacity building within residents and progression through a pipeline of leadership has ensured that residents can flow in and out of a broad swath of resident activists as their circumstances dictate though their collective efforts and relationships formed therein provide a great incentive for them to stay in the community longterm go austinvamos austin has learned how to be more flexible as new realities and realizations emerge in more recent years of gava the most important change is the formal incorporation of community organizing into the model and staffing organizersmany of whom live in the zip codes of focusexist both at the geographic level working with sitebased teams and across sites at the sector levelsetting aside the subject matter leads for coordinated school health early childhood and physical activity efforts and leading food retail efforts responsible for resident engagement and leadership building within their designated scope it is these organizers and the executive director who provide much of the leadership outreach and sense check of what will work they are the connection between the power of evidence and the reality of lived experience by those most directly impacted author contributions ah cp sb and nr can confirm that they are authors of the mentioned manuscript and that their authorship consisted of the following substantial contributions to the conception or design of the work or the acquisition analysis or interpretation of data for the work and drafting the work or revising it critically for important intellectual content and final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved conflict of interest statement the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest the reviewer mhf and the handling editor declared their shared affiliation copyright © 2018 hussaini pulido basu and ranjit this is an openaccess article distributed under the terms of the creative commons attribution license the use distribution or reproduction in other forums is permitted provided the original author and the copyright owner are credited and that the original publication in this journal is cited in accordance with accepted academic practice no use distribution or reproduction is permitted which does not comply with these terms

placebased health efforts account for the role of the community environment in shaping decisions and circumstances that affect population wellbeing such efforts rooted as they are in the theory that health is socially determined mobilize resources for health promotion that are not typically used and offer a more informed and robust way of promoting health outcomes within a community common criticisms of placebased work include the difficulty of replication since engagement is so specific to a place and limited sustainability of the work in the absence of continued institutional structures both within the community and supporting structures outside the community to keep these initiatives resilient this paper describes a placebased initiative go austin vamos austin gava which was designed to harness the strengths of placebased worknamely its specificity to place and community from the start the project was designed to balance this specificity with a focus on developing and utilizing a standardized set of evidenceinformed implementation and evaluation approaches and tools that were flexible enough to be modified for specific settings this was accompanied by an emphasis on leadership and capacity building within resident leaders which provided for informed intervention and demand building capacity but also for longevity as partners philanthropic and otherwise moved in and out of the work

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challenged youth of the philippines the sphere of influence of the university has extended outside the metropolitan area students would travel for hours to get their education at this prestigious university the strategic location of the polytechnic university of the philippines allows several modes of transportation public utility vehicles such as buses jeepneys and taxis traverse two national roads the arsenio h lacson avenue and ramon magsaysay boulevard light rail transit 2 traverses above several national roads including that of ramon magsaysay boulevard aurora boulevard up to marcos highway the location of its last station to date is the santolan station lrt 2 is now on its expansion program two stations will be added and the terminal point will be in masinag antipolo city inside the mabini campus is the terminal ferry station the route of which is thru the pasig river the doortodoor concept becomes the ultimate goal of seamless travel however for a developing country such as the philippines faster means of transportation would not be an automatic choice more often than not the cost of transportation will determine the choice commuters would make the burgeoning student population experienced by the city of manila has grown exponentially in the past decade it has become more evident in the steady increase of users of the lrt 1 and lrt 2 both of which pass through the university belt in the city of manila lrt 2 specifically pureza station is a few meters away from the three campuses of the pup it is one of the most preferred modes of transportation by the staff faculty and students especially those residing in areas of quezon city and from the province of rizal however from pureza station some will take a tribike or a tricycle the proliferation of tricycles and tribikes has exponentially risen as the pollution of the university grew the growth of these types of transport was not a consideration when the metro roads were constructed but occupied a significant part of it the tricycle industry has proliferated over the last 14 years despite the absence of formal policies from the government the demand for this mode of transportation will continue to grow with the increase in the tricycleriding population objective of the study the studys objective is to determine how the doortodoor concept affects the carrying capacity of the road in a higher educational institution such as the two campuses of the polytechnic university of the philippines which ndc compound houses colleges of engineering architecture communication and the mabini campus the research is vital to improve the mobility and safety of pedestrians and drivers and build better roads and sidewalks with an end finding a possible solution for the complimentary and supplementary existence of this transport phenomenon of the doortodoor culture of the pedestrian in this case the pup community and the constituents of the district of sta mesa manila methodology the research employed the observational methods and the survey method using the inputoutputprocess the observational method was done by recording the observation by taking photos at different times and days of the week it involves recording plans such as what information should be gathered where it should be gathered and how it should be gathered and recorded the researcher had no control over any variables in the observational method therefore the research must be carried out so that the findings do not contradict one another in addition the survey method was employed to understand the commuters behavior in the doortodoor context of transportation the questionnaires include the linear path description which recounts the movement of the respondents from their house to the school and their preference for transportation or movement from their origin and destination to illustrate the use of the two research methods the inputoutputprocess model was employed transport history in the philippines the available transportation mode in the philippines during the spanish colonization was limited to horse or carabaodrawn carriage by land the horsedrawn carriage is usually used by the elite and could be generally seen in the city streets while the carabao pulls sleds for farm folk and their produce in the city of manila the pasig river and its tributaries were an essential means of transporting goods and people roads were narrow and intramuros the center of governance by the spaniards cobblestones was used as the road while most provinces were either asphalt or dirt road the first car to roll in the streets of manila was shipped from france to the philippines in 1900 it was also around the years 1900 to 1946 during the american colonial period that the filipinos were introduced to the automobile industry soon after more roads were built during the american colonial period the horsedrawn carriage inspired horsedrawn trams and eventually electrically powered tramvias operated by the conglomeration of manila electric and light co during the 2 nd world war the tramvias were the most hardhit transport mode american cars were also converted into taxis and military vehicles to jeepneys there were several studies with the same attempt to provide a mass transport system that would address the ballooning need of the population in 1980 through executive order no 603 the light rail transit authority was created under the chairmanship of thenfirst lady and governor of metro manila imelda romualdez marcos the construction started in 1981 and was operational in december 1984 from baclaran to central terminal near manila city hall the track from central terminal to monumento became accessible to the public when it was opened on may 12 1985 mrt 3 started in 1989 4 years after the completion of lrt 1 mrt 3 runs from north avenue quezon city connects to lrt 2 via araneta station and intersects lrt i in taft avenue station lrt 2 is the relatively newest it began in 1996 and partially opened in 2003 with santolan to araneta centercubao station in operation in 2004 the remaining station from cubao to legarda station was opened and eventually connected to lrt 1 via recto station lrt 2 has been the mode of transport for students in the university belt of manila the tricycles and pedicabs largely proliferated when the lrt 2 became operational the bulk of this 3wheeled transportation can be seen near the stations of pureza and legarda about 94 of these motorcycles and tricycles have 2stroke engines3 emitting delicate particulate matter which poses a danger to public health the pedicabs and tricycles near legarda station cater to students in some of the most prominent schools in manila such as the university of santo tomas far eastern university university of the east and the mendiola consortium college of the holy spirit st jude college and san sebastian college in pureza these modes of transport are servicing the schools such as eulogio amang rodriquez institute of science and technology de ocampo college and the pup manila as a university hub the genesis of higher education institutions can be traced inside the walls of intramuros which literary means within the walls in spanish education was a tool used by the spaniards to propagate the roman catholic faith religious orders ran the schools inside the wall the luster of intramuros as the center of government education and commerce diminished after world war ii it has taken a toll on both its physical and historical prominence the american government focused on rehabilitating manila the philippines capital howard taft and forbes commissioned daniel c burnham a prominent architect and urban planner to rehabilitate manila through his concept of the city beautiful movement while there was a conscious effort on the part of the planners to the historical significance of intramuros it was not patronized by the people much of the areas in intramuros were used as storage facilities and parking spaces for the trucks soon after the schools inside the walls of intramuros were reestablished in other parts of manila figure 3 shows the proliferation of schools due to these movements it has created the phenomenon of a university belt which paul p zwaenepoel coined to describe the movement of the higher education system in the philippines the genesis of the university belt started in intramuros and the relocation of the university of santo tomas to sampaloc district triggered the movement outside the walls as mentioned by pinlac the university belt today can be traced from the north university of santo tomas towards the south de la salle university both of which belong to the top schools in the philippines as rated by the quacquarelli symonds fig 3 map of the manilas university belt polytechnic university of the philippines and its environs the genesis of the pup can be traced to 1904 the institution started as a business school to address the needs of the private and government sector established by the city school system in 1908 its status from a city school became a primary business school named the philippine school of commerce however in 1952 through republic act 778 the school was renamed the philippine college of commerce and took a new campus in 1965 in sta mesa manila the bureau of animal industry formerly used the campus site with an adjoining multistory tenement housing constructed for the philippine army in 1972 the college took a new turn when it was given a new mandate through presidential decree 1341 the philippine college of commerce was converted into a chartered state university and was bestowed pup through its new directives new courses were offered and the population increased exponentially to date the manila campus alone is a host to more than 50000 students faculty and staff pup is nestled in the highlydense residential area of the district of sta mesa along pureza street where the cea is located also host to the pio del pilar elementary school the universitys existence in the district became the catalyst in the area it attracted entrepreneurs to convert their residences to accommodate commercial spaces and in some cases even converted their homes for student lodging the increased population can also be attributed to some of the students from the provinces who have graduated and secured employment in the city becoming permanent community residents it has also triggered the need for more goods and services including transportation the direct access of pup from the national road of ramon magsaysay avenue is through pureza st pureza is a twolane street perpendicular to anonas st which serves as the entrance of the cea coc and the main campus the photo essays show the proliferation of ambulant vendors on the streets where the sidewalks are narrow when the sidewalks are a little wider either the establishment owner will claim it or another ambulant vendor will occupy it figure 4 shows that a more considerable percentage of the sidewalks in the vicinity of the study is less than 100 meters in width which explains why people are walking on the streets and figure 5 provides an overall view of the width of the sidewalks which significantly affects the individuals reactions on how it is utilized the sense of safety comfort and level of interest cannot be considered an option for pedestrians options are not available to them since the sidewalks are relatively narrow concerning the number of users during school days the growth of inner street transportation the phenomenon of tricycles and tri bike growth in the philippines can be traced to the culture brought about by the jeepneys which started after world war ii filipino entrepreneur leonardo s sarao converted the us military jeep left by the americans during world war ii to an eightseater public utility vehicle it became one of the symbols of the philippines as a nation the decorations are very flamboyant both on its interior and exterior the jeepney would convey messages of a familys aspirations as reflected in its graphical paints over time the jeepney was customized moreover it can now accommodate 16 to 20 passengers some have upgraded to the airconditioning system the jeepneys stopped where ever and whenever the passenger would ask the driver to halt this phenomenon started the culture of the filipino context of doortodoor the passenger would ride the jeep and would go down at the exact location they wish so as not to walk extra steps even though provisions for jeepney stops and ordinances for penalties for not following traffic regulations have been created if given a chance both the passenger and drivers would violate the provision when the philippine government was created to control public transport vehicles by providing franchises on specific routes the doortodoor culture of the filipinos was somehow hampered but for a brief period while tricycles have been plying some routes in rural and urban areas it was limited ultimately the need to address the culture of filipino not wanting to walk provided a window of opportunity for business through tricycles and tri bikes due to the sheer population of the pup numerous business establishments have gravitated toward the institution the transportation sector is one of the groups that finds a good market in pup two types of inner street transportation are available in the area of pup these are tricycles and pedicabs tricycles are 2stroke engine motorcycles with a sidecar that can accommodate three passengers plus two passengers at the back of the driver thus it can accommodate 4 to 5 passengers a pedicab is a bicycle with a sidecar that can accommodate a maximum of 3 passengers as shown in figures 6a andb while the route of tribikes is shown in figure 7 table 1 shows the number of tricycles and pedicabs per tricycle operators and drivers association and pedicab operators and drivers association the accreditation of the tricycles and pedicabs does not reach the land transportation franchising and regulatory board however the city or municipal council would serve as the accrediting authority approving the operation of tricycles and pedicabs would refer to the accreditation of the toda and poda it would be the associations initiative to regulate the number of units therefore it would be safe to assume that route measure capacity is not considered as it is evident in the number of units plying the route from the main road of ramon magsaysay where the lrt station is located it is around 300 meters to the cea building 400 meters to the coc and 12 km to the main campus from teresa st towards anonas st the distance to main building is 120 meters to the coc is 400 meters and 500 meters to the cea results of the study the strategic location of the pup and its strong standing in higher education as the number one choice of employers will continue to attract students to enroll in the institution as a staterun institution the university is constrained in accepting the number of students every academic year because of budget constraints however the institution finds ways to accommodate aspiring students the burgeoning number of students has provided economic growth in the community as it has also taken a toll on the infrastructure of both the school and the community of the 300 respondents 185 students used pureza to visit their buildingtable 2 the number of students who take pureza st to their building and the mode of transportation shows that 125 or 67 of 185 go through pureza st while 115 or 43 passthrough anonas teresa sts results show 159 or 86 of the respondents using pureza would walk rather than ride a tricycle or a pedicab and 47 or 41 of respondents from anonasteresa walk instead of taking the tricycle or a pedicab the choice of significant transport is the jeepney followed by either light railway transit or philippine national railways the total patronage of the tri bikes and pedicabs is 92 or 31 of the total respondents this may seem low however if 30 is subjected to the total pollution of pup of 50000 this will amount to 15000 possible passengers daily on a school day from monday to saturday walking from pureza to the college of engineering and architecture building receives the highest preference percentage of 120 or 65 the volume of pedestrians tri bikes and pedicabs are relatively higher during the weekdays for the entire day compared to weekends this is evident that the existence of the university and other learning institutions within the area contributes to the number of road users conclusions and recommendations urban designers are interested in the environmental qualities of places that make them better for walking not only as settings for physical activity but also as sensorial and social settings however the carrying capacity of the roads in metro manila in general and the sta mesa district in particular has steadily grown and the congestion experience has also metastasized this experience is seen to be the trend in the next couple of years as decentralization is not on the table for most schools in the city of manila the polytechnic university of the philippines will remain a lodestone as far as higher education is concerned it has proven its significance in producing the competent graduates that employers seek this is one of the indicators that would confirm that the students will continue to patronize and consider the university for their education however suffice it to say that this will also continue to take a toll on the capacity of the road networks around the community the amount of air and noise pollution is contributed by the tricycles the road networks around the community were not designed and have not adjusted to the road users brought about by the university and the business that gravitate because of their existence the culture of filipinos not wanting to walk the extra propelled the proliferation of tricycles and pedicabs the volume of tricycles and pedicabs has taken the road space for cars and trucks in the streets of pureza and anonas thus slowing down the traffic the narrow sidewalks do not conform to the prescribed sidewalks of the philippine national building code of a minimum width of 120 meters unobstructed some sidewalks are elevated around 10 meters from the ground because of the fear of lot owners flooding which makes them nonnavigable for physically challenged people the narrow sidewalks expose pedestrians to danger because they would have to walk in the streets as seen in figure 3photo essay of pureza st the situation of pedestrian obstacles maneuvering the streets of pureza and anonas the noise and air pollution contribution of the tricycles and the volume of tricycles and pedicabs occupying the streets might be perceived as a minor problem or for some not even a problem because people have seemed to survive the situation for years already however this phenomenon seems minuscule because people have assimilated into the situation and students would come and go it cannot be denied that the pollution the tricycles are creating will eventually take its toll on the health of permanent residents of the area the noise affects the classes in the college of engineering and architecture especially those held on the ground and 2 nd floor since none of the classrooms are airconditioned the decibels the tricycles are creating are 38 above the tolerable prescription of the ched memorandum order the problem has to be addressed on the level of the city government together with the local officials and stakeholders such as the polytechnic university of the philippines and the pio del pilar elementary school homeowners and business owner including the ambulant vendors initial recommendations to address the problem at hand are the following 1 the issuance of the franchise of tricycles and pedicabs has to be regulated in addition a more scientific basis for using the rmc road measured capacity has to be implemented with the assistance of the planning division of the city of manila in close coordination with the university 2 the proliferation of motorized tricycles contributes not only to air pollution but noise pollution as well since the area is host to two public educational facilities where the airconditioning system is not a priority consideration of a phaseout of the tricycles instead of nonmotorized vehicles such as pedicabs and bicycles can be an option 3 the city of manila needs to review its land use and zoning mainly the issuance of building permits that can regulate the structure setback for a possible widening of the sidewalks the need to identify the builtenvironment constructs and the measures that can be used to quantify walking with ease 4 it will help eventually promote walking for pedestrians with ease and safety regarding the physical characteristics of streets and their edges five urban design qualities could be measured imageability enclosure human scale transparency and complexity during schools days monday to friday to allow half of the street to be walkable at 700 am 500 pm after this period it can be a twoway street again because the classes start at 730 am and the last class starts at 600 pm and ends at 900 pm the tricycles and pedicabs in the blue line can go around hippodromo street to the main campus and the colleges of engineering architecture and communications it will permit walkability in the streets and decreasing the tricycles towards nonmotorized transportation will reduce noise and air pollution it will encourage people to walk as walking can help improve ones daily existence quality by increasing energy levels improving sleep quality assisting with mood and overall life quality researchers and urban planners may find the review helpful in developing walkability studies and defining policies to improve walkability

seamless travel in the shortest possible time is the primary goal of commuters the government and the private sector ease of transport has been synonymous with economic growth the faster the transaction of goods and services the quicker the return on investments transportation permeates our daily existence more than smartphones more than television more than food culture or commerce more even than twitter or facebook humes 2016 p8 creating a transportation ecosystem means transforming our cities transportation systems to provide a seamless transition across all modes benway 2017 raghunathan a u 2018 people will travel far and wide to address their wants and needs today transportation accessibility affects a significant portion of the population and many affected people people with disabilities learning disabilities temporary restrictions the elderly and so on are excluded from mobility bekiaris e 2020 polytechnic university of the philippines pup has provided the intellectually but financially

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introduction t he hiv epidemic in latin america is primarily driven by sexual transmission and is highly concentrated in men who have sex with men 12 although men who engage in transactional sex in latin america have 35 times the risk of hiv compared to men in the general population 3 and 23 times the odds of hiv compared to msm who do not engage in transactional sex 4 little research has considered disparities in access to hiv treatment among this population research has shown that elevated risk of hiv among men who engage in transactional sex may be potentiated by complex social issues including stigma and discrimination at multiple levels 56 power dynamics introduced with an economic transaction that may influence ability to negotiate condom use as well as psychosocial problems 7 despite this disproportionate burden and risk no studies to our knowledge have specifically considered differential engagement in hivrelated medical care among hivinfected msm sex workers compared to other hivinfected msm hivinfected msm who engage in transactional sex may delay care seeking as a result of social and structural stigma and economic and psychosocial factors which may limit access to healthcare 8 9 10 11 12 recent evidence has demonstrated earlier initiation of antiretroviral treatment results in reduced sexual transmission of hiv 13 given the potential for substantial disparities in access to hiv medical care in populations of msm who engage in transactional sex and the importance of engagement in hivrelated medical care to reduce hiv transmission addressing gaps in the literature to understand how msm who engage in transactional sex are engaged in hivrelated medical care is important an understanding of differential treatment patterns among subgroups of msm may allow for development of tailored treatment and secondary prevention interventions to address this we compared current engagement in hivrelated medical care and art use between hivinfected msm in latin america who engage in transactional sex and those who do not methods participants and procedures in 2012 an anonymous online survey was completed by over 36000 members who were 18 years of age or older of the largest sexualsocial networking site for msm in spanishand portuguesespeaking countries in latin america and the caribbean detailed study methods are provided elsewhere 14 in brief an email with a link to the survey in either spanish or portuguese was sent over 30 days to nearly 643000 members who had logged on in the past 90 days and whose site profile indicated that they lived in spain portugal or any spanish portuguesespeaking countryterritory in latin america or the caribbean the present analysis was limited to respondents who currently live in one of 17 countries in latin america reported being cismale reported being hivinfected and had complete responses to questions about engagement in transactional sex the study was approved by the institutional review board at the fenway institute at fenway health boston massachusetts measures transactional sex the primary exposure of interest engagement in transactional sex was assessed by asking participants if any man had paid them in exchange for engaging in oral or anal sex in the previous 12 months hivrelated outcomes respondents who reported being diagnosed with hiv were asked to report whether they were currently receiving medical care for hiv and whether they were currently taking art to treat hiv for those currently taking art after receiving instructions normalizing the difficulties of adherence respondents were asked approximately how much of their prescribed art they have taken in the last month instructions indicated that 0 means having taken no medication 50 means having taken half of the prescribed medication and 100 means having taken every single dose of the medication adherence was modeled as a dichotomized and continuous variable covariates a series of covariates hypothesized to be associated with both transactional sex and hivrelated medical care outcomes were assessed sociodemographic variables included age sexual orientation education incomeclass and type of living environment additionally psychosocial factors included the following measures which have been described in detail elsewhere and shown to be associated with transactional sex 15 current depressive symptoms current alcohol dependence any recent hard drug use in the context of sex any experience of intimate partner violence in past 5 years and history of childhood sexual abuse finally respondents were asked to report if they had any condomless anal sex in the past 3 months with any male or transgender partner statistical analysis we calculated frequencies and proportions of hivcare related variables by engagement in transactional sex and conducted a series of bivariate and multivariable twolevel randomintercept logistic regression models with the following dependent variables regressed on engagement in transactional sex engagement in hivrelated medical care currently taking art and 100 adherence to art in addition to assessing adherence to art as dichotomized by 100 adherence versus less than 100 adherence a twolevel randomintercept linear regression model was fit to examine adherence continuously all analyses were conducted in stata 121 results in this sample 186 of hivinfected respondents reported having been paid for sex with another man in the past 12 months men who reported engaging in transactional sex were significantly less likely to report being engaged in hiv care while men who reported engaging in transactional sex were less likely to report being on art once in care and being fully adherent to art if prescribed these differences were not statistically significant in models adjusting for demographics and psychosocial measures respondents who were paid for sex with another man in the past 12 months were less likely to be currently receiving medical care for hiv compared to those who were not however no significant differences were seen by engagement in transactional sex with regard to being on art or art adherence treating art adherence as continuous indicated that engagement in transactional sex was associated with a 212 decrease in art adherence level however this was not statistically significant additionally adjusting for reported condomless anal sex in the past 30 days with a male or transgender partner did not meaningfully change the reported associations discussion results of this analysis suggest that there are disparities in receipt of hiv medical care associated with recent engagement in transactional sex among hivinfected msm in latin america the ability to access hivrelated medical care is related not only to availability of care facilities but also barriers and facilitators to engagement and retention in care and these factors may be compounded for msm who engage in transactional sex for example stigma and discrimination may limit care seeking to a greater extent among men who engage in transactional sex given multiple sources of stigma previous research suggests that msm may face sexual stigma from multiple dimensions stigma from healthcare providers may limit disclosure of sexual orientation or sexual behaviors among msm if they anticipate discrimination following disclosure 16 among people living with hiv hiv and healthcare stigma has been associated with decreased careseeking behavior 912 msm who engage in transactional sex may experience additional stigma due to being involved in sex work which is illegal andor socially unacceptable across most of latin america and which has been described as a barrier to care seeking among female sex workers 1718 although experienced andor perceived stigma could act as a mechanism through which msm who engage in transactional sex in latin america have decreased engagement in hiv care we were unable to quantify experiences of stigma in this study future work should consider the role of experienced andor perceived stigma specifically as a barrier to engaging in care in this population decreased engagement in care among msm in transactional sex may also be mediated through psychosocial factors prior research in this population showed that individuals who engaged in transactional sex had a higher burden of depressive symptoms and substance use than those who did not 15 depressive symptoms and substance use have both been shown to increase risk of hiv transmission independently and may have even greater effects in combination 19 in addition these factors may be associated with decreased uptake of and retention in medical care and adverse hiv outcomes even independent of treatment adherence 20 addressing depression and substance use disorders in this population may improve linkage and retention in hivrelated medical care among msm who engage in transactional sex interestingly although participants who engaged in transactional sex were less likely to be engaged in hivrelated medical care prior research by this team 15 and by others in other regions 21 indicates that msm who engage in transactional sex are more likely to have a history of hiv testing and of hiv diagnosis 2223 this may indicate that men who engage in transactional sex are aware of their increased risk and thus are more likely to test for hiv but that there are structural interpersonal and individual factorsincluding differential power dynamics due to social or economic position physical or sexual violence substance use andor psychological distress 7 which are major barriers to linkage and continued engagement in care if diagnosed programs should explore ways to engage these individuals in care at the time of testing particularly by providing culturally competent case management and supportive services 2425 results of this study must be considered in the context of several limitations this study represents a convenience sample of members of a socialsexual networking website for msm and all measures were selfreported hiv serostatus was selfreported and known hiv infection is a function of both having been tested and testing positive it is unknown whether individuals with undiagnosed hiv infection would have been engaged in care had they known about their hiv infection and how this could influence results however these results demonstrate that among people who know their hiv serostatus those who engage in transactional sex have greater disparities in engaging in hivrelated medical care additionally we were unable to classify the frequency with which participants engaged in transactional sex whether or not they identified as a sex worker and if they exchanged sex for money drugs or other goods similarly we did not assess how frequently hivrelated medical care was received and by whom it was provided there may be important differences between these groups that are not detected here further work is needed to characterize how these differences affect receipt of hivrelated medical care despite these limitations this analysis is the first to assess whether engagement in transactional sex is associated with hivrelated medical care among a large sample of hivinfected msm in latin america and identifies important gaps in hiv treatment in this population conclusion while further research is needed to support these findings and to examine barriers for careseeking among men who engage in transactional sex in latin america the results of the current study suggest that hiv prevention and treatment interventions in this population may be most effective by focusing on linking individuals to care and reducing real or perceived barriers to continued engagement in care including ensuring the existence of culturally competent and sensitive providers and providing individuals with services to support them to overcome personal interpersonal and contextual challenges to hiv care author disclosure statement no competing financial interests exist

men who have sex with men msm who engage in transactional sex are at increased hiv risk and face complex barriers to care seeking among 2035 men recruited through an msm socialsexual networking website in latin america and who reported being hivinfected 186 91 reported being paid for sex with another man in the past year engagement in transactional sex was associated with decreased odds of receiving medical care for hiv aor 057 95 ci 037085 no significant differences were seen in being on antiretroviral therapy art or art adherence once in care interventions in this population should focus on reducing barriers to engagement in care

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background health is increasingly gaining attention from regional organisations alongside more traditional aspects of regional cooperation like trade or security 1 with regional organisations in the global south seen to be important policy venues within multilevel governance of health 2 however the way that health policy is framed and understood as an issue for regional cooperation varies across organisations and has been shown to be influenced by contextspecific social economic and political views on health policy by member states 3 4 5 in africa regionalism has been influenced by international trade and economic interests colonial histories alignment of social and economic policies and disease threats to public health although health is not generally the core interest for organisations in regional governance 67 recent health crises however have increased attention to the role of regional bodies in health sector planning and response the 2014 ebola outbreak in west africa for instance highlighted the importance of regional organisations in health emergencies as well as their involvement in strengthening public health and health systems in the global south 89 currently the coronavirus disease 2019 pandemic similarly highlights the importance of regional actions to improve health preparedness and response in africa 910 it has also underscored the critical contributions of regional cooperation to legitimize the experience of states and health systems with outbreaks across the continent to network national decisionmakers to share information to improve infrastructure such as laboratories and to use research capacity of african scientists and institutions for local knowledge to inform and implications for policy makers • given the multisectoral composition of national health research systems national policymakers from the health higher education and science policy sectors may be individually unaware of various regional organisations involvement and activities where intersectoral coordination is lacking decisionmakers across sectors may benefit from collectively identifying which regional organisations are supporting these systems and assessing in what ways • national governments may need to strengthen the mandates of regional bodies and grant them additional authority to realise the potential gains these bodies can achieve in terms of governance and coordination of health research • several opportunities exist for regional bodies to contribute to improving health research in africa there are particularly notable gaps in financing of health research and advocacy which regional organisations may be strategically placed to address in the future implications for the public health research systems are important to help governments plan and improve health services for the public and to respond to new crises and outbreaks research in the health sector also can be a potential driver of economic activity innovation and growth yet many african countries still struggle with capacity in this important area regional organisations that are made up of and serve multiple member states across the african continent can play important roles in strengthening and coordinating health research at national levels this research helps understand the ways these regional bodies are working to do so and important gaps that could be addressed in the future it also proposes future directions for research to contribute to empirical exploration of narratives on regional cooperation for health research key messages plan health responses 11 12 13 national health research systems serve as a key component of a states ability to respond to both acute and longterm health needs 14 they however have also been seen to provide key economic development opportunities through specialised areas of expertise hightech employment and innovation thus we need better understanding and answers to an important question what is the role of regional bodies in strengthening health sciences research and health research systems within and between countries in africa hscir includes fundamental clinical applied and implementation research on human health and wellbeing as well as the determinants prevention detection treatment and management of disease 1516 the landscape of regional cooperation for health and hscir in africa has undergone key institutional changes at the continental level in recent years for example the launch of africa centres for disease control and prevention in 2017 and the transformation of the new partnership for africas development planning and coordinating agency into the african union development agency in 2019 have been two key changes there have also been several programmes initiated at the regional level to improve the funding of research and development including hscir towards meeting goals of the science technology and innovation strategy for africa 2024 of the au despite signposts of strategic activity in african regionalism for health the roles of regional organisations in hscir have not been extensively documented or analysed one important reason to explore their role is because regional cooperation may support opportunities for equitable improvement of hscir performance between countries in africa 17 research on national health research systems found that countries which showed higher performance on metrics such as publications and trials as well as greater human resources and institutional capacity have generally benefited from substantial longterm international partnerships and collaborations 1819 yet relying on international funding and partnerships to develop hscir at a national level risks generating inequalities between countries regional cooperation has been seen to be a useful approach to reduce inequalities in research capacity of national health research systems for example the development of a regional laboratory can bring efficiency gains to countries with little or no national research infrastructure 20 regional organisations could therefore in theory support a coordinated approach to strengthening hscir that reduces disparities in hscir between african states whether through regional financing schemes building regional centres of excellence 21 or promoting knowledge and technology transfer between african countries currently little is known about what is already being done by regional organisations in africa in this area drawing extensively from a research report 22 this paper therefore aims to understand what regional organisations are doing to strengthen hscir and health research systems in africa conceptual approach while the literature identifies some examples of regional bodies influencing hscir in africa we explore this more systematically by considering the key elements typically held to be central to state hscir capacity to do this we utilise the four key pillars of health research systems governance creating and sustaining resouces producing and using research and financing 23 these pillars and their subelements can be seen in figure 1 the pillars have been widely adopted to evaluate the functions of health research systems indeed the world health organization regional office for africa has formulated the targets in its regional strategy for health research in africa around these essential pillars and has been regularly assessing and monitoring the development and progress on each of them 27 28 29 30 31 32 consequently the pillars provide a comparable established and justifiable framework to consider how regional cooperation may contribute to strengthening hscir in countries and national health research systems specifically we explore which activities reportedly undertaken by regional bodies could support each pillar while also reflecting on what regional stakeholders think regional bodies can or should be doing in relation to each pillar to further identify gaps in areas of activity that may be particularly useful for regional bodies to address methods we mapped regional organisations across africa involved in hscir and conducted 18 interviews with key informants from 15 of them we defined regional organisations as those with membership of at least three countries within in any of the five regions of the continent defined by the au or with membership spanning more than one region we used this definition to emphasise the importance of regional organisations comprised of member states as distinguished from regional networks associations or consortia the former are likely to interact directly with representatives of government institutions as key policy stakeholders for national health research systems whereas the latter are more likely to have relationships with individual researchers research institutions or labs practitioners or nongovernmental organisations the mapping exercise aimed to identify african regional bodies active in at least one of the key pillars illustrated in figure 1 we began with a list of key regional stakeholders identified from previous research on national health research systems 18 and all regional economic communities of the au we further canvassed members of expert networks active on the continent to identify additional organisations ah conducted a manual search of all organisations websites and their governing strategic and policy documents to identify hscirrelated activity or stated impact in any of the four pillars organisations documents were also used to identify additional regional bodies for the list documents from newly identified organisations were then searched and the process continued until no new organisations were identified we included regional organisations if they met our broad definition of an african regional organisation had activity related to at least one of the key pillars and if they were not extensively governed by members outside the african continent following analysis by ah and cmj and indepth discussion with jst and rm the final stakeholder map was validated by all authors it included 22 main regional organisations the african academy of sciences was the only organisation we included which did not meet the eligibility criterion according to our definition of regional organisations our decision to include it as the only nonmember state based regional organisation in the study was justified by its relevance at the time of study as a regional science funding platform mandated by nepad for this purpose in 2015 we judged this decision acceptable given consensus among partners and expert networks about the unique position of aas with its mandate expanded in collaboration with an au agency to accelerate and fund excellence in african science including hscir 1 for each regional organisation ah collected the following data from their websites relevant suborganisations headquarters location official mandate for regional cooperation geographic subregion of the organisations mandate member states description of the organisations role in supporting hscir and links to hscir specific activity organisations were then categorised by their primary mandates in economic political or technical cooperation as summarised in table 1 ah in collaboration with cmj analysed data from the mapping exercise by looking for either evidence of involvement or declared goals or intentions of involvement in hscir based on information and documents from websites decisions about the classification of organisations according to whether throughout the recruitment process we identified the most relevant informants for interviews in dialogue with key contacts in these organisations only one informant declined to participate stating that their organisation did not do anything in the area of hscir however one informant was unable to find any availability in their agenda for an interview despite expressed interest and multiple attempts to accommodate their schedule and several did not reply to any email or telephone contact including instances when they were recommended by internal colleagues pillars for strengthening health research systems the data analysed for this paper come from 18 interviews conducted remotely mainly by jst rm and cmj with informants from 15 regional organisations between january and april 2021 half of the informants were in senior technical or operational positions and half were in executive and strategic posts the structured interviews asked about the roles challenges and opportunities of these bodies in strengthening hscir across the continent within and between countries jst rm and cmj deductively coded the interview data according to the key pillars for hscir that regional organisations are involved in how they are carrying out this work and in which pillars they perceive they are having impact cmj then carried out a comparative analysis of the activities across all the organisations seeking to understand the advantages different regional organisations have in working in particular areas the gaps in activities and common themes of barriers and facilitators for regional organisations working to support hscir in africa questions arising from the comparative analysis were discussed indepth together with jst rm cw and jp to validate the results collectively as a research team strengths and limitations there are several strengths of this study the use of semistructured interviews allowed us to query the perspectives and access the experiential knowledge of key informants working in regional organisations in africa these data are qualitatively different from information that would be gathered from documents or websites because the interview allows for followup probing and exploration of specialist and insider knowledge about the regional organisation which is well documented knowledge about interviews with decisionmakers 33 it is through methods of collecting data from interviews with senior executives and managers in regional organisations that we could best answer our research question about their role in hscir strengthening and gain insight into their perceptions of positionality and impact within a regional or national landscape to support health research systems as such our methods explicitly intended to collect data beyond publicly available communications such as websites and organisational documents to question not only whether regional organisations were involved in hscir strengthening but how they were involved the website content and policy documents to support our selection of priority organisations was generally limited to the continental organisations and rather scarce or absent for many regional communities despite their involvement as per our interview data the findings should be considered within potential limitations related to the representativeness of the organisations interviewed despite a rigorous and multifaceted informant recruitment process as detailed above several organisations and regional economic communities are missing from our interview data we do not think this is a major limitation as a comprehensive picture of every regional organisations role is not essential to meet our research objective furthermore we are not making claims of generalisability of our findings to all regional organisations in africa although we did not interview all prioritised organisations the representation of economic organisations mandated to improve the economic situation of african states such as trade organisations and economic cooperation groups political organisations mandated to regulate and negotiate political relationships between nations within africa such as multilateral organisations and other normative institutions technical organisations mandated to provide technical expertise support andor coordination of development activities or policy technical organisations mandated to provide technical expertise support andor coordination of higher education activities or policy technical organisations mandated to provide technical expertise support andor coordination of health activities or policy technical organisations mandated to provide technical expertise support andor coordination of science activities or policy a mix of regional organisation types and expertise make our findings on comparative advantages and common themes relevant as a purposive sample across this range however different strengths or gaps may have been identified by speaking with additional regional economic communities and other technical organisations like the east african health research commission which has a specific mandate in health research results most organisations interviewed stated being active in two or more pillars the most frequent of which were governance and producing and using research we found differences in involvement according to expertise by type of organisation the organisations which reported being active across all four pillars were generally those with health or higher education expertise the financing pillar had the least amount of reported activity from the organisations in our study table 2 provides an overview of the 15 organisations it presents details of each organisation and which pillars we identified where at least one activity was undertaken this is not weighted to represent volume of activity nevertheless it paints a broad picture of where different organisations efforts fit into a framework of improving core functions of health research systems looking at each pillar on an aggregate level we also found important differences within our sample when we compared regional organisations reported activities against those where they felt they achieved impact figure 2 provides this comparison governance of health sciences research the governance pillar refers to the policy and legal frameworks and institutional structures to steer and manage hscir including ethical governance most of the organisations we interviewed reported being involved in supporting the governance of hscir in africa in some way however africacdc and who regional offices were the regional organisations which appeared to have the most authority and leadership in this area across the continent we found the activities carried out by regional organisations involved in hscir governance to include agendasetting and strategy development the provision of guidance for national governance of health research the harmonisation of policies within regional communities and the coordination of national health research at the regional level overall these activities seem to focus on regional integration of policies regulations priorities standards and norms linked to hscir according to informants own perceived impact of their organisations their activities in this pillar appeared to have been successful within subregions especially when they are led by bodies with technical expertise in health or higher education the main mechanism by which regional organisations are involved in governance of hscir at the national level appears to be through their efforts to support harmonisation of national policies across four policy areas pharmaceutical policy public health policy higher education policy and intellectual property policy according to our interviews policies on medicines and therapeutics are one of the key regulatory policy domains which regional organisations focus their harmonisation efforts on to improve inspection approval and use of highquality and affordable medicines for example organisation de coordination pour la lutte contre les endémies en afrique centrale has developed a common pharmaceutical policy across its 6 member states and west african health organisation uses a single medicine registration process for all 15 of its member states many organisations have worked together towards the establishment of the african medicines agency by the au which was formally in november 2021 as the body responsible for regulatory systems for medicines and medical products in africa many informants expressed high expectations for this continental agency whose antecedent was the african medicines regulatory harmonization initiative by nepad implemented by regional economic communities with technical support from who some organisations also stated activities to harmonise public health policies and medical practices across their member states similarly regional bodies specialising in higher education reported focusing their involvement in hscir governance on harmonising policies and standards for academic professional development in universities and evaluation criteria for education quality for instance in 2017 east african heads of state declared the subregion a common higher education community to support integration of higher education policies and standards in various fields in the domain of ip african regional intellectual property organization promotes harmonisation of ip rights and laws within member states across multiple subregions we also found a group of intergovernmental organisations that are more specifically trying to set the agenda for strengthening hscir at the continental level organisations such as audanepad who africa regional office and africa cdc have developed strategies intending to establish a shared policy framework for countries to adapt and align their own hscir policies and programmes for health research systems 2734 who afro also has an internal mechanism to advise the regional director general on monitoring implementation of regional policy on health research and on supporting countries to improve their national health research systems the final activity carried out by regional organisations under the heading of hscir governance is the coordination of national health research activities africa cdc is a unique technical organisation among those interviewed due to its mandate from the au as a designated authority to coordinate the health research agenda and integrate research and analysis practices across the continent africa cdcs approach to coordination differs from others included in our study because the headquarters works through its 5 regional collaborating centres that have relationships with their corresponding regional economic communities and with member states through national public health institutes the strategic vision of africa cdc is to have a nphi in every african country to strengthen public health capacity links to its networked multilevel approach to coordination this contrasts to the coordination apparatus of who regional offices the other main technical organisation with a health mandate on the continent with more political features of coordination with direct relationships to governments through ministries of health one advantage of who however is the organisations presence incountry which in theory supports its coordination activities however informants underscored that whos comparative advantage as a normative organisation is around technical assistance guidelines and evidence support with its coordination efforts between states and other regional bodies not being its main strength key gaps governance multiple informants expressed coordination challenges due to limitations in member states willingness to collectively participate in policy harmonisation even if it falls within the mandate of the regional organisation from our interviews informants perceived the greatest gap when it comes to continentwide or interregional coordination few organisations seem to be coordinating across remits of multiple stakeholders at the continental level the audanepad mainly coordinates with the regional economic communities but not every bloc has an organisation with health expertise africa cdc coordinates with nphis via its regional centres and who coordinates with ministries of health while these au and un agencies may coordinate specific programmes there is no systematic general coordination happening nor is any agency formally mandated with responsibility for that across regional communities or continental agencies this siloed coordination poses a problem when regional bodies may not be liaising with the main institution mandated for governing the national health research system in a specific country creating and sustaining resources for hscir the resources pillar includes human resources institutional resources and research infrastructure we found that organisations with mandates in health higher education or science which had activities related to hscir governance were also typically involved in strengthening resources for hscir however this was less seen for bodies with economic or development mandates we found more regional organisations were involved in promoting human resources and individual skills for hscir and fewer to be involved in strengthening research institutions and infrastructure table 3 provides a summary of the range of activities by regional organisations to strengthen resources and infrastructure for hscir africa cdc who regional offices waho and cames were identified to be the regional organisations in our study carrying out the most comprehensive activities to strengthen resources africa cdc and oceac also reported supporting southsouth collaboration and knowledge transfer by twinning universities and labs for training exchanges for researchers we found that organisations like waho and cames have supported networking between research institutions but this was rare among the regional organisations in our sample who afro and africa cdc stand out in this pillar for their work across the continent with public institutions that make and implement decisions about hscir their efforts seem complementary with who working with governments through ministries of health and africa cdc with the public health workforce for hscir through research institutions and nphis working to improve national health research systems through its regional strategy for health research who afro advocates that ministries of health incorporate health research as a health sector responsibility and use research to improve policies programmes and interventions for example throughout the covid19 pandemic who afro has shared standard research protocols with member states to support rapid and rigorous knowledge generation across the continent furthermore both of the who regional offices covering countries in africa have carried out training to improve health research governance within countries which they reported has led to the establishment of ethics committees in several countries when it comes to funding programs for the development of human resources for research across the continent aas is a unique organisation among those in our sample designated by the au as an advisory and implementation body for its agenda 2063 and the science technology and innovation key gaps resources research infrastructure is critical within countries to have the physical environment equipment and material resources available for researchers the majority of regional organisations did not report being involved in or investing in research infrastructure development in member states while regional organisations for the most part do not fund health research infrastructure improvements regional centres of excellence have been cited as opportunities for hscir infrastructure development at the regional level regional organisations could also encourage and routinise hscir infrastructure development as part of any investment in human resources development despite the human resource development interventions reported the distribution of skilled researchers remains uneven across the continent multicountry teams have been set up by waho aas and cames but more can be done by regional organisations to facilitate networking as one informant emphasised this is a particularly important role for regional health organisations to convene research networks that foster equity in research collaborations by including researchers from countries without researchactive universities andor insufficient faculty for research education and training in their respective regions producing and using health sciences research the third pillar for strengthening hscir refers to the production and use of knowledge like the governance pillar most of the regional organisations we spoke to stated involvement in this pillar but few organisations were found to be involved in knowledge production itself some technical organisations in health are conducting hscir research inhouse but most are doing research with partners and consultants most of the activity reported in this pillar related to knowledge dissemination and translation we found this to be a potential strong comparative advantage for regional organisations which have the convening power and in some instances the official mandate to bring together researchers and policymakers to discuss research uptake regional organisations are playing a role in knowledge dissemination and use in multiple ways who emro and who afro have conducted training for evidence use in health policy and practice in countries that request it including for drafting policy briefs for decisionmakers they also advocate to member states to set up evidence into policy networks as part of their normative role to work with ministries of health to strengthen national health research systems the same regional organisations convene policy forums that bring together researchers policymakers and sometimes beneficiaries of the results to inform and raise awareness for using research in decisionmaking further mechanisms of who regional offices to support this are regional scientific journals and programmes such as the evidenceinformed policy network dissemination through publications best practice guidance and conferences are among the more traditional ways of sharing knowledge that regional organisations utilise but multistakeholder platforms that bring decisionmakers and researchers together was found to be the most common knowledge translation strategy used for example the ecsahc sees its primary role as one of knowledge translation by facilitating access of national policymakers to research that responds to their policy challenges such as through their best practices forum but discussions about evidence use are also part of their core business working with ministers of health in the ecsahc annual meetings some organisations have also used multistakeholder platforms to support innovation for example the iuceas academia publicprivate partnership forum is a platform that brings together universities government and private sector to create synergies and facilitate innovation and commercialisation key gaps production and use many regional organisations have the authority and legitimacy to help facilitate platforms that convene and connect epistemic and policy communities however few of them have the mandate or capacity for coordinating or managing such multisectoral networks on an operational level unless supported through a longterm program the regional organisations interviewed for our study also do not really have the mandate to produce knowledge with a few specific exceptions the majority generate data on specific themes through partnerships with universities or research institutions the au and who have been promoting evidenceinformed decisionmaking for several years and regional organisations generally reported that the forums they organise contribute to that agenda the knowledge translation and dissemination work was reportedly carried out by regional bodies through specific platforms to increase research utilisation but many informants expressed that this must be supplemented by advocacy for research use to government policymakers but informants recognised that there are still gaps in capacity for research use by policymakers noting room for improvement in advocacy this ongoing advocacy is seen as fundamental from the perspective of regional organisations because multiple informants highlighted that the lack of understanding prioritisation and value of research by decisionmakers is one of the major barriers to research use they encounter the knowledge translation and policy platforms at the regional level should be supported by improving capacity within national institutions to use health research such as through dedicated research synthesis units however informants underlined that the ability to use research also relies on the receptiveness of decisionmakers and whether and how they consider research in their decisionmaking process financing health sciences research financing represents the final core pillar explored capturing funding for hscir at the regional level or contributions to funding schemes or programmes at the national level we found fewer regional organisations involved in hscir financing than in the other three pillars of health research systems even for organisations with a health mandate internal funding was marginal organisations generally sought funds from partners for research grants to incountry teams in member states or to conduct their own research however as reported above few have mandates for knowledge generation regional organisations in our study reported more indirect involvement in hscir financing through networking between their members and international donors and advocating for funding from national budgets of african governments there are a few organisations contributing directly to funding hscir in member states but this is on a limited scale except for aas whose mandate is to fund and promote science technical organisations in health were found to be the main regional bodies providing hscir financing through small grants or facilitating access to research funds through collaborating partners for example several organisations fund research projects on themes of interest while who emro offers competitive research grants to countries in the region key gaps financing as an au agency audanepad was the only organisation interviewed that has the potential to reach and interact with wide range of government ministries other than health and heads of state but there has been limited success in advocacy to convince governments to invest in hscir although some organisations reported that efforts to increase health sector budgets have seen some improvements nearly all informants cited dependence on foreign and external funds as an important barrier for ownership and local benefits of hscir on the continent international partnerships are also facilitators for hscir capacity strengthening but informants were concerned that reliance on these funds could have negative impact on longterm sustainability of independent researchers and research institutions in africa regional organisations we interviewed expressed that regional economic communities should be more involved in mobilising alternative sources of funding to supplement public investments from governments and universities in hscir several informants highlighted two important targets of advocacy for hscir financing which they considered gaps and untapped resources and which regional organisations are uniquely positioned to approach the first is development finance institutions such as bilateral and regional development banks which have become increasingly interested in health yet questions remain about how regional organisations can advocate convincingly to these finance institutions on behalf of the member states the second new target for advocacy is the private sector and business informants from several regional organisations acknowledged that their engagement with the private sector as a source of investment in hscir has been lacking despite the potential to do much more with this sector in africa one way to do this could be for regional organisations to work with member states to sensitise governments to the benefits of private sector investment in hscir regional economic blocks could also help create a legal environment for private sector investment in national health research systems and private sector institutions as research producers several informants noted that large african corporations could contribute to financing hscir in a sustainable way for example the unitaid model is one potential mechanism that might be adapted in the african context as innovative financing through the private sector organisations like audanepad sroeauneca and afdb have opportunities to advocate for economic development through innovation agendas but they have not been actively fostering connections with private sector and industry in their activities with countries crosscutting issues looking across regional organisations involvement in these pillars we can identify several barriers and facilitators to their ability to help strengthen hscir in countries such as the lack of prioritisation of hscir at the national level donordriven hscir priorities histories of collaboration between groups of member states and the internal institutional capacity of regional organisations to collaborate and work in hscir some of these are also among important challenges for regional organisations previously identified in wahos work to strengthen hscir in west africa 35 three key crosscutting issues emerge from our analysis as particularly important in influencing regional organisations involvement in strengthening hscir in africa mandates matter in analysing organisations activities related to strengthening the pillars of hscir institutional mandates and areas of authority of regional bodies were among the most common influential factors mentioned that affect their involvement in any given pillar while many regional organisations share a general mandate to support integration the policy areas that this extends to and the resources available to facilitate and maintain programmes to achieve that agenda vary organisations with policyarea mandates related to line ministries responsible for governing hscir at the national level seemed to have comparative advantages in pillars of governance creating and sustaining resources and using research this technical expertise and mandate come through as important factors which are supported by their relationships and access to experts and decisionmakers including through policy and epistemic networks in their member states in these policy fields however even when health is part of an organisations core mandate there is no regional organisation in our study whose mandate is health research or hscir the au and un organisations like africa cdc audanepad and who regional offices are unique technical organisations given their intergovernmental mandates for health or development across a large geographic scale each have different institutional designs with mechanisms for working with member states africa cdc through its 5 regional collaborating centres audanepad through the regional economic communities and who through direct work with countries via ministries of health and their country offices this contrasts to the work carried out by regional bodies in subregional blocks with technical organisations in health and development who work directly with dedicated country representatives from ministries to their organisations and other institutions like universities in member states power institutional authority and state sovereignty related to mandates and institutional design regional organisations were also found to exercise their authority to support hscir in different ways for example many organisations exhibit epistemic power within their domains of expertise as recognised and legitimate authorities in policy areas of health development education or science however the expertise of regional organisations is moderated by constraints on their persuasive or coercive power to effect and enforce change based on their expert knowledge structurally many of the regional organisations we interviewed are governed by member states and as such statebased regional cooperation relies on the decisions and voluntary actions of states which can be a barrier since regional organisations do not have authority to enforce national implementation of decisions taken at the regional level many reported that the commitment of membership to regional work is necessary because state inaction or state action that does not align with regional priorities can hinder progress one of the main strengths of regional organisations is their convening power and access to decisionmakers which is an asset for advocacy many of them have direct access to ministries of health education science and innovation or finance as well as heads of state in some instances this provides opportunities to influence political commitment create dialogue and mobilise african and international stakeholders however translating institutional legitimacy and prestige into action for strengthening hscir at the national level has seen slow progress and with varied results for instance the development of the audanepad continental strategy for health research and innovation in africa 34 has demonstrated the epistemic and convening power of the organisation to engage with the regional economic communities member states and other stakeholders to collectively set and agree on an agenda but moving towards its implementation may require other forms of power and cooperation that can leverage support produce change and foster collective action collaboration trust shared interests national priorities the final crosscutting theme for regional organisations is collaboration with their member states and other stakeholders barriers to collaboration included the difficulty to work across partners and member states who have different and sometimes competing priorities the history of collaboration in a subregion and strong networks between the countries were seen to be valuable foundations for proactive and sustainable approaches especially when they can link up with the work of centres of excellence and research leaders in the subregion as seen in west africa there was strong agreement in the data that collaboration with trusted partners had been vital because most of the work by regional bodies on hscir is done through collaboration research on regional collaboration for hscir in other regions across the global south has also shown the role of partnerships with national research institutions international ngos development partners and funding agencies to be critical to the success of regional organisations work to strengthen hscir 36 37 38 regional organisations noted that they can often be in the positions of brokering such collaborations between external partners and member states or african partners and as such they try to ensure those have mutual benefits for countries however dependence on these funds can risk concentrating hscir in areas of interest to international partners for which the outcomes do not necessarily address the priorities for the country or needs at a more local level this is a concern for regional bodies which help to connect external funders with member states since these organisations can be used by interests from outside the region to influence african decisionmakers discussion our results on the role of regional organisations in relation to the four key pillars of health research systems have shown that organisations with technical mandates in or related to health reported being engaged in all pillars with the most activity in governance and the use of health research regional organisations involvement in governance was mainly reported around setting regional agendas and policy harmonisation across member states for those that reported contributing to the development of resources for hscir it was mainly through initiatives for strengthening human resources with few involved in developing research institutions networks or infrastructure overall regional organisations reported being more involved in dissemination than production of research with respect to funding regional organisations were more indirectly involved through facilitating contacts between funders and research teams or advocating member states to increase their budgets for hscir regional organisations identified several gaps in activities where they believe their involvement should increase better coordination within and across subregions strengthening infrastructure for hscir at the national or regional level improved training and advocacy for research use and engagement with the private industry sector and development institutions to increase financing of hscir beyond the individual pillars however we also identified key crosscutting themes in relation to mandates authority and collaboration that were particularly relevant to shaping the influence and activity of regional bodies on hscir in africa from our findings we identify three issues for regional cooperation in efforts to improve hscir in africa first more clarity is needed on the role of regional organisations in framing the agenda for strengthening hscir in africa this raises questions about whether governance of hscir at the regional level is topdown or bottomup regional organisations work in different ways within the institutional landscape of health governance more globally at the interface of the global arena and the nationallocal arena 39 in some instances they serve as an intermediary within a topdown approach to governance and adapters of global standards norms and practices 4041 in others they act as a convenor of local or national expertise and interests to coordinate and advocate a bottomup approach to health and rights 3 42 43 44 these are not mutually exclusive and organisational behaviours and strategies may shift in response to internal or external factors in both modalities the proximity of regional organisations to a broad range of national stakeholders is an asset for example in this study we found intergovernmental organisations are developing strategies and frameworks for countries to adapt and align their national policies and programmes for health research systems yet it is unclear whether these regional policies are intended for policy transfer and replication in countries or whether they are rather intended as targets to set evaluation criteria against which progress in countries will be monitored by regional organisations organisations see their role as providing implementation support for these policies but this is still lacking on a wide scale with seemingly little being reported by regional organisations to support policy learning among countries and challenges to tracking the implementation and impact of regional policy decisions in individual countries second the ways that regional organisations build support or participate in networks for hscir are unclear whether that is in research networks or networking between regional organisations and other hscir stakeholders in their region previous research on national health research systems has shown that regional research networks can be important mechanisms to foster research leadership and research culture as well as generate advocacy for hscir within countries 18 we spoke to only two organisations that reported actively and financially supporting the development of regional research networks in africa however regional organisations recognised that a lot of research capacity development at the regional level is supported by regional networks research platforms and think tanks and often with collaboration of universities and other partners both within and outside africa like the african population and health research center there is an opportunity for networking the networks that could fit within the broader integration mandates of regional organisations to facilitate synergy for health research networks to interact and serve as key resources for regional organisations work with member states especially given overlapping memberships when states belong to multiple regional organisations further it may be important to consider the networks that regional organisations belong to as context for understanding their activities and roles in health and hscir third there is incoherence in the lack of development of regulatory institutions for health research or science and innovation despite the larger efforts to harmonise regulation in subregions for select policy areas similarly international funding is rarely available for regulatory capacity strengthening at the national level 18 yet developing statutory institutions for hscir with regulatory and coordinating mandates support an enabling environment especially to integrate coordination between government authorities and research institutions 1845 relatedly while many national decisionmakers and researchers see the development of a national health research law as the gold standard for formalising the national health research systems 45 none of the regional organisations in our study reported working with countries to support the development of a legal framework for hscir there is emergent knowledge on the health policy agendas and programmes of regional bodies in africa that when put in conversation with our findings offers perspectives for further research notably yeates and surenders analysis of regional economic communities integration of health policy into their overall policy functions found that public health and healthcare is increasingly a strategic interest of these regional structures but with differences in the way health policy is institutionalised and prioritised at the regional level 46 although yeates and surender use a health systems framework for their analysis of health policy and programmes there are analogous themes and crosscutting issues to our findings from using a health research systems framework for instance yeates and surender highlight that responsibilities for health within regional economic communities have not always been consolidated under health directorates although some communities have their own regional health or health research organisations one of their significant findings is the persistence of a siloed vertical and narrow approach to health within regional health policy and programmes without much emphasis on health system strengthening or universal healthcare 46 we suggest that this lack of integrated and crosscutting approaches within the health domain at the regional level raises questions about institutional capacity of some regional organisations to address hscir pillars across sectors our research has shown that health research systems at the national level are intersectoral by definition involving health higher education and science technology and innovation policy actors and stakeholders 18 so when health policy within regional organisations is structured by discrete issues or driven by funding of shortterm projects this may be a challenge for supporting health research systems which necessitates working across severalsectors within states regional organisations may only have ministerial counterparts and state representatives in a single sector the means that it would be difficult to inform and advocate for regional level support and involvement in strengthening hscir especially from member states with weak coordination of the national health research system ultimately regional organisations are mainly governed by ministers and representatives of member states while continental organisations vary more in terms of accountability mechanisms thus the wishes and resources of member states are indispensable for the definition of regional priorities and their implementation based on results from both studies one avenue of future research on why some regional organisations are not reporting any activities in health or health research to understand why member states are not using regional governance as a strategic venue to support their national systems related to this yeates and surenders conclusion is critical of the health policy approach and discourse of regional economic communities as being framed more through an economic growth than human rights and social justice lens 46 whereas we found that the use of an economic growth frame for strengthening health research systems is desirable by many state actors as it provides an objective which links to national development plans that prioritise transitions to knowledge economies underpinning strategies being advanced by states for investment in research development and innovation 18 the results of the present study highlight the actual and desired role expressed by regional organisations for advocacy to improve sustainable financing for hscir and their framing of the need and multiple benefits for these investments will be a critical aspect of how they fulfil their role but there are clear signs of rapid advancements in regional policies and strategies related to health and health research facilitated as a consequence of health crises yeates and surender note that several activities to strengthen regionalist approaches to health like in regional disease surveillance are relatively new since the west africa ebola outbreak of 20142015 46 similarly there have been multiple initiatives by the au and africa cdc since the beginning of the covid19 pandemic made possible through regional cooperation and coordination to build regional efforts around preparedness and response to health crises including strengthening hscir 47 conclusion within the literature on regional cooperation and health in africa this is one of the first attempts to identify and explore what regional organisations are doing to strengthen hscir and what roles they play in supporting health research systems in africa our findings show that many organisations are doing something related to supporting hscir but technical organisations with mandates or expertise in health or higher education policy fields seem to be most involved with activities across all key pillars of health research systems whilst regional organisations are not contributing much directly to financing hscir they are advocating for african governments to increase investment in hscir future development of hscir in the african continent should include strategic thinking about the roles comparative advantages and capability of regional organisations to facilitate hscir capacity and growth regional bodies in africa will no doubt play a key role in this particularly in the wake of covid19 we hope this mapping and analysis can help contribute to future work in this important area ethical issues the lse research ethics committee approved the study and informed consent was obtained before all interviews either verbally or in writing competing interests authors declare that they have no competing interests authors affiliations 1 department of health policy london school of economics and political science london uk 2 recherchesanté développement yaoundé cameroun 3 the centre for rapid evidence synthesis college of health sciences makerere university kampala uganda 4 lse health london school of economics and political science london uk endnotes 1 since the time this research was conducted and data analysed in april 2021 with the paper submitted in may 2021 the aas is no longer serving in this capacity as host and implementer of a financing platform due to an internal governance crisis 48 the alliance for accelerating excellence in science in africa initiative has been reestablished as the african science foundation in december 2021 temporarily hosted by price waterhouse cooper in kenya also as of december 2021 audanepad is host of the coalition for african research initiative supplementary files

background regional cooperation on health in africa is not new the institutional landscape of regional cooperation for health and health research however has seen important changes recent health emergencies have focussed regional bodies attention on supporting aspects of national health preparedness and response the state of national health research systems is a key element of capacity to plan and respond to health needs raising questions about the roles african regional bodies can or should play in strengthening health research systems methods we mapped regional organisations involved in health research across africa and conducted 18 interviews with informants from 15 regional organisations we investigated the roles challenges and opportunities of these bodies in strengthening health research we deductively coded interview data using themes from established pillars of health research systems governance creating resources research production and use and financing we analysed organisations relevant activities in these areas how they do this work and where they perceive impact results regional organisations with technical foci on health or higher education versus economic or political remits were involved in all four areas most organisations reported activities in governance and research use involvement in governance centred mainly around agendasetting and policy harmonisation for organisations involved in creating resources activities focused on strengthening human resources but few reported developing research institutions networks or infrastructure organisations reported more involvement in disseminating than producing research generally few have directly contributed to financing health research informants reported gaps in research coordination infrastructure and advocacy at regional level finally we found regional bodies mandates authority and collaborations influence their activities in supporting national health research systems conclusion continued strengthening of health research on the african continent requires strategic thinking about the roles comparative advantages and capability of regional organisations to facilitate capacity and growth of health research systems

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introduction 11 background online carnivals in the chinese context have received extensive attention from english literature however under a double burden of both difficulties of data collection due to strict censorship and linguistic barriers behind the highcontext languages few has paid attention to the content and form of carnivalesque language in the chinese context and the presentation of its features of transgression and polyphony in addition as a hot theme in digital carnivalesque activities the exposure of corruption has not received enough attention from the english academy either this article attempts to fill these gaps it explores online discourse on corruption incidents and the content and form of carnivalesque languages in the chinese digital context by using the qualitative method this paper argues how the theme of hatred for the rich behind complex sentiments are generated and shared in digital carnival and how attenders form responses to the mainstream language in the quasiseparate space under authoritarian censorship via egao production theories on online carnival and social media vernacular carnivalized activity has a long history in the material world the motivation of which originates in sensual confrontation against the official serious and hierarchical world of order where the privileged have the power to dominate the common masses who are submissive when facing authoritarian oppression and religious dogma from medieval squares to virtual cyberspace the internet enhances carnival in the digital filed by applying global open access decentralized interactive modes and personal empowerment of the internet in a cyberspace that is not limited by geographical striction the dissemination of information easily occurs among attenders of distinct regions cultures and identities everyone shares the same identity netizens as a response to reality the free but virtual utopia brings the imagination of freedom and equality reflects an inverted version of the real world and forms a contrast those who live in rigid discipline and enjoy the subordinate status of others are pulled out of their status in the hierarchy obtaining a fresh cyber identity they either join the grassroot and become carnivalesque attenders on a cyber square or become objects of ridicule from the former in carnivalesque activities the text of languages serves as a medium of symbols for communicating behaviors and symbolizing interactions the language of the wild in the carnivalesque escapes from the characteristics of written and formal language in the order world both in form and content as informal combinations of words and phrases online carnival language does not follow the requirements of formal language in terms of grammar vocabulary sentence pattern etc in terms of content carnival language is free from the formal official and serious requirements of written language and is full of exaggerated ironic and comedic expressions of emotions carnival language is also a mirror that reflects the dominant style of discourse it breaks free from rules and hierarchies and responds to the polite and official narratives of the former through unorthodox expressions such as insults and cursing however carnivalesque language is not only an escape from reality but also a return in the online carnival language is the mask and costume of inverted identities endowed by the attenders behind which people wantonly take on different roles and make performances satirically mimicking the serious behaviors of those in power and endowing with hilarious traits through the creative reuse of official language in addition as a linguistic toolkit carnival language also imitates the mapping of sensual and physical contact in the material scene in the linear and cyber plane it also releases passions and desires of a subject which are suppressed by the seriousness and strict hierarchy in the daily routine and resonated with others in the virtual square of carnival full of a sense of catharsis subversion and popularity the authoritarian character of carnival in the chinese digital context is characterized by strict censorship on keyword searches to limit the presentation and dissemination of certain information making the cybersquare as quasiseparate space impure as not absolutely free and partially restricted thus since the suspension of all hierarchies privileges norms and prohibitions is nonexplicit attempts at collective resistance within bakhtins theoretical framework appear to be weak and exhausted rather than politically progressive in the chinese digital environment scholars have abandoned the full retention of the politicized character of the carnival in favor of focusing on its original part venting emotions in an ironic manner rather than a form of direct resistance because such an activity does not set off a social movement or pose a direct threat to the party and the state many scholars have conceptualized egao to examine the hidden features of the carnivalesque language that represents netizens redeployment of such censorship as a weapon of satirical criticism egao is a satirical wordplay with a sense of dark humor irony and satire often to mock and ridicule power holders compared to the wild vernacular egao clearly carries a stronger subjective intention in online culture its the practice of puns and wordplay to simultaneously mock and evade censorship however egao is not the entirety of carnival language direct and aggressive expression is also a faction of carnivalesque literature in the following section this paper also focuses on the direct expression of carnival texts as carriers of emotions and their meanings in a sociocultural perspective as there is little englishlanguage literature that focuses on the complexity of chinese as a highcontext language and the interplay of diverse forms of spoofing currently the english literature focuses only on its subtle resistance to the censorship on keyword how does egao manifest itself in longer and more complex carnivalesque language such as sentences most of these keywords are homonymic transformation of political events people or even names of political movements therefore mastering only textual analysis of keywords is far from truly management the original text base of the dominance of egao research method this paper conceptualized two types of carnival languages namely the direct expression and egao in the chinese context to make a theoretical extension this paper would focus on the egao production of phrases sentences instead of simple key words this paper chooses the exposure of corruption cases as an entry point to study chinese netizens carnivalesque behavior and language online englishlanguage scholarship has not paid due attention to chinese netizens fervor over corruption cases it is worth mentioning that the targets to be paraded and abused in the virtual carnival is always the corrupt cadres being abandoned by the government instead of the later itself this paper examines the feelings of carnivalesque netizens towards corrupt officials and the vehicle through which they express such feelings the language of carnival this paper adopts a qualitative analysis method to collect reports on corrupted officials incidents and the netizens comments on the incidents in social media it firstly collects and combs reports on the corruption officials incidents on the internet through official mouthpieces we media platforms the governments webpage and other social media this article also collects netizens comments on carnivalesque activities on specific corrupt officials exposures on zhihu weibo little red book wechat baidu forum tianya forum sohu and other public platforms amounting to a total of 325 netizens textual comments which are mainly produced in focused discussions on social media platforms or in the comments sections of news report however the strict official censorship mechanism makes it difficult to organize news and comments that are made years ago so this paper mainly forms its analysis on recent data afterwards this paper categorizes analyzes and decodes linguistic symbols in netizens comments this paper conducts indepth semistructured interviews with a sample of 16 netizens who posted comments as attenders of the carnival via phone conversation the interviews cover their linguistic deployment as participants in the carnival as well as the generation of emotions the sample in this paper does not wipe out differentiation in demographic characteristics of the disproportionately large china digital languages in carnivalesque activities expose of corruption incidents initiating heated discussion online the internet amplifies the negative social impact of official corruption by exposing it to the public corrupt officials receive public attention and heated debates when substantial evidence of their acceptance of bribes abuse of power or extramarital affairs are posted on the internet this paper first summarizes the cases of internet corruption exposures since the decades and presents them chronologically in table 1 the expose of corrupted incidents mainly took place before 2013 a case that sparked internet media coverage and widespread discussion among netizens on all major platforms that year was the incident of the badger game of lei zhengfu in 2012 a video of him having sex with a woman was intentionally exposed by criminal groups that intend to blackmail him on the internet he was discharged from his position because of the enormous political damage caused by public attention and was later jailed after being found guilty of taking bribes the case of lei was the start of a badger game on cadres to ousted them and subsequent cases with similar scripts have even been named after it such as the case of six lei zhengfu in hengyang in 2014 the case was broken by leiyang online forum in which six officials were blackmailed by a criminal syndicate after a video of their sexual relationship with a woman broke in the end the officials involved were dismissed from the party and administratively removed from their posts substantial evidence of inappropriate relationships between officials and women can cause huge repercussions when it festers on the chinese internet similar cases include the case of the onehusbandtwowives secretary of district committee the guangxi sexual photo gate and the diary gate of the tobacco bureau it is worth mentioning the latest case of a stateowned enterprise cadres careerending stroll a street photographer in the commercial center of chengdu inadvertently took pictures of a married stateowned enterprise cadre holding hands with a young woman who also works in the company which then set off a firestorm on major online platforms subsequently the authorities investigated and dismissed the cadre for the negative social impact he caused which is not corruption or abuse of power in addition to scripts that come to light on the internet as a result of inappropriate malefemale relationships exposure to bribetaking or abuse of power is also a common narrative early exposures of related cases include the case of the director of high price tobacco official zhou jiugeng was brought to the attention of netizens for making inappropriate comments in front of the media he was then exposed for his high spending on cigarettes watches and automobiles whose incomes were not comparable to his job title the authorities then launched an investigation and zhou was finally sentenced to 11 years in prison similar cases include a case of the expensive watch bro case the expensive watch bro who was discussed by public opinion for wearing an expensive watch at work and was eventually found to be corrupt the housing girl zhai jiahui whose father was investigated as a cadre for having multiple properties exposed on the internet and case of guangzhou housing uncle cai bin case the above cases sparked a wideranging discussion on social media as soon as they came to light and were addressed on various platforms the carnivalesque catharsis of emotional gathering behind haterich mentality the unfolding of clues and incriminating evidence about officials corruption involves netizens human flesh searching and extracting information about them the widespread and rapid dissemination of messages also unfolds in the textual activities of the internets carnivalesque activities this section discusses how the symbolic language of internet carnivalesque activities serves as a vehicle for the hateful mentality of the rich carnival activities are emotional and such emotions get resonated with others in the virtual square of the carnival as cyberspace of an imagined utopia the emotions of netizens towards the official corruption incidents are complex embodied in jealousy anger dissatisfaction disappointment and confusion as a mapping of the world of order the emotions in the frenzy are amplified and festered in the debate on the gap between the rich and the poor and social inequality based on the generalization and decoding of the data the motivation for the fermentation of emotions can be categorized as a hatetherich scenario which is reflected in the irrational and unconventional negative representations of keywords such as the rich the dominate the powerful and the privileged in the data the hatred of the rich can be interpreted specifically as hostility to the high consumption level of officials and the illicit sources of their wealth as the combination of the two counteracts the legitimacy of the hierarchy of the existing order the rhetoric of the wealthhatred episode is often expressed in carnivalesque linguistic form and content there is a great deal of namecalling sarcasm and cursing abuse of the appearance and behavior of the officials involved is a common phenomenon in literate production for example a comment discussing lei zhengfu on a social media platform said there are people who want to get laid with a man like him with a pigs face and a pigs body so its no wonder hes a rich man there are tons of similar comments about lei zhengfu in forums lei zhengfus looks are considered ugly in internet comments the comment involved an insult to lei zhengfus looks and an analogy to a pig which is synonymous with uglylooking animals in the chinese context in addition curses appeared frequently in comments on incidents of corruption and bribery by corrupt officials corrupt dogs raiding peoples fat the corrupted should die and so did there all families bad luck for eight lifetimes expletives that are not recognized by mainstream representations also appear frequently such as direct insults like dog bastard asshole another is a way to use carnivalesque language as a parody of physical contact in the material world simulating scenes of corrupt officials inappropriate sexual behavior through the verb all he knew is to insert insert and insert all day with his beauty in virtual carnival attenders simulate behaviors in the physical world through their vivid and informal deployment of verbs which are used to construct virtual stage scenes as an essential part of the carnivalesque performance these languages exemplify the deviation of carnivalesque language from the language of reality which serves as a vehicle of outward sentiments with means of direct expressions carnival rhetoric is the vehicle and tangible manifestation of the hatred of the rich hatred of the rich could be observed prominently among the participants and was characterized by a range of negative emotions such hatred of the rich is fueled by improper sources of income besides emotional expressions offer netizens the possibility to form and strengthen a common identity the same emotional flow is generated in the discussion of the incident of the corrupt officials and such emotional flow makes the participants develop a feeling of a collective hatred of the rich in the carnival people perform on the virtual stage display the symbols of the carnival language in the interaction and strengthen the identity of oneself as a participant of the carnival as well as a holder of the viewpoints as in an interview with a netizen informant i feel great joy and a sense of belonging i get a lot of likes and approval from many netizens for a casual insult to a corrupt official online in real life i would be called vulgar and rude so i had to hide it netizens from all over the country broke through the georestrictions and gathered in the virtual square of cyberspace to speak their minds people disguise themselves as anonymous netizens to participate in the grand carnival ceremony in which they share their common negative emotions of anger dissatisfaction disappointment and confusion and try to focus amplify and demonstrate against corrupt officials in cyberspace through words the shared discontent and the underlying hatred of the rich make them share a sense of collective belonging and strengthen their identity in real life the repressed emotions of dissatisfaction and anger towards corrupt officials are fully released on the internet recreation and reuse of mainstream language carnival behavior attempts a weak criticism against authoritarian order the finding of this paper discusses the language of carnival in chinas digital context as a weapon of satirical criticism in terms of the seriousness of its authoritarian propaganda the depoliticized playfulness of its archaic features the deconstruction in the language of satire and the circumvention of its strict censorship the censorship of the chinese internet is considered too strict and its locking of various keywords leads to the restriction of netizens free speech expression to circumvent censorship netizens strategically use expressions that imply cryptic symbols to avoid censorship and to express their own intentions whether politicized or apolitical this paper focuses on one of these strategies egao which based on our interview data can be referred to as reusing the positive in a negative sense or an ironic repetition of positive mainstream discourse netizens try to deploy positive speech to express the nonmainstream ideology or obscure message hidden behind it which needs to be decoded by the viewers specific sociocultural context when discussing corruption incidents the deconstruction and reuse of official language used to promote their ideology and of words that have a positive connotation in the chinese context has become a twofold way to avoid political censorship and to express their views in a witty manner for example a comment on the woman involved in the soe cadres careerending stroll incident who had an inappropriate sexual relationship with an official described the woman in question as a female celebrity with an establishment of stateowned enterprises the woman was a former established employee of a stateowned enterprise in this comment the formalized word establishment of soe describes the type of employment relationship the woman has with the company ie her personal information is entered into the establishment committees files and the employee serves as a regular staff member of all levels and types of agencies institutions and some special institutions under the jurisdiction of the state mingyuan which originally meant a young woman born into a privileged class family was later used pejoratively in the internet context as a proxy for prostitutes this comment combines mainstream positive words and is deconstructed by the viewer in the carnival context as a veiled satire on the womans status as a woman with a good social status and a stable job but who has become a common target of the internets crusade because of her inappropriate relationships with men and women in addition speech that is not on the blacklist of keywords is able to evade authoritarian censorship mechanisms tactfully and strategically according to our interviews with the informant other comments involve the deconstruction of serious language and the avoidance of authoritarian censorship and these remarks need to be analyzed in the sociocultural context of the chinese internet an example is the deconstruction of the identity of corrupt officials as leaders leader or lingdao is a serious identity construction in the chinese context representing an individuals privileged social status economic wealth and political power quotations used in mainstream language to encourage praise and glorify leadership and its deeds are used in the carnival to satirize and parody its corruption and other violations of morality and law eg the leader has the best eye for hiring no wonder the leaders are so busy they are cultivating the passion for work of their female comrades and no wonder the leaders are so busy they are cultivating the passion for work of their female comrades and no wonder the leaders are so busy they are cultivating the passion for work of their female comrades and everyone do their own work and do not pry into the affairs of the leaders according to an interview with an informant as a viewer of the above comments informant i consider these words are very ironic leaders are good at employing people and are teased for being good at digging up women as concubines leaders are busy with their official duties and are teased for spending time in illicit relationships with female subordinates doing ones job well means not prying into the private life of the leader or beware of being removed from office the above statements continue the behavior and approach of the mainstream discourse in the carnival context retaining the original words of praise for the image of the leader as busy with official duties good at exploiting the strengths of subordinates positions and authoritative in the hierarchy but giving it a completely different meaning in the carnival context the carnivalesque language of the chinese context hides its true attributes under authoritarian scrutiny in a covert highcontext mode a carnivalesque parody of the corrupt officials subordinate staff status quoting and improving on his mainstream serious language represents a mask a performance of identity and a parade of his leaders bad deeds designed to tear down the hypocrisy of the serious propaganda and expose its hidden signs of ugliness conclusion and discussion taking the exposure of corruption cases as an entry point this paper explores the theme of carnivalesque activity in chinas digital field which is the carnivalesque presentation of the hatred for the rich mentality in public discourse by taking carnivalesque language as its vehicle this theme also becomes the source and motivation for the dissemination and sharing of carnivalesque sentiments on social media in addition to the production of direct carnivalesque language such as curses insults or virtual parodies of physical contact in the material world nondirect carnivalesque language can also be an ironic parody and repetition and reappropriation of real language in other words this paper conceptualizes two types of carnival language in the chinese context which are detachment from and return to real language the direct informal expression and the implicit reuse together constitute the two parts of carnival language which suggests that carnival language is a mirror independent of the real world and that it also reflects the content of the reality with netizens heated debates over the exposure of corrupt officials as an analytical focus this paper explores the gap left by previous research on the linguistic content and form of egao in the chinese electronic sphere as well as the themes hidden behind the complex emotions of egao activities previous articles have conceptualized the notion of egao which has been used to analyze chinese netizens use of homophones of keywords as a strategic deployment to evade the authoritarian censorship mechanisms of the chinese internet this paper expands the study of the word source pool of egao to include key phrases and sentences in addition to keywords and provide empirical data as evidence this paper argues that egao as part of carnivalesque language takes the form of not just a redeployment of keywords but also a reinterpretation and use of the vocabulary and syntax of the dominant language the politically progressive nature of online carnival has been the subject of scholarly scrutiny the deployment of egao reflects netizens avoidance and protest against authoritarian censorship rather than direct conflict and the target of their offense is also corrupt officials as criminals rather than the government since no transfer of netizens discontent from the incident into a critique of the governing paradigm is reflected in the interview data besides the spurning of the corrupt is highly consistent and largely overlaps with the communist partys concept and implementation of governance since president xi jinping came to power in 2013 the anticorruption storm on the mainland has continued unabated for more than a decade such findings provide new perspectives as well as challenges for the study of internet carnivalesque activities in china its status as an activity strictly subject to authoritarian scrutiny is surprisingly characterized as a noninstitutional anticorruption political activity as a start this paper focused on analyzing the textual content of carnival literature because it is through a full understanding of its texts that a discussion of its political significance can be made meaningful 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

discussion on corrupted cadres is heated in the chinese digital context which is categorized as being carnivalesque by the chinese academy however it did not draw enough attention from english literature under carnivalesque theory this paper tends to fill the gap the objective of this study is to explore the language production of the carnivalesque vernacular in the chinese digital context it collects 325 comments on chinese social media on the expose of corruption and conducts indepth interviews with 16 informants as attenders of the online carnival the results of the study revealed a landmark compilation of the hot debates on corruption in public discourses and illustrates the content and form of carnivalesque languages in a chinese context in content it serves as a vehicle of a mentality of hatred for the rich behind a complexity of emotions and assists in negotiating with authoritarian censorship mechanisms through egao production besides it is a complex of disengagement from and return to the compared language in reality