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introduction overall life satisfaction among older adults is a central indicator in aging research representing a cognitive evaluation process of the subjectively perceived quality of life 723 life satisfaction is influenced by numerous factors which are closely linked to social inequality 16 in this context poor health low financial resources or social isolation are considered as typical threats and potential stress factors that may lead to adverse outcomes in life 11 these factors can unfold an enormous negative impact on the perceived quality of life in old age 221 the association of risk factors with adverse outcomesin this case a marked decrease in life satisfactioncomes into full force when the individual cannot draw on protective reserves the presence of individual risk factors therefore acts as a disposition for vulnerability the absence of corresponding protective factors subsequently manifests the individuals vulnerable state according to grundy 11 p 107 vulnerable older people are defined as those whose reserve capacity falls below the threshold needed to cope successfully with the challenges that they face vulnerability within the biological aging process becomes more and more visible as the physical capacities generally diminish and the individual risk of dying increases 1121 advantages and disadvantages in old age with regard to health social relations and financial situation on the individual level are described to emerge within a cumulating process over the life course 69 which leads to increasing heterogeneity in higher age groups 4 considering these aspects a significant dispersion of vulnerability among older adults is expected with varying outcomes 17 recent research takes up the idea of heterogeneity in old age and has criticized the empirical implementation of the different dimensions of vulnerability to decreased life satisfaction as merely isolated influencing factors the simultaneous occurrence of risks in different life domains is usually ignored 1722 although inequality research implies that financial healthrelated and social disadvantages in old adulthood interact with one another resulting in an accumulation of adverse effects on life satisfaction 226 following this argument shin et al successfully assessed multidimensional vulnerability by conducting a latent class analysis with data from the health and retirement study along four dimensions of vulnerability they identified six different vulnerability profiles among these healthrelated and social vulnerability combined exerts the strongest negative effect on subjective wellbeing closely followed by the combination of material healthrelated and social vulnerability 22 these findings support the idea of considering vulnerability to low subjective wellbeing as a multidimensional phenomenon despite the existence of risk factors that challenge the coping process the negative impact of stressful events on life satisfaction does not necessarily have to occur if the individual draws on protective reserves that can buffer the negative impact of risk factors on perceived quality of life protective factors generally reduce the likelihood of disorders occurring in the presence of stress 11 they appear either on the personal level or outside the individual social support is defined as emotional material instrumental or informational help provided by significant members of social networks 20 referring to vulnerability it is not sufficient just being a part of a social network moreover the helping exchanges within social networks need to be mobilized in cases of a stressful event 21 typically social support is considered as an external protective factor related to the influence of stressful events on mental health or depressive symptoms in old age 20 although empirical evidence supports the moderating role of this phenomenon the strength of this buffer effect might be at some point overemphasized 20 based on the critical interrogations mentioned above we propose the basic hypothesis that vulnerability acts as a composite measure including risk factors from different dimensions the aim of this study is twofold first we take up the idea of multidimensional vulnerability among older adults and use data from germany to construct a latent variable reflecting the material physical mental and social dimension of vulnerability second we apply this construct in relation to overall life satisfaction referring to external coping resources we expect that the negative direct effect of vulnerability on life satisfaction is moderated by social support data and methods for the empirical analyses the fourth wave of thesurveygermanhealthupdate is used which was carried out between november 2014 and july 2015 the dataset comprises a sample of 24016 respondents aged 15 years and older in private households from the german resident population the core questionnaire of the geda survey based on the third wave of the european health interview survey includes questions on subjective functional and mental health chronic diseases potential causes of diseases support and social networks and the use of medical care and treatment questions are also asked on other healthrelated topics such as care for diabetes mellitus working conditions and issues related to disease prevention 1519 the relevant sample is limited to persons aged 65 years and older multidimensional vulnerability manifests in four dimensions material physical mental and social 22 these dimensions of vulnerability were measured using the following indicators income below the poverty risk threshold healthrelated functional limitations number of chronic diseases a lack of close or intimate social relationships and mental health problems to measure income below the poverty risk threshold the two lowest categories of the net monthly equivalent income were used as a proxy the 5item scale of activities of daily living was used as an indicator of physical health limitations individuals who had problems in at least one task of adl were categorized as having healthrelated functional limitations additionally the number of chronic conditions and risk factors were used as an indicator of multimorbidity living alone in the household indicates the social dimension of vulnerability mental health problems were assessed by the 8item scale of the patient health questionnaire 14 with respondents with a score of five or above indicating mental vulnerability life satisfaction as the outcome variable is measured using an 11point scale from 0 to 10 3 social support representing the main effect in this study is measured using the oslo 3item social support scale 5 in order to verify that the selected variables can estimate the latent construct of vulnerability on the basis of one dimension an exploratory factor analysis was carried out in a first step using the principal component factor method subsequently a confirmatory factor analysis based on generalized structural equation modeling with probit link functions and including missing values was conducted 24 to assess the model fit of gsem in more detail the root mean square error of approximation and the comparative fit index were calculated as proxies using a linear structural equation model with the same variables based on maximum likelihood with missing values as a result of cfa a continuous latent variable on multidimensional vulnerability was estimated which was used in the further analyses in order to investigate the moderation of the relationship between multidimensional vulnerability and life satisfaction by social support the factor values of the latent variable vulnerability were converted into a manifest variable from this manifest variable and social support a multiplicative term was calculated measuring the potential interaction in the subsequent models these variables were used to estimate linear models on the basis of mlmv in a stepwise procedure first the bivariate relationship between life satisfaction and vulnerability was estimated in the second step the degree of social support and the interaction term were added to the model the final model contained further control variables such as gender age and general selfefficacy the intercorrelations of the study variables as well as their mean values and standard deviations are listed in the electronic supplement all statistical analyses were performed using stata 160 24 original contributions bernoulli results measuring vulnerability the results of cfa in fig 1 show a satisfactory overall fit to the data 30351490 bayesian information criterion 30418200 rmsea 0010 90 confidence interval ci 0000 0023 cfi 0998 referring to multidimensional vulnerability indicated by material physical mental and social vulnerability as vulnerability is a latent exogenous variable and needs a normalizing constraint the association with income poverty is constrained to 1 however within the measurement model the adl and multimorbidity scales as well as the phq mental health problems scale show the strongest associations with the latent variable vulnerability the subdimensions of physical and mental health thus seem to play the most important role in measuring multidimensional vulnerability among older adults while living alone shows comparatively lower associations the latent variable of the measurement model corresponds to a continuous factor score ranging from very low to very high levels of multidimensional vulnerability about one in five respondents has no vulnerability in any of the dimensions which corresponds to very low factor scores slightly more than half of the respondents have a rather low vulnerability with a prevalent risk in either one or two dimensions of the study participants 18 show high to very high vulnerability scores corresponding to the prevalence of risk factors in 3 or more dimensions thus multidimensional vulnerability is characterized by a rightskewed distribution as shown in fig 2 overall the factor scores reveal gradual trajectories of vulnerability in much greater detail than would be possible with categorical variables on different groups of vulnerability multivariate analysis vulnerability has a significant negative impact on life satisfaction adding social support to the regression model shows that the effect of vulnerability changes while social support also significantly influences life satisfaction these effects persist under control for age gender and selfefficacy the interaction coefficient vulnerability × social support is also found to be significant and points in the opposite direction the negative effect of vulnerability on life satisfaction is moderated by social support and therefore becomes less pronounced when the level of social support increases controlling for age gender and selfefficacy for each unit of social support adds 0143 to the main effect of vulnerability reducing the negative coefficient accordingly when social support is strong the effect of vulnerability on life satisfaction is 0039 instead of 0468 to validate these results an additional model was calculated without social support and the interaction term but with a group comparison for the social support categories this model shows a significant χ 2 test for group invariance of parameters which confirms a moderation of the association between vulnerability and life satisfaction by social support 10634 p 0005 data not shown the older age group reports higher life satisfaction compared to the younger respondents selfefficacy yields a positive coefficient while gender does not show a significant correlation with life satisfaction figure 3 shows the predicted margins of life satisfaction by level of vulnerability moderated by social support while there is a general gain in life satisfaction through social support a stronger effect becomes visible for vulnerable people in particular the relative difference in life satisfaction increases as the vulnerability level rises depending on the degree of social support discussion the results of this study are twofold first by creating a continuous latent variable to represent different degrees of vulnerability the concept of vulnerability becomes multidimensional and contributes to the current debate over the conceptualization and operationalization of vulnerability 17 second the analyses reveal a negative correlation between this construct and life satisfaction but that this relationship is mitigated by social support vulnerability theory argues that vulnerability can exist simultaneously in multiple life domains and affect perceived quality of life 25 the analyses of shin et al 22 represent a crucial step in the empirical assessment of multidimensional vulnerability to a marked decrease in perceived quality of life implying that cumulative life risks affect subjective wellbeing more thantheserisks occurringinisolation however this approach could lead to conceiving vulnerability as an attributed condition and therefore entails the risk of stigmatization that ends up ascribing a social role to the affected people which is linked to certain behavioral expectations of this role rather the present study takes up the idea of the situation of vulnerability 17 and therefore allows adding context to the solely individual vulnerability represented in the latent vulnerability variable the situation of vulnerability is described as a set of circumstances in which individuals experience multiple difficulties that may interact to increase the risk of being harmed 17 this definition makes it obvious that the measurement of vulnerability has to be multifacetted and differentiated and should focus on a universal concept of vulnerability capturing vulnerability as a multidimensional construct and establishing a measurement tool is a promising approach to future research as this could contribute to a vulnerability assessment that becomes comparable across studies and disciplines consistent with previous studies revealing a negative relationship between vulnerability and perceived quality of life on singledimensions 21121 theresultthat multidimensional vulnerability has a negative impact on overall life satisfaction is not surprising equally unsurprising in this context is the observed buffer effect of social support 520 less known so far however is that with increasing degree of vulnerability the buffering effect of social support also increases meaning that more vulnerable people profit to a higher degree of social support than less vulnerable people regarding the degree of vulnerability the differences in life satisfaction between poor versus strong social support range from 07 to 16 points at first glance this might seem quite small but looking at the findings of guven and saloumidis 12 a 10 increase on the overall life satisfaction scale is associated with a lower mortality risk of 4 percentage points therefore these differences have substantial significance and social support can thus be regarded as an important protective factor for older adults in vulnerable situations these findings have direct practical relevance as they show that older adults facing multidimensional vulnerability particularly need special external support to achieve a higher level of life satisfaction identifying the multidimensionally vulnerable is a major task for actors in community work and could benefit from a standardized and generally accepted assessment and screening of vulnerability moreover potential services of external social support are at least as broad as the composition of vulnerability in older adults to create helpful measures the federal and local governments should collaborate with scientific research on models of external interventions based on subsidiarity and solidarity this call for a mix of tailored interventions addresses actors on different levels such as public health the welfare state and the community inthelightof this multidimensional perspective aging describes a process that involves the accumulation of successive and timevariant changes in different domains within different settings essentially this involves intraindividual and interindividual differences in the process of development and adaptation and is based on life span psychology 1 the process of change does not affect all the domains of a particular individual at the same time and to the same extent which leads to the simultaneous existence of more vulnerable and more resistant domains this results in a highly individual combination of domainspecific expressions that are unique in each human being unravelling this accumulation and making it possible to measure it in its complexity is a promising research goal as this is relevant for policy makers and practitioners but above all for the individuals themselves because it reveals their needs and strengths and enables tailored interventions based on individual profiles limitations increasing the significance of the study results would entail the following changes in the study design use of longitudinal data in order to identify a baseline regarding overall life satisfaction and investigate for cause and effect oversampling older persons with multiple risk factors to gain a deeper understanding and a more differentiated picture of vulnerability in old age practical recommendations our findings can be useful in suggesting approaches for practitioners original contributions

background multidimensional vulnerability among older adults characterized by low levels of individual resources in different life domains has been insufficiently studied this phenomenon is considered to be associated with a marked decrease in overall life satisfaction social support is supposed to buffer the negative effect of multidimensional vulnerability on life satisfaction methods analyses are based on the german health update dataset geda 20142015ehis the analytic sample includes respondents ≥ 65 years n 5826 confirmatory factor analyses were performed to construct a latent variable from the indicators income poverty activities of daily living adl limitations multimorbidity mental problems and living alone multivariate linear regression models estimate the relationship between vulnerability and life satisfaction with a special focus on the interaction between vulnerability and social supportthe analyses supports the multidimensional construct of vulnerability social support considerably moderates the negative relationship between vulnerability and life satisfaction as the degree of vulnerability increases the influence of social support becomes more pronouncedthe assessment of vulnerability as a multidimensional construct helps to depict the life situation of older people in a more differentiated way vulnerable older adults with a small or unreliable social network while finding it difficult to access practical help need additional external social support to achieve a high level of life satisfaction

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background pacific island countries and territories are some of the most vulnerable to natural hazards the effects of which are exacerbated by poor development and climate change 1 many pics are situated within or close to the typhoon belt and the boundary between the australian and the pacific tectonic plates increasing the risk of cyclones hurricanes flooding earthquakes tsunamis and volcanic eruptions 2 the sexual and reproductive health and rights of women girls men and boys and gender diverse individuals are significant health concerns in all humanitarian contexts including those caused by natural hazards the risk of sexual violence increases in insecure and unstable settings and in contexts where protection from legal social and community support systems have been undermined by displacement or disruption 3 humanitarian contexts may increase risk factors for sexually transmitted infections including hiv and disrupt access to treatment and prevention services 4 maternal mortality is reportedly ten to 30 percent higher in humanitarian contexts compared with noncrisis settings 5 in these contexts women and girls will often give birth without skilled birth assistance or necessary resources increasing the risk of preventable mortality and morbidity a lack of access to newborn care can also jeopardise infant survival 6 in response to these critical health needs the interagency working group on reproductive health in crises has developed a set of objectives activities information and resources focused on preventing sexual violence and assisting survivors reducing the transmission of hiv and managing stis preventing excess maternal and neonatal mortality preventing unintended pregnancies and moving to comprehensive srh services as soon as possible 7 these aims are encompassed in the minimum initial service package for sexual and reproductive health in crisis situations a coordinated set of priority activities to be delivered in response to srh needs the sphere humanitarian charter and minimum standards in disaster response have incorporated the misp for srh as a minimum standard of care in humanitarian response 8 the misp for srh was initially proposed in the mid1990s and updated objectives and activities were included in the interagency field manual on reproductive health in humanitarian settings of 2010 and most recently in 2018 in 2007 ippf with support from the australian government launched the sexual and reproductive health in crisis and postcrisis situations initiative sprint was established to improve the health outcomes of crisisaffected populations focusing on reducing srhrelated morbidity and mortality this initiative is led by ippf in collaboration with its member associations and other national and international partners and is dedicated to building country capacity to implement global standards including the misp in crisis contexts 9 ippf is the worlds largest federated reproductive health nongovernment organisation providing srh services in more than 160 countries with a strong presence in nine pacific island countries 10 the current phase of the sprint initiative is implemented with 13 locallyowned plain language summary pacific island countries experience many disasters including cyclones and earthquakes the international planned parenthood federation has been working in the pacific to help build skills to improve the response to sexual and reproductive health and rights during disasters this paper describes research to identify capacity building activities that helped prepare organisations in fiji and tonga and how this affected the delivery of srh during tropical cyclone winston in 2016 and tropical cyclone gita in 2018 key informants in senior positions from relevant organisations were recruited and interviewed by telephone zoom skype and email we used a framework that described different levels of capacity across phases of the disaster management cycle to analyse the data eight key informants described differences in fiji and tongas preparedness activities before tropical cyclones winston and gita that affected the way in which services were delivered the tonga family health association was well established as a key player in srh service delivery before gita and had built relationships and delivered training for disaster response to staff across a number of organisations including the ministry of health these preparedness efforts facilitated a smooth and rapid response in fiji the response was initially affected by a lack of training role clarity and coordination but linkages were quickly built to deliver care and services participants highlighted the importance of personal relationships individuals and organisations motivation to respond and strong links with the community to deliver srh care this study highlights the need for inclusive activities at individual organisational and national levels within countries and across the pacific region to build capacity for a srh response keywords sexual and reproductive health pacific islands humanitarian crisis preparedness capacity building disaster response member associations including the reproductive and family health association of fiji and the tonga family health association in the pacific 11 since its launch there have been three phases of sprint activities under the initiative have included advocacy for the misp misp coordination capacity building institutional strengthening and srh in emergency service deliveryresponse the program aims to raise the profile of the misp and promote a comprehensive approach to reproductive health that considers pre during and postcrisis phases the establishment and ongoing support of national srh coordination mechanisms and the provision of capacity building and tools to prepare and respond in the acute phases of crises are central to these aims sprint also works to support the integration of the misp into country emergency response and disaster risk reduction policies in 2017 ippf established its global humanitarian hub in bangkok and the pacific humanitarian hub in suva these coordinate humanitarian work across the east and southeast asia and oceania region and the south asia region in collaboration with member associations and other national and international partners in 2018 ippf launched its global humanitarian strategy demonstrating a commitment to an integrated and comprehensive approach to srhr in emergencies and linking this work to its longterm development mandate 12 a critical component of this is the colocation of the subregional office for the pacific and pacific humanitarian hub in suva to coordinate and share lessons between humanitarian and development programming in the pacific 12 the united nations population fund plays a critical role in supporting the work of ippf at the regional and countrylevel by prepositioning reproductive health kits containing essential drugs basic equipment and supplies needed to provide srh care in crise 13 the pacific island countries of fiji and tonga regularly experience cyclones and in the period 20162018 had introduced preparedness measures under the sprint program on the 20th of february 2016 severe tropical cyclone winston the most intense tropical cyclone in the southern hemisphere on record reached maximum intensity near fiji causing extensive damage and 44 deaths on the 12th of february 2018 category 4 tropical cyclone gita the worst the country had experienced in 60 years peaked severely impacting tonga this paper reports on research that examined capacity development activities undertaken as part of the sprint program in fiji and tonga and how these enabled the srh response to cyclone winston and cyclone gita this study identifies the different approaches to capacity building and response in the two settings and delivers recommendations for future efforts and investment in line with the objectives of the misp misp for srh methods this descriptive qualitative study involving eight key informant interviews sought to identify activities that were carried out by sprint partners including ippf member associations other nongovernment organisation and communitybased organisations and the ministries of health in fiji and tonga to foster workforce organisational and community capacity development before cyclone winston and cyclone gita in addition interview questions explored how these activities influenced the type scope and timeline of srh response to these cyclones and mitigated challenges to delivering the misp we used the reporting guide outlined by obrien et al 14 to present our findings in this paper we define capacity development as efforts to improve the knowledge and skills of those providing srh care information and services building support and infrastructure for organizations and developing partnerships with communities 15 the research was informed by a framework designed to assess public health emergency response capacity 16 across various levels and the phases of the disaster management cycle this study was however only concerned with the preparedness and response phases study setting fiji and tonga were selected as case studies to explore preparedness and response to srh needs in crises both countries have a shared experience of tropical cyclones but have different cultural and demographic fig 2 a framework of capacity building in srh in emergencies adapted from 16 contexts fiji is a melanesian country with a population of 897295 while tonga is a polynesian country with a population of 105845 1718 while both are uppermiddleincome countries 19 and have youthful populations tonga is more densely populated srh indicators also differ across the nations fiji has a contraceptive prevalence rate of 30 percent while tongas cpr is 17 adolescent fertility rates are similar in both fiji and tonga 17 while the percentage of women subjected to physical and sexual interpersonal violence in their lifetime differs respectively 20 the fiji national disaster management office is the fiji governments coordinating body for natural disasters while the ministry of health and medical services has identified maternal newborn and adolescent care and genderbased violence amongst the top health priorities in a reproductive health response 21 srh in emergencies is absent from the fiji ministry of health reproductive health policy 22 and there are srhrelated gaps in the fiji national disaster management plan 23 that was current at the time of cyclone winston the emergency management and response structure in tonga is led by the national disaster council and directed by a national plan that does not include srh 24 disaster management is noted in a generic manner in the national health strategic plan 25 while srhie is identified in a government srhr needs assessment 26 published before cyclone gita both countries have adopted a national cluster system based on the un model the key clusters involved in any srhie response include the health and nutritionhealth nutrition and water sanitation and hygiene cluster and the safety and protection cluster at the time of cyclone winston and gita the 2010 version of the misp for srh was the standard applied in both responses recruitment study informants were recruited purposively to engage individuals from key organisations and included staff who were directly involved in the preparedness and response efforts to cyclones gita and winston we sought a diversity of perspectives including government and ngo workers across both countries health and disaster response sectors information about the study was sent to key individuals with an invitation to participate in an interview during the recruitment and datagathering processes several communication challenges were experienced due to the interviewers remoteness which made it difficult to establish contact with respondents and develop rapport these were overcome by multiple contacts and discussions with individuals over a 6 month period data gathering the findings of a desk review informed the development of questions for the interviews and helped identify possible participants a stakeholder reference group were invited to provide input into the interview questions and these were piloted in january 2020 due to the covid19 pandemic australia closed its international borders in march 2020 prohibiting travel to tonga and fiji as a result interview data were collected via telephone zoom skype and email multiple contacts with key informants enabled thick descriptions to be built and saturation to be reached through concurrent analysis that identified no new patterns emerging rigor was also sought by inviting some informants to check the data for credibility kb and ad met regularly to discuss the data and ensure a detailed audit trail was collected due to the small number of informants and unique context respondents have been deidentified as much as possible to ensure confidentiality to maintain anonymity direct quotes included in this report are not attributed to individuals analysis data were analysed using a template as described by king 27 coding was directed according to categories that aligned with the aims of the study and the process was managed using the qualitative research software qsr nvivo 12 an initial template was developed based on the list of codes to identify themes in the textual data and these were modified as the analysis continued the framework of factors influencing srhie response together with a broad understanding of capacity and capacity development programming informed the template used for data analysis this allowed for the consideration of a wide range of factors that may influence the effectiveness of sprintsupported training other capacity development efforts and the response ethical approval this study was granted ethical approval by the human research ethics committee of the university of technology sydney fiji national health research ethics committee and the tonga national health ethics and research committee findings eight key informants were interviewed for this study we outline the findings according to the preparedness and response phases preparedness before cyclones winston and gita fiji before tropical cyclone winston in fiji key informants reported that few capacity development activities had been implemented to support the delivery of the misp staff from the ippf subregional office for the pacific the member association rfhaf and partners were involved in the response to winston and of these only one responder had received training on the misp this training had been provided during the second phase of the sprint initiative and a significant amount of time had passed since the completion of this training with no followup refresher training or opportunity for the individual to apply their new knowledge or skills staff from the srop were familiar with the misp due to their involvement in reporting and supporting regional humanitarian work however at that time they had not received a formal orientation to the package at the onset of the cyclone two surge capacity staff members from ippf were deployed to fiji to conduct a crash course for responders on the basics of the misp and coordination skills needed to support the response in fiji these staff members had been involved in implementing srh services during crises in different contexts a key informant stated …the crash course in fiji it was really focused on coordination and how to handle yourself and your staff in crisis situations how to be more tolerant more strategic and how to react quickly to how fast things are the way things change so it was really preparing them psychologically and emotionally on what would happen because family planning hiv maternal health sgbv theyve been doing this for how many years… they know this stuff participants appreciated the practical nature of this training with one explaining that when we did the crash course they focused on what we would be doing further capacity development strategies were deployed to ensure those involved in the response including nursing staff and volunteers were familiar with where their tasks fit within the misp implementation to clarify roles and to explain each medical missions processes and procedures in addition to these formal training sessions these two experienced ippf staffmembers remained with the incountry and sropsupported response teams for ten days to advise guide debrief and build daily on lessons learnt tonga in tonga key informants reported that training had been implemented well before the onset of cyclone gita this training had been conducted alongside other preparedness activities including a national stakeholder meeting on the misp training on longacting reversible contraceptives orientation to sexual and gender based violence in emergencies and attendance at cluster meetings and interagency coordination with stakeholders in 2017 ippf humanitarian pacific team members and the tfha hosted a national stakeholder meeting to orient participants on srhie and the misp training also continued during the response when gaps in the provision of psychosocial support for sgbv survivors were identified especially on the island of eua a halfday orientation on sgbv in emergencies was conducted in 2018 for field responders facilitated by unfpa and supported by sprint response funding in collaboration with tfha ippf pacific humanitarian hub and the moh a total of 42 tongatapubased clinical staff nurses and midwives were trained in basic concepts and fundamental guiding principles in dealing with a range of sgbv issues gita therefore provided the opportunity to upskill clinical staff building competence networks and relationships key informants also noted that the tfha staff had attended several cluster meetings as a key stakeholder these included meetings with the health nutrition water sanitation and hygiene cluster and the safety and protection cluster involving the moh un agencies and ngos responding to sexual and reproductive health needs after cyclones winston and gita an srh response was launched in the aftermath of both tropical cyclones winston and gita the scope of these responses differed and table 1 summarises these against the objectives of the misp key differences are seen in preventing and responding to sexual violence and planning for comprehensive srh services integrated into primary care safe and rational blood transfusion in place was not reported in either setting fiji the training at the onset of the cyclone response led trainees with the support of surge staff to initiate a family health subcluster to facilitate a collaborative srh response with the moh medical services teams and partners according to one key informant this was essential otherwise reproductive health would have been lost in the health cluster because they had so many other concerns before the guidance that was provided during this training staff had found this a challenging time we had to learn which cluster meetings to go to we had to see where we fit into the security one and the health clusters even in the health clusters we had to fight even to have a reproductive health cluster within the health cluster which wasnt there before… thats why we were so disadvantaged there was a lot to handle links with the moh also required strengthening one informant said there was collaboration there was an existing mem it was therefore reported that we had to make extra efforts to be brought in these extra efforts in the form of advocacy by motivated ippf srop and ma representatives and guided by surge capacity staff led to the establishment of the subcluster in collaboration with ministry of health and medical services and the delegation of responsibility to rfhafachievements regarded as impressive by several respondents they also strengthened the relationship with government an outcome explained by one respondent as crucial because these are the things that will really hinder you will make it very difficult for one humanitarian team to operate if you do not have the support from your own leadership and if the government doesnt trust you while informants noted initial uncertainty regarding which cluster meetings to attend they were also aware of general confusion at the time of the response at that time… there were so many organisations that came in with different agendas and they wanted to be the first in despite this all agreed that coordination had improved postwinston and support had increased since the establishment of the ippf humanitarian pacific hub with one respondent stating that the situation is better coordinated not like before when we were looking and finding ways with the existing system of the government but now we know after the misp after the setup of the humanitarian arm here its more coordinated and its quicker medical missions were launched the day after the brief training in fiji the rfhafippf sprint team delivered family planning counselling and referred pregnant women in their third trimester to birthing units they distributed clean delivery kits contraceptives and dignity kits the team also provided safe spaces for displaced women and girls and community awareness on gbv though skill weaknesses in this area were noted we were just at that point strengthening the objective two components of misp and so i think at that time we couldnt even consider ourselves a player at that point because we were not involved in the gbv or the protection work in fiji lessons were learnt and applied as the srh response progressed with one responder reflecting that the first intervention… was really disorganised but after that when we came to the second one we were able to take a lot of lessons and even recommendations from the community about how we could do it best and we even incorporated that intervention when we went to the west the collation of supplies and logistics also delayed the medical response as no action had been taken for securing these during the preparedness phase one informant said what delayed our trip was we had to buy the stuff and get our dignity kits another stated at that time we were trying to rent vehicles and they were all out… and that was a drawback because we were a bit late in our response… there was no coordination and we should have booked the car but we had all these competing agendas roles were not always clear to responders who reported taking on many functions so i was everywhere i dont really understand what was my role at that time because i seemed to be doing everything i coordinated i went to the village headmen i went to the ministry of health for meetings then i wore my nursing cap when i gave the injection and i was also the driver in addition to misp work staff were engaged in activities that were not related to srh the chief of the village we visited was sick and because it was so far away up the mountains and there was no transport we had to get the chief man because he had something that needed medical attention and because we were there we had to drive him down to the main hospital but we had to do it and after a hurricane its not that easy to drive the fiji roads where you have bridges washed away and big potholes so that was something besides the misp that we did during our response however informants stated that such activities were necessary to build rapport and the willingness of staff to accommodate these additional needs was wellregarded by recipient communities some challenged the importance of srh response believing that the focus should be shelter and food this required a strategic and respectful approach its actually about convincing the masses why it is important it was not an easy job but we were able to tell them during a disaster and after… women wont stop having babies during a disaster…the communities came to appreciate that and that was quite a good feeling ippf surge staff remained with the incountry and sropsupported response teams in fiji for 10 days to advise guide and debrief one informant recalled the good thing about it is after every village we went to no matter how late it was we would sit together as a team… and go through the day… we built on our lessons learnt every day and we had the two support persons there and they were really observers when we provided the service except the doctors and counselling but they would attend the information sessions and go in and see how we would demarcate the areas and the signs and they would help explain properly and they would feedback to us in the evening more broadly it was reported that knowledge skills and relationships developed during this response have been utilised and built upon in subsequent preparedness efforts and humanitarian action further advocacy for the integration of srhie in emergency preparedness plans collaboration with government at various levels for capacity development training of clinical program and volunteer staff incountry and coordination with other key ngos have been undertaken by rfhaf and supported by the ippf humanitarian pacific hub established since winston all geared towards being misp ready and having strong systems in place tonga key informants were optimistic about the response to gita explaining that overall the response was good and the tfha team felt they were in control staff were described as highly motivated with one informant declaring it was new for us and became very exciting for us to provide the misp and we were able to get dfat who is the donor to join us on one of our visits and they were happy with what we showed comparisons were made with the response in fiji and one key informant stated tonga the population is much smaller than fiji and the tfha members as well have a very strong relationship with the ministry of health i think those two things there were a few things to their advantage for example one of the national disaster management office coordinators actually sits on the tonga family health board and also a ministry of health officer in addition relationships and networks developed with the moh ngos and communities during preparedness activities were easily activated in response to gita when the moh made an official request to the tfha to facilitate srh services and education to communities affected by tropical cyclone gita on 19th february 2018 the tfha formed a core team with the moh and ngos to undertake these activities in coordination with the hnwash and safety and protection clusters one individual stated that the tfha had a very good relationship with the australian dfat post in tonga maybe because theyre just down the road theres that active engagement even during normal times however there was still a rapid learning curve when it came to moving from the training room to disaster implementation the assistance provided by the ippf humanitarian hub including the training and development of a response plan and proposal for funding was regarded as a big advantage by a key informant staff roles were expanded when the tfha team agreed with the moh to include cervical cancer diabetes and high blood pressure screening in the response given the high burden of noncommunicable disease in the tongan community as in fiji it was identified that staff lacked capacity to address objective 2 of the misp responding to sexual violence they instituted a brief training intervention to increase the capability of nurses to counsel and refer identified cases despite informants expressing satisfaction with the response some pointed to necessary improvements including the need to better think through transport to outer islands as staff had to rely on fishing boats and tailoring dignity kits to suit the local context plans to improve preparedness were in train including undertaking misp readiness assessment the integration of the misp into the national reproductive health policy and lobbying to include the misp in the tongan governments goal to respond within the first 72h of an emergency shared insights key informants agreed on several issues including that preparation is key for any response and that this must include hands on skill development and building and maintaining strategic relationships and community links as explained by one participant 80 of your response lies in how prepared you are and being prepared doesnt just mean that you have clinicians trained or the resources prepositioned its about being part of a national support network… we need to have those linkages to national level we need to have those policies in place we need to have the buy in from the key ministries…and i think we need to have partnershipsthese play a great deal in the preparedness needs and definitely capacity building at the ma level not just for the clinical or program staff but for youths engaged at the board level for governance and so people are clear about what their role is and how that contributes to the bigger broader picture of meeting peoples srh needs the engagement and motivation of sprintsupported individuals and teams was regarded as an important driver of the response in both settings this was seen in the many efforts to overcome obstacles in fiji and tonga nd the commitment to dedicate long hours and heavy work to meeting the needs of affected communities this combined with technical knowledge developed through capacity development was described as key you need passion and technique for humanitarian response you can teach technique but you cant teach motivation and passion…thats why i was confident with any response as long as im working with the right people and these were the right people on the ground but they need the knowledge and that knowledge that technique can be provided through training and support respondents from both tonga and fiji noted a lack of systemic data collection on the status of vulnerable and marginalised groups during the response this lack of data was seen as a barrier to mobilising an effective srhie response and planning future responses in tonga this need for reliable data was reported to extend beyond particular groups to a general shortage of demographic and healthrelated data at a country level one informant called for standards for reporting and country appropriate indicators to allow the comparison of responses while unfpa provided commodities for distribution they did not assume an implementing function during the cyclone responses it was suggested however that unfpa involvement in monitoring and evaluation would have benefited the response in both countries discussion this study found that differences in fiji and tongas preparedness at the individual organisational and systems levels prior to tropical cyclones winston and gita influenced the type scope and timeliness of the sexual and reproductive health response in fiji activities were concentrated on ippf support to provide training to rapidly scaleup the capacity of responders at the onset of the disaster and to strengthen relationships and access to platforms for coordination in tonga individual and organisational capacity had already been established alongside interorganisational networks across the sector and at the national level respondents in tonga reported feeling prepared and confident this is likely to be linked to the investment in preparedness activities and capacity building before gita that was not present in fiji before winston despite an existing memorandum of understanding with the fiji moh regular communication appears to have lapsed in contrast considerable work had been undertaken in tonga to build and maintain relationships with the government ngos and communities for srh response these capacitybuilding and preparedness activities in tonga allowed the response team to take clear and directed action engage with established coordination partners and platforms and implement a relatively harmonised response the gaps in preparedness in fiji meant that there was a lack of clarity in initial efforts and time was lost at the onset of the response despite these early challenges however adaptations were made to capitalise on the motivation existing capabilities position and relationships of those involved in the response to winston this study found that a range of approaches to staff capacity building such as regular inservice workshops in tonga and rapid training at the onset and during the disasters in both countries followed by mentoring and support motivated and engaged staff in the provision of srh and broader health services to affected communities this emphasises the need for regular ongoing training and supportive strategies that are relevant and contextualised training is often the focus of capacity development 28 and a review of organisational change in the sector 29 concluded that training is only weakly linked to actual practice in humanitarian agencies and therefore needs to be supported by other capacity development initiatives the limited effectiveness of training programs highlights the need for training to be situated within a set of buttressing strategies so that staff can apply knowledge and skills in the field pearson states that the design of training interventions should be informed by an indepth understanding of the context and the identification of opportunities and constraints and appropriately aligned to broader capacity development initiatives a systematic review of studies examining the transfer of training into practice for srh in humanitarian settings found that individual training organisational sociocultural political and health system factors all contribute to the ability of trainees to apply newly acquired knowledge and skills in their work settings 30 this highlights the need for comprehensive activities at multiple levels within a country and across the pacific region to build capacity for an srh response the training and subsequent mentoring and technical support provided by ippf surge staff was reported to be indispensable in fiji highlighting the importance of these buttressing strategies to support capacity development efforts and optimise the application of knowledge and skills to action our study found that informants highlighted the importance of learning by doing of feedback and support and of building capacity through the process of implementation across both country contexts role flexibility was noted along with the need to be adaptable in incorporating nonsrh response activities as relevant to the local context factors at an organisational level also influenced the srh response in both contexts the support of management and program staff and the availability of surge capacity and technical guidance was widely appreciated while this together with the formalisation of partnerships and regular meetings and training are important activities to ensure the currency of coordination efforts in readiness for activation so is the institutionalisation of srhie in national policy and accountability mechanisms 31 national policies that highlight srhie as a priority and embed the misp into disaster risk reduction planning with attached investment and key performance indicators support the delivery of essential services in emergencies the latest fijian national disaster risk reduction policy 20182030 postcyclone winston notes the challenges of genderbased violence and that reproductive health services are likely to be disrupted during disasters while it includes strategies to support specific groups such as pregnant women and lgbtqi people the policy stops short of noting the misp 32 it has been noted that while the sprint initiative has been implemented across several regions to improve organisational and national capacity preparedness training for communities across the sector more broadly has been largely neglected 33 at the same time our research notes that both rfhaf and tfha have established relationships with communities and that they could be further supported to prepare for and better respond to disasters one approach to building relationships could be through participatory training activities with communities using available curriculum in reproductive health and gender 34 while preparing for anticipated disaster scenarios through training is important so is the ability of individuals organisations and communities to adapt and be flexible to apply skills to new situations and problems the covid19 pandemic has provided an opportunity to examine more localised ways to address the provision of srhr and build national and regional capacity to improve disaster risk reduction strategies and plans a western pacific regional action plan for response to largescale community outbreaks of covid19 has been developed 35 however srhr is notably absent in this document despite this pacific island nations including fiji and tonga have implemented various strategies to ensure a srhr response demonstrating their resilience and innovation 36 much work remains to be done to better build and connect capacity strengthening activities from the individual to national levels not just for preparedness and response but for recovery and mitigation efforts limitations this study is limited by the small number of participants however those interviewed were key informants involved in the decision making during the preparedness and response phases of cyclones winston and gita insights from a diversity of participants in fiji and tonga may have provided further detail regarding the activities that were undertaken these interviews were conducted sometime after the cyclones and the memories of some informants may have been compromised however this study was focused on highlevel activities and many had prepared for the interviews by consulting internal documents multiple contacts with participants enabled the researchers to follow up on details and check information with informants we were mindful of possible social desirability bias and interview data was assessed for both positive and negative responses and imbalances were not noted conclusion this research has outlined the need for comprehensive activities at multiple levels within a country and across the pacific region to build capacity for an srh response in crisis situations while the sprint initiative has been implemented across several regions to improve organisational and national capacity preparedness activities training for communities can be strengthened the study highlights the importance of formal partnerships regular communication institutionalising srh in policy and accountability mechanisms and training to ensure coordination efforts are uptodate in disaster readiness abbreviations gbv genderbased violence ippf international planned parenthood federation larc longacting reversible contraceptives lgbtqi lesbian gay bisexual transgender queer intersex misp minimum initial service package for sexual and reproductive health in crisis situations moh ministry of health ngo nongovernment organisation ohchr office of the united nations high commissioner for human rights rfhaf reproductive and family health association of fiji srop subregional office srhie sexual and reproductive health in emergency srhr sexual and reproductive health and rights sprint sexual and reproductive health programme in humanitarian settings stis sexually transmitted infections tfha tonga family health association un united nations who world health organization competing interests ad and kb do not have any competing interests to declare rd is employed by ippf and mk was employed by ippf at the time of the study however rd and mk had no role in the studys design or the collection and analysis of the data and interpretation of the findings • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research 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background pacific island countries are vulnerable to disasters including cyclones and earthquakes disaster preparedness is key to a wellcoordinated response to preventing sexual violence and assisting survivors reducing the transmission of hiv and other stis and preventing excess maternal and neonatal mortality and morbidity this study aimed to identify the capacity development activities undertaken as part of the sprint program in fiji and tonga and how these enabled the sexual and reproductive health srh response to tropical cyclones winston and gita methods this descriptive qualitative study was informed by a framework designed to assess public health emergency response capacity across various levels systems organisational and individual and two phases of the disaster management cycle preparedness and response eight key informants were recruited purposively to include diverse individuals from relevant organisations and interviewed by telephone zoom skype and email template analysis was used to examine the data findings differences in the country contexts were highlighted the existing program of training in tonga investment from the international planned parenthood federation ippf humanitarian hub the status of the tonga family health association as the key player in the delivery of srh together with its long experience of delivering contract work in short timeframes and strong relationship with the ministry of health moh facilitated a relatively smooth and rapid response in contrast there had been limited capacity development work in fiji prior to winston requiring training to be rapidly delivered during the immediate response to the cyclone with the support of surge staff from ippf in fiji the response was initially hampered by a lack of clarity concerning stakeholder roles and coordination but linkages were quickly built to enable a response participants highlighted the importance of personal relationships individuals and organisations motivation to respond and strong rapport with the community to deliver srh discussion this study highlights the need for comprehensive activities at multiple levels within a country and across the pacific region to build capacity for a srh response while the sprint initiative has been implemented across several regions to improve organisational and national capacity preparedness training for communities can be strengthened this research outlines the importance of formalising partnerships and regular meetings and training to ensure the currency of coordination efforts in readiness for activation however work is needed to further institutionalise srh in emergencies in national policy and accountability mechanisms

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p soriasis is a very common chronic inflammatory skin disease with high costsofillness and high impact on healthrelated quality of life the disease typically manifests in itchy scaly pruritic plaques of the skin but can also affect the joints it often goes along with severe comorbidities such as diabetes mellitus depression or cardiovascular diseases the prevalence of psoriasis varies significantly between different countries and regions around the world psoriasis prevalence correlates with latitude the lowest prevalence rates occur in the equatorial region and the highest rates in northern europe australia and north america regional variations also exist at the country level a study by springate et al in the uk showed a northsouth gradient with higher prevalence rates in the north of the uk similar tendencies were found in a recent study in germany with higher rates in the north and northeast and lower rates in the south however causes of these regional differences in prevalence rates are unclear as the aetiology of psoriasis is very complex and not fully understood the disease is multifactorial and arises from a genetic predisposition interacting with epigenetic and nongenetic factors altering the functionality of the skin on the one hand nongenetic factors can be lifestyle related these include nutrition tobacco and alcohol consumption comorbidities obesity and others those factors are often related to lower socioeconomic circumstances hence more deprived regions with poorer inhabitants and worse health infrastructure would be expected to have higher prevalence rates of psoriasis this association was found in a swedish cohort study for several autoimmune disorders on the other hand nongenetic factors can be related to the living environment cold weather low humidity ultraviolet radiation and air pollution can trigger the emergence of psoriasis and amplify the symptoms of the disease knowledge of the reasons for regional differences in prevalence of psoriasis can help decisionmakers and providers to detect risk factors and therefore adjust and improve psoriasis care in germany the aim of this study was therefore to determine which regional sociodemographic characteristics and environmental factors are associated with higher regional prevalence rates of psoriasis in germany materials and methods dataset and data preparation psoriasis data all data were analysed at the regional level of the 402 german national counties for psoriasis prevalence the national association of statutory health insurance physicians provided nationwide ambulatory claims data from 2015 to 2017 on billed psoriasis diagnoses according to the international statistical classification of diseases and related health problems 10 th revision as this study used only secondary data on an aggregated level no ethics approval was necessary for included were all people covered by statutory health insurance shi covers approximately 90 of the german population with shi applying to approximately 728 million persons in accordance with recommendations for analysing chronic diseases in routine data cases were defined as having at least 2 confirmed billed diagnoses in different quarters within 1 year to avoid the overestimation of prevalence due to misdiagnosis prevalence rates for each county are directly ageand sexstandardized using all people with shi with at least 1 medical doctor consultation in the respective year the place of patients residence served as regional reference sociodemographic data for regional sociodemographic characteristics the german index of socioeconomic deprivation developed by the robert koch institute germanys central scientific institution in the field of biomedicine was applied the gisd includes 8 indicators in the 3 dimensions education occupation and income we included the 5point scale version in the analyses the gisd is available only for 2017 assuming that socioeconomic deprivation is a slowly changing construct the score for all years was used in addition the study included the regional mean age in years which was also accessed via the indicators and maps for spatial and urban development database of the institute for research on building urban affairs and spatial development as a measure of urbanity the official scale for settlement structure types of the bbsr was included 1 counties being big cities 2 urban counties 3 rural counties showing densification and 4 sparsely populated rural counties environmental data environmental data on temperature precipitation and sunshine hours were available from the climate data center of germanys national meteorological service on raster level considering high dependencies raster divide the geographical surface into regular cells of identical size they were transformed into county level for temperature the study used annual mean temperature winter mean temperature and summer mean temperature for the years 2015 to 2017 temperature is specified in degree celsius the study had no access to data on humidity at the county level and precipitation data were included as an alternative the annual sum of monthly precipitation for germany was used the study had no access to nationwide data on uv radiation hence sunshine hours were used as an alternative the annual sum of the monthly rates from the dwd was used healthcare data because prevalence is measured in billing frequencies it is assumed that the number of billing physicians may have an influence therefore the study included the regional density of physicians as control variables in germany not only dermatologists but also general practitioners and other specialties may treat psoriasis hence the study included the regional density of all physicians gps and dermatologists data on the density of all physicians and gps per 10000 inhabitants at the country level were available for all years in the inkar data data on the density of dermatologists were not available from inkar therefore these data were accessed via the database of the central research institute of ambulatory health care in the federal republic of germany data on dermatologists are available at the county level per 100000 inhabitants therefore the data were converted into n per 10000 inhabitants descriptive statistics for each year and each variable the mean with standard deviation minimum maximum and extremal quotient were calculated the eq is the result of dividing the maximum value by the minimum value by showing the ratio of the area with the highest value and the area with the lowest it is an expression of the regional variations here we used values within the 1 and 99 percentiles to avoid the influence of outliers this method is not applicable for negative values for the prevalence of psoriasis and the significant determinants maps of regional frequencies at the county level were plotted spatiotemporal regression to identify regional determinants of the psoriasis prevalence rates at the county level multivariate spatially autocorrelated firstorder process regression analyses were performed the inference is based on bayesian statistics using markov chain monte carlo simulations which was run for 2200000 samples this procedure was performed 3 times producing 3 different simulations with independent markov chains the posterior median point estimate and 95 credible intervals are reported from the model which are computed from the results of the 3 simulations together in the spatiotemporal regression model the chosen binary neighbourhood matrix takes dependencies of adjacent neighbours into account and controls for spatial and temporal autocorrelation of the dependent variable the ageand sexstandardized prevalence rate of psoriasis at the county level was set as dependent variable this rate does not follow a poisson distribution and therefore a gaussian model was performed as independent variables the abovementioned variables at the county level were included the variable selection for the model was conducted backward stepwise and significant variables remained in the model all data analyses were carried out using r core team r and qgis 3221białowieża advances in dermatology and venereology acta dermatovenereologica results descriptive statistics the mean ageand sexstandardized prevalence of psoriasis increased from 16863 per and the mean gisd 317 the regional distribution of psoriasis prevalence and significant variables is shown in fig 2 spatiotemporal regression the geweke diagnostic for mcmc convergence showed values between 14 and 16 and therefore met model fit criteria for the regression analyses the spatiotemporal regression models identified regional determinants for the counties psoriasis prevalence rates the final model with 3 simulations included 5 significant independent variables gisd age sunshine hours annual temperature and number of dermatologists each unit increase on the gisd scale resulted in an increase in county psoriasis of 4177 and each year older in mean age resulted in an increase of 3763 per 10000 statutory health insured persons with each extra mean hour of sunshine the prevalence decreased approximately 0039 and with each °c higher in temperature the prevalence increased by 4218 per 10000 persons with shi each additional dermatologist per 10000 resulted in a prevalence decrease of 0070 per 10000 persons with shi the other independent variables did not show an effect on regional variation in the psoriasis prevalence at the county level these were removed from the model in the course of the backward stepwise regression as their credible intervals covered zero and therefore their associations were not significant discussion this study aimed to identify sociodemographic and environmental determinants for the regional prevalence of psoriasis the applied spatiotemporal model using several national databases in a multisource approach detected regional socioeconomic deprivation mean age annual mean temperature and annual sunshine hours as significant factors influencing the prevalence of psoriasis the association between higher regional socioeconomic deprivation and higher prevalence of autoimmune disorders including psoriasis was also found in a swe german index of socioeconomic deprivation scale 15 317 15 500 317 15 500 317 15 500 within the 1 and 99 percentiles na not applicable as the eq cannot be determined for values ≤ 0 sd standard deviation eq extremal quotient advances in dermatology and venereology acta dermatovenereologica v andrees et al determinants of regional variations in psoriasis prevalence 46 acta derm venereol 2024 dish study the underlying reasons for this could be manifold possible explanations can be higher risk for lifestyle triggers such as psychological stress obesity smoking low income and less healthy nutrition in more deprived areas the association of higher mean age with higher psoriasis prevalence rate at the county level is supported by the literature psoriasis is a chronic disease with onset often in adult age hence there is more psoriasis in older populations in the current study this finding is of special interest as the advances in dermatology and venereology acta dermatovenereologica prevalence rates utilized were already agedstandardized this indicates that regions of older age per se are more susceptible to psoriasis risk factors the environmental determinants for psoriasis may initially appear contradictory higher temperatures are associated with higher prevalence rates and more sunshine hours with lower prevalence rates however these factors are not necessarily geographically related fig 2 shows that in germany sunshine hours and temperature are not closely related the relationship between sunshine hours as a proxy for uv radiation and psoriasis is suggestive as the association of less psoriasis with higher uv radiation is well known and uv light is also used as therapy it is notable that individuals skin can respond differently to uv light depending for example on their diet or the length of time of uv exposure in addition to crude uv exposure the production of vitamin d might be an additional factor for the association between sunshine hours and psoriasis as vitamin d uptake firstly occurs via sunshine exposure associations between low vitamin d level and psoriasis have been observed literature on psoriasis and temperature is rare and controversial worldwide studies show lower prevalence rates in warmer regions however this might also be due to the association with uv radiation in those regions the current study found warmer temperatures to be associated with higher prevalence rates this might be due to the effect of sweating on the skin as well as a risk of heat intolerance among psoriatic patients since the magnitude of the effect is unclear and since there is a lack of data on environmental temperature acting on the skin in the population this topic is subject to further investigation in contrast precipitation did not show an effect on the prevalence of psoriasis in this model this might be because precipitation is not directly associated with psoriasis and was used as a proxy for humidity low humidity however is known to be associated with higher prevalence rates of psoriasis for all environmental factors it should be noted that germany is geographically a relatively small country with less substantial differences in environmental conditions such that environmental effects are rather low in this analysis as this study utilizes billing data we controlled for the number of physicians in the county that could bill the diagnosis of psoriasis notably gps and all physicians have no influence on the prevalence whereas the number of dermatologists has a very small influence that the prevalence decreases with increasing number of dermatologists might be due to our m2q criteria for case definition because of this definition cases that are treated at the dermatologist and are treated so well there that they visit the doctor less often could end up not recorded here one limitation of this study is the use of accumulated data at the county level which could lead to ecological fallacy however as this accumulation is on a small spatial scale the results are relatively reliable a further limitation of such geographical exposure studies is the lack of control for absences from the place of residence here individual travel behaviour or previous residence may confound the regional effects as has been shown for skin cancer another important aspect is the use of billing data there is a chance of underestimating the realworld prevalence as people with mild psoriasis might not seek medical treatment nevertheless because the study used a nationwide dataset covering approximately 90 of the population with equal healthcare access there is only a low risk of bias for the temporal and spatial analyses this large dataset including time series and several important determinants is a major strength of this study in combination with the complex and thorough methodology the application of this dataset has a strong significance in conclusion the occurrence of psoriasis is associated with a highly complex combination of internal and external factors the external factors can be sociodemographic and environmental and can cause even within small areas very different prevalence rates in order to optimize prevention and healthcare of psoriasis it is important to detect the exposure factors that can trigger psoriasis and understand their regional occurrence

psoriasis is a very common chronic skin disease with large variation in regional prevalence rates which cannot be attributed only to genetic differences in the population the current study therefore analysed sociodemographic and environmental factors that might influence regional prevalence rates by means of spatiotemporal regression analyses and analysis of ambulatory claims data in germany the results showed that higher regional mean age more social deprivation less sunshine hours and higher temperature were associated with higher regional prevalence rates of psoriasis

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background with an aging canadian population informal caregiving has become increasingly important available research evidence suggests with regards to care remaining in ones home is usually preferred by older adults themselves 12 which is in keeping with the governments intention to transfer the responsibility of care to families at home canadas public health care system has undergone a great degree of restructuring 34 with an ever growing increase in care provided in the community in the homes of families and friends of those requiring care 5 this transfer of care responsibility has shifted what were formally medical tasks from care professionals such as nurses and doctors to familyfriend caregivers the majority of the caregiving tasks from personal care to medical procedures provided to communitybased elderly adults with mcc are now the responsibility of family caregivers with only complementary services provided by the health care system longterm institutional care is only available for those who can no longer manage at home is costly and often requires the family caregiver to play a central role in service delivery consequently caregiver strain is a growing concern an important and littlestudied issue in the provision of care at home by informal caregivers is the increase in older adult patients with chronic illness and more specifically multiple chronic conditions gilmour and park 6 determined that of all communityliving older adults in canada 33 have mcc providing informal care for these older adults can be particularly challenging in view of their high use of healthcare services high risk for adverse events and impaired ability to selfmanage their own care 7 8 9 further the intensity of healthcare use has a direct relationship with the number of chronic conditions 710 finally having mcc can impair patients ability to adhere to treatment and selfmanage their care which increases their dependency on family caregivers and the probability of adverse health outcomes 11 sustaining family caregivers and maintaining the health of family caregivers is critical yet we know little about the caregiving experience for this population particularly as it is affected by social location social location refers to either a groups or individuals placelocation in society at a given time based on their intersecting demographics such as age sex economic class sexual orientation gender education race immigration status geography etc 12 13 14 15 and is often examined using an intersectionality framework an intersectionality framework understands that social locations are intertwined and unable to be separated such a framework is interested in equity and social justice and understands social location to be shaped by the influences of interacting and mutually constituting social processes and structures impacted by power time and place 16 17 18 we have yet to fully comprehend the combined influence of social location on peoples health and have little indication of how their health may change over time given the dynamic nature of caring for older adults with mcc we attempt to do this in this paper by answering the following research question how does social location influence the experience of family caregivers of older adults with multiple chronic conditions throughout this paper caregiver refers to familyfriendneighbor informal caregiver literature review the growing population living with mcc has a great impact on the family caregivers who provide care for them family caregivers provide up to 80 of the care for communityliving older adults with mcc undertaking the majority of the costs and burdens associated with caregiving 19 although some family members are happy to care for a lovedone caregiving unfortunately often results in sacrifices to their own health and wellbeing with the level of caregiver strain shown to have a direct relationship with the number of chronic conditions the older adult has increasing negative health outcomes and health service use in caregivers 20 with respect to older adults with specific chronic diseases those that had diseases which involved declined cognitive ability such as dementia required particularly intensive caregiving from family caregivers for example patients with dementia which is usually characterized by significant reduced memory loss communication deficits or even complete loss of functional daily activities often require a constant caregiver 21 the literature suggests that those who care for care recipients with cognitive impairment are at elevated risk of experiencing caregiver stress or burden 22 further caregivers of patients with dementia reported high burden 23 increased depression and anxiety 2425 lowered level wellbeing and poor physical health 23 among caregivers of older adults with various medical issues those caring for recipients with dementia have been found to experience more negative mental and physical health outcomes such as strain 23 on the other hand it is important to note that family caregivers in difficult situations can and do experience positive consequences related to caring for a loved one 26 existing research evidence has also shown that the health status of the care recipient plays an important role in caregiver mental health in care recipients with alzheimers disease patient cognitive status has been found to be a significant predictor of objective burden for caregivers 27 as well as depression 28 similarly overall functioning ability of care recipients has also been associated with increased burden for caregivers 2829 in addition research evidence suggests the status of the caregivers physical health mental health 283031 as well as demographic variables such as older age and being female increased their risks of caregiver depression 2832 and anxiety 25 one especially important connection with the mental health of caregivers is the available research on family dynamics 33 high family cohesion has been associated with less caregiver burden and depression 33 and family conflict has been associated with increased caregiver depression and anger sustaining caregivers and maintaining the health of caregivers is critical given that our health system relies on family caregivers as the backbone of care yet we know little about the caregiving experience for this population as it is affected by social location social location refers to either a groups or individuals placelocation in society at a given time based on their intersecting demographics age sex economic class sexual orientation gender education race immigration status geography etc 12 13 14 15 we have yet to fully comprehend the combined influence of these intersecting demographics on peoples health and have little indication of how they may change over time given the dynamic nature of caring for older adults with mcc further a social location or diversity lens would allow the identification of vulnerable caregivers which can then better supported in these often complex and potentially stressful or burdensome situations we attempt to do this in this paper with respect to informal caregivers of persons with multiple chronic conditions there are some clusters of literature related to informal caregiving and a number of variables of diversity or social location such as gender age education geography and social connectedness however most of this literature is focused on caregiving of persons with single not multiple conditions the literature review is organized around these variables of diversity beginning with gender gender although there has been a rise in male caregivers women still provide the majority of informal care to older adults 34 as a result the effects of care giving can differ between genders in terms of wellbeing women are more likely to report lower wellbeing or health status regardless of the condition of the care recipient 323435 specifically poorer physical health is found among dementia caregivers 32 and negative psychological health is found among stroke caregivers 35 male caregivers on the other hand often have better wellbeing both physically 36 and mentally 3637 women are more likely to experience symptoms of depression and caregiver burden especially when caring for persons with dementia 3236 38 39 40 41 women caregivers also tend to be at a greater risk for comorbidities and chronic illnesses regardless of the care recipients disease 4243 with respect to seeking outside help for care giving tasks men are more likely to pursue help from others 363741 when caring for persons with dementia while women are more likely to take all of the responsibilities of caregiving upon themselves 324144 however women caregivers are more likely than men to have social support 343845 while men are at greater risk for social isolation 42 age older caregivers are at greater risk for experiencing burden compared to their younger counterparts 46 47 48 49 50 when caring for persons with either stroke or dementia older caregivers are also more likely to be living with chronic illnesses themselves however the prevalence of developing a chronic illness correlates more strongly with younger dementia caregivers when compared to the general population 43 thus there appears to be a significant correlation between age and burden education the level of caregiver education can impact caregiving for example dementia caregivers with a lower level of education are more likely to experience symptoms of depression than caregivers with a higher education level 29 higher educated caregivers of persons with dementia or stroke are more likely to experience a better quality of life and satisfaction 51 and better physical 52 and mental health 53 surprisingly dementia caregivers who are more highly educated were found to experience a greater burden of caregiving 54 finally stroke caregivers with lower education are more likely to experience feelings of fear and isolation 55 likely due to the fact that they lack information about and the initiative to seek social support services geography the location in which a caregiver lives in relation to the care recipient as well as care services can also influence their experiences of care giving for example gort et al 56 found a statistically significant relationship between dementia caregiver collapse and not living with the care recipient this indicates that caregivers are more likely to experience collapse when they are living apart from their care recipient in addition caregivers who live a great distance from care services have a hard time accessing them 57 rural caregivers especially cannot conveniently visit the doctor and hospital and therefore are more likely to experience negative physical symptoms 5859 geographical distance has also been found to influence families to place loved ones with dementia in longterm care facilities or homes 60 families living farther away from the older adult with dementia are more likely to place them in a longterm care facility rather than choose to provide informal care social connectedness the degree of social connectedness can have a great impact on the experiences of care giving frequent sources of social support for stroke and dementia caregivers include colleagues neighbours and friends 6162 a strong negative correlation has been found between depression and social support indicating that caregivers who lack a social support network are more likely to experience symptoms of depression 38 63 64 65 66 this association is mainly found among stroke and dementia caregivers in general caregivers who have high levels of social support report higher levels of wellbeing and general health 65 caregivers who are also spouses tend to experience greater consequences socially hong and kim 67 found that caregivers of their spouses with dementia rated themselves as having less social support and poorer physical health than caregivers who were not spouses of the care recipient tang and chen 68 studied stroke caregivers and found a similar association indicating that spouses who were satisfied with their social supports also had a better perceived health status caregivers who have a strong social support network are more likely to be satisfied with their role as a caregiver 69 have a positive attitude towards caring for dementia patients 70 or find meaning in care giving 71 little is known about how these variables representing social location interact this qualitative study explored these parameters to enhance understanding of experiences of caregiving for older adults with mcc at the intersection of these social locations this is particularly needed given that none of the studies noted above considered caregiving for a person with mcc but rather focused on only a single condition as far as we know this is the first qualitative study to explore the influence of social location on caregivers of older adults with mcc methods the data presented herein is a thematic analysis of a qualitative subset of a large twoprovince study conducted using a repeatedmeasures embedded mixed method design 72 following research ethics approval from both mcmaster university and university of alberta caregivers were sampled from the two provincial jurisdictions of alberta and ontario inclusion criteria for the study were a informal caregiver whether family or friend of an older adult with mcc living in the community b care recipient has three or more chronic conditions and was diagnosed with either dementia diabetes or strokethree common conditions for older adults in the last 6 months prior to participating in the research c caregivers are english speaking a multipronged snowball recruitment strategy was employed although not reported on here all participants in the sample participated in two survey interviews six months apart these survey interviews were held either facetoface or over the telephone a subset of 20 survey participants per province were invited to participate in a third qualitative stage following the second survey these participants were purposively sampled to represent the various axis of diversity chosen for the intersectionality analysis this qualitative stage provided an indepth understanding of how the experience of caregiving was impacted by the multiple determinants of interest while also probing the dynamic nature of caregiving for older adults with mcc interviews were semistructured audiotaped and transcribed verbatim interviews averaged 1 hour in length participants were assigned a code to ensure their anonymity the codes are reported as either ap or op followed by their participant id number the questions were aimed to understand the overall experiences of caregivers taking care of someone with mcc examples of these questions include please tell me about your experience as a family caregiver caring for someone with many chronic conditions what is the biggest challenge for you all transcribed data were imported into nvivo the analysis emerged in three stages for a detailed analytical process see sethi 73 in the first stage charmazs 74 constructivist grounded theory method was used to develop initial codes focused codes categories and descriptive themes in the second and the third stages intersectionality analysis 75 76 77 was used to develop final analytical themes to develop the final analytical themes attention was paid to how participants social locations such as age education gender geography ethnicity etc 12 13 14 15 intersected simultaneously to shape their caregiving experiences such analysis extends beyond genderspecific and social determinants frameworks and focuses on a variety of multilevel interacting social locations forces factors and power structures that shape and influence human life 18 the variation across the acuity of the mcc experienced by the older adults being cared for clearly has an impact on the caregiving experience given the dissimilarity of the diseases and disease patterns of the older adults being cared for the analysis presented herein has not accounted for the variation in the caregiving experience as impacted by the diagnosed diseases but has rather combined the experience of caring for older adults with mcc as defined above results as outlined in table 1 19 male and 21 female informal caregivers consented to participate in the study the respondents ranged in age from 18 to 90 years and lived in an urban census metropolitan area region a census metropolitan area is defined as an area consisting of one or more neighbouring municipalities situated around a core a census metropolitan area must have a total population of at least 100000 of which 50000 or more live in the core 78 most participants were married participants reported the following ethnicities caucasian black chinese southeast asian and other nineteen participants had a university degree at the time of the study only 13 were working for pay one participant reported an annual household income of less than canadian 10000 14 earned between 10000 39999 9 earned between 40000 69999 and the income of 10 families exceeded 70000 when asked if their finances met their needs participants reported their needs met as totally inadequately not very well with some difficulty adequately very well and completely the median number of chronic conditions in the care recipients was 7 with the mean being 6983 and the range being 313 the greatest number of care recipients had dementia followed by diabetes and stroke overall the findings suggest that caring for individuals diagnosed with mcc had a multiplicity of challenges first the caregivers were never sure about which condition was causing discomfort to the care recipients further such caregiving was also very demanding as it required constant vigilance of multiple ongoing conditions caregivers were fearful that medication for one condition may conflict with the other medications being taken for other conditions related to this participants noted that they needed to consult with multiple doctors about the care recipients conditions this task was often difficult …a lot of the medical specialties they dont connect well with each other individuals found caregiving for persons with dementia in combination with other chronic conditions as more arduous than caregiving for persons with other conditions a caregiver with both parents diagnosed with dementia notes …theyre struggling through the dementia theyre struggling with each other they dont understand you know where they are sometimes what day of the week it is the personality change is another complex aspect of dementiaalzheimers that participants found challenging its more of the personality and the who is this like identity yeah this is my mom but … who is this woman who has she become i dont identify her meaning a lot to me because that person is gone right it doesnt mean that my mom doesnt mean anything to me but my mom is gone so that person is gone there was an underlining essence in participants responses that regardless of whether caregiving was undertaken willinglyvoluntarily they were unprepared to provide care for individuals with mcc one caregiver powerfully expresses this sentiment…you dont like the demands that are placed on you you feel almost like an untamed horse being put in a bridle or something laughing like its not very comfortable and youve got to get used to it a husband caring for his wife with mcc notes you have no life your own life gets put on hold and the demands of this person get more and more as time goes by and so you have less and less to be yourself and thats the biggest thing im most working on is to retain me in all this the following four themes describe the overall study findings caregiving trajectory where three caregiving phases were identified work family and caregiving where the impact of caregiving was discussed on other areas of caregivers lives personal and structural determinants of caregiving where caregiving sustainability and coping were deliberated and finding meaningself in caregiving where meaningmaking was highlighted theme one caregiving trajectory participants responses suggest that in their caregiving journey there were three caregiving phases these include the initial middle and late phases each of these phases is explained below phase one initial phase the initial phase represented the period of time when the caregiver first assumes the caregiving role …if i was to say what was the worst part it would have been that first six months was the worst for others this period lasted for up to two years the first 2012 to 2013 christmas was very tough because all of a sudden we had got her in this routine from july to december another observes i think maybe the first couple of years that…id say that my mom had alzheimers it was hard regardless of the duration of time there was consistency in most participant responses that this stage was very intense in terms of learning about the caregiving role and being prepared to provide care for family members with mcc learning often included the challenges related to understanding of various medicalrelated issues since care recipients had more than one medical condition medical yeah well im just trying to think of…when she first came home she had a gtube for instance and i had to learn like how to flush that out and like how to like change the dressing in it every week and stuff she doesnt have that anymore in this stage participants had difficulty managing time and taking care of their health since they were overwhelmed with the demands placed on them for caring for someone with mcc participants were more likely to do everything on their own a daughter who was taking care of her mother noted yeah i think maybe the first hmm first couple of years…i was there almost every day and i just felt i couldnt say no those who did seek respite and other supports had to endure a waiting period …in the beginning we didnt really have the services that we needed like healthcare services that we needed to take care of her at home and that was pretty stressful… some participants struggled emotionally when dealing with their new caregiving role as the person had multiple chronic conditions …at the beginning it was really hard cause i was yelling at her blaming her and you know its just very time consuming and its hard it is really often there was a feeling of guilt yeah yeah like as i said the first part the first few years depression you just feel guilt you sort of feel youre giving up your whole life for them everything stops you feel resentment you feel oh havent i helped you enough in my life financially and…mostly financially right participants who were caregiving for individuals with dementia had great difficulty especially in the first couple of years dealing with the care recipients loss of memory a caregiver illuminates i think maybe the first couple of years that…id say that my mom had alzheimers it was hard because youre attached to this identity as a daughter and what no … when she started not recognizing us and our names phase two middle phase as participants moved into the second phase they had learned to adjust to the changes in their life due to caregiving for individuals with mcc yeah you sort of…its difficult to adjust to this change… but you know gradually over time you adjust and yeah you know learn to more or less deal with it … in this phase they accepted their caregiving role i think ive accepted the caregiver role it just came at a weird time in my life another participant adds … its like when you have a new baby you feel resentful that suddenly your lifes not your own but you get used to it right it is what it is and youve got to grow up right this phase highlighted the formation of some routine in their life caregivers understood that they needed help with their caregiving duties i think perhaps one of the things thats changed from when i first started to now is that i realized that i cannot do it all… as they sought out supports such as personal support workers for personal care they learned to balance caregiving with managing their personal andor professional lives i think another hardest struggle was hard to balance and its a little bit more balanced out now … with the passing of time life became more organized i had at first when i first started two years ago i didnt understand how i had to do everything now that ive got everything organized… being organized developing routine and regaining some balance lost in the initial phase provided opportunities for selfcare phase three late phase the late phase is characterized by the caregiver showing confidence in their caregiving duties i think ive sort of grown into the role and i feel quite competent actually at this point in terms of the role that im playing in addition participants appear to accept the care recipients diagnosis in this phase a participant states i guess really understanding and accepting that you know the memory thing normally it doesnt initially sound like its a medical problem it sounds more like its…you know the person is just sort of careless and whatever surely you can remember that kind of thing you get the idea how come you cant remember that at the same time they learned to set caregiving boundaries i had to kind of tell my dad in a nice way and i didnt know how to do it without creating problems and so he kind of backed off a little bit in addition to accepting health care supports such as home support services participants joined support groups or caregiver associations to educate themselves about the disease some participants even educated others and became advocates for the care recipient a daughter advocating for her mother stated …everybody needs an advocate for them and so i am happy that i can do that for her and i think every elderly person well everybody in the hospital every sick person kind of needs that there was not only acceptance of the care recipients diagnosis but a willingness to speak about it with others i think that like i said im not ashamed to talk about it openly whereas i used to… its a stigma right this final phase also seemed to portray participants understanding that there were some positive outcomes from taking on the caregiving role for example in the initial phase participants were scared of healthrelated caregiving duties but later gained healthrelated knowledge as a result of the caregiving role a participant expresses his views first first yes and i have learned a lot like i never knew how what it takes or how to look after an elderly person like cant do anything for themselves because there are ways you turn the way you clean the way you take care of them the way you feed them because shes peg percutaneous endoscopic gastronomy tube fed and at first just seeing the tubes i was scared another participant adds i feel good … i am of some value to my parents theme two work family and caregiving this theme addressed the impacts caregiving had on participants work family and health this theme was further divided into three subthemes caregiving and workcareer that highlights how employment impacted caregiving caregiving and family highlights the loss of intimacy and family conflicts resulting from the demands of caregiving and caregiving and health highlights the physical and mental health impacts on caregivers and loss of social networks due to the constant need for care as the care recipients had mcc these are briefly discussed below caregiving and workcareer managing paid employment and caregiving work was taxing for the eleven caregivers who also were employed one participant confided so you cry every night and it affects you because with the full time job i had i closed the door and cried and laughing a couple of employees saw me and its embarrassing in a similar vein an adult son describes his challenges in balancing paid work and caregiving i moved in in 2010 at the end of 2010 took time off of work inevitably dealing with both my parents made it difficult for me to return to work emotionally i wasnt strong enough to go back to work and i basically stayed here to care for him to be a support you know emotional mental physical support while we waited for the inevitable… female caregivers employed in paid and unpaid work were …squished between two places often working multiple jobs that required them to compartmentalize work and home life to manage both many were managing multiple roles that is taking of the house family and spouse as the frequency of emergencies and hospital appointments increased it was harder for some participants to integrate paid work with caregiving commitments for those caregivers who were employed a wide range of strategies were used in order to best meet the demands of the caregiving role four decided to leave paid work due to the time commitments of caregiving as working far away from home created challenges for a wife taking care of her husband indicating the impact of geography in caregiving she moved closer to be available to him on short notice she notes i could be closer in case something happened to him cause weird things like id come home to find tea towels burnt and stuff scorched stovetops and stuff but id come home to find out that nobody had been here all day you know intersection of geography and ethnicity is implicated in an immigrant caregivers decision to relocate to help his mother and be closer to his siblings growing up in uganda he was taught to take care of his parents especially mothers thus he felt a strong sense of responsibility to provide care to his parents he relocated and moved in with his mother as the primary caregiver one participant took early retirement while others either took time off work reduced their workload or dropped down to parttime hours finally one participant mentioned that they had to put their educational goals on hold the data suggested that the work culture was critical in the participants ability to remain employed well ive been lucky at work that my boss is very understanding emotional the boss above her is not understanding at all and thats a whole other horrible story laughing similarly another participant describes his work culture as accommodating his caregiving role great employer very understanding i can phone my boss and say i gotta run its ten oclock ive got a problem at the old folks home and snap you know you pass off the oncall cell phone pager whatever you go right for one caregiver without the introduction of a new duty to accommodate policy where human resources assist workers to meet their caregiving or other needs she would have been unable to keep her job caregiving and family there were clear differences in responses between spousal and adult children caregivers with regards to the impact of caregiving on family relationships for spouses the challenges were mainly related to not being able to do those things they had done in the past as a couple a husband notes the challenge is finding things to do together that she can participate in and she doesnt care to watch much television not that thats something you do together other than sitting side by side but the things wed enjoy like walking and traveling and concerts and so on are no longer possible and her eyesight is affected and because of the breakdown in communication between her eyes and the brain there was also loss of physicalsexual intimacy in marital relationships due to mcc a wife caregiver explains hes like a child that i help you know theres no more physical relationship theres none laughing findings from adult children caregivers reveal several conflicts there were often struggles between parents and adult children as caregivers due to past unresolved issues a caregiver observes i think in my mind always thinking about the past and all the crappy things that happened between us and all the crappy things that my mom did like the bad things she did and the things she should have done i dont know why i am thinking of all these of things but… adult children caregivers also reveal sibling conflicts with respect to the caregiving task itself for example there were family troubles when caregivers perceived that their siblings were not contributing equally to caregiving …its more the sibling i wouldnt call it rivalry but the sibling uneven contribution but if someones selfish and tight with their money theres nothing you can do about it you cant force your sibling even in families where siblings made a collective decision about caregiving there was always difference of opinions about what was best for the care recipient sometimes these differences of opinion caused deteriorated family relationships and created health issues ive kind of you know had it out with my sisters and said blah blah blah like i kept it in for a long time and i think that caused me like i dont want to say chest pain but added stress and pressure that i didnt need caregiving and health findings suggest that participants health deteriorated as a result of the physical andor emotional demands of caregiving for a person with mcc the following quote demonstrates the caregiving and health relationship im on antidepressants but you cant even tell laughing yeah when my dad got sick and i just felt like i couldnt cope crying all the time i hate crying all the time its so embarrassing but i dont know if thats just a trigger… participants who had to deal with their own physical andor mental health issues found caregiving particularly arduous a participant explains i think probably on my emotional and psychological health its had a huge impact ive had depression since i was probably 11 diagnosed when i was 14 and thats caused me issues over the years and i find it really really difficult i dont have the freedom i used to have to step back when im not functioning very well… the stress of caregiving for multiple care recipients took a heavy toll on the participants bodies the issue of deteriorating health was particularly visible in older individuals taking care of their spouse a caregiver to her husband observes about nine months to a year ago my health started to go downhill and home care services they just stepped in on one of the trips to the hospital with name of care recipient there was a lady there from home care services and she just for some reason she just came in she was talking to care recipient and she looked at me and she said i think youre the one that needs home care laughing the following quote further highlights how age impacts caregiving experiences i guess as were both growing older and hes deteriorating…im not in good shape so its getting harder and harder moreover the lack of leisure time or time for selfcare was clearly indicated in participants responses due to lack of time for social interactions participants were not able to optimize their social connectedness a participant observes you have no life your own life gets put on hold and the demands of this person get more and more as time goes by and so you have less and less to be yourself women who were sandwiched between taking care of their spouse andor children as well as their care recipient parent had even less time for selfcare and infrequent participation in social activities a participant observed that even when she and her husband took some time off caregiving was always on the back of her mind likewise an adult child adds even if i went to the movies i would have to have my blackberry on for phone calls in case i was needed theme three personal and structural determinants of caregiving the gendered nature of caregiving was particularly apparent in adult childrens responses i felt that it was expected and not asked it was just youre a girl and girls care give and boys dont so i definitely saw like oh you know the gender divide and the expectations a participant argues hes the darling little boy thats a hard thing too that he seems to be the favourite crying when i do everything from a male caregiver perspective women were better caregivers as … to do this job you need to be compassionate and understanding which are things that men arent usually blessed with laughing and but ive had to learn that … another caregiver agrees i mean being the son and also falling into a role that you know… from my perspective easier to a woman i find it stressful you know men did yard work helped fixing things around the house andor looked after the inheritance it was generally the women who provided personal care often there was discomfort for male caregivers to provide personal care to their mother especially when there were cultural norms against it …it was difficult for me when she could not manage to what you call to change her dresses or at night especially in the evening time when she wanted to put on her nightgown and go to sleep and she wouldnt do it and that was…i used to feel how should i put it very sad because what you call culturally it was a nono for a son in our culture to do that for a mother a male chinese participant provides an alternative cultural facet suggesting that parents live with the son and not the daughter …its a culture thing boys take care of parents and girls…its not their responsibility… so i have a lot of already a lot of expectations on me but my parents sometimes dont remember that like im not a machine even though this participant was considered the primary caregiver of his parents his mother would not allow him to give her a massage as it was culturally a gendersensitive issue in his own words im a boy yeah she feels uncomfortable… id like to but i cannot yeah the findings suggest that attitudes and beliefs about caregiving was an important component in caregiving sustainability for example spouses commitment to marital vows was a sustaining factor for most spouses interviewed the following quote reflects such commitment well you know the marriage vows we took was you know said in sickness and in health until death us do part so when problems come up you deal with them you know and you find the best solution you can thats just the way it is similarly for adult childrengrandchildren having a positive attitude towards caregiving helped them through trying periods furthermore participants who during their caregiving career were generally active and took good care of their health by eating well exercising andor taking time for selfcare indicated that caregiving did not negatively impact their health financial health emerged as an important component of caregiving sustainability while financial difficulties added to the weight of caregiving having a financial cushion eased the burden of caregiving furthermore decluttering andor having an physically accessible housing situation made caregiving a safer and more comfortable experience for both caregivers and care recipients possessing skills such as being able to cook or having some medical background andor hobbies aided participants in coping with the caregiving role educating themselves about their care recipients mcc either through the internet reading andor attending programs relieved some of the stress while gaining some control over the situation volunteering attending support groups andor day programs andor using humor assisted participants in managing demanding times friends andor family emerged as the most important sources of support and feeling socially connected helped caregivers meet the arduous demands of caring for those with mcc however for immigrants without family and friends caregiving were particularly lonesome for lack of interpersonal networks and weak social capital …were immigrants we dont have brothers and sisters or cousins or nieces or nephews or anything so its just myself to take care of him religion andor spirituality provided comfort and meaning to life and assisted caregivers cope with caregiving stresses as evident in the following quote spiritually i have a lot of faith and ive accepted that ive been chosen to do this and with god i put god in front first and foremost i think that is what keeps me doing it and keeps me going theme four finding meaningself in caregiving even though there were many physical mental emotional andor financial challenges faced by caregiving participants they were able to find meaning in their caregiving role spending time together brought caregivers closer to their care recipient family bonding is expressed in this long and persuasive quote …even though its very sad its brought some good in the sense that my family members are less spoiled like they know that they have to step up now so its a good thing and its kind of like you know its like a family bonding moment as well because when youre helping one person when you all have the same goal you learn by each other a little bit too so like there are things like very small things like before we never used to eat dinner together and now we do right participants indicated that caregiving made them more empathetic an adult child expresses gratitude i mean theyre thankful for what i do but i also feel like i also have them to thank for a lot of different things so i kind of see it as like kind of giving back… similarly other adult children caregivers expressed a sense of gratitude in being able to give back to their parents and that by spending quality time with their parents caregiving enhanced family cohesiveness by creating a …sense of togetherness as a family as noted by an adult daughter i think one of the things that happened as a result of caregiving was that walking away and sort of taking distance was not as optional as it had been and so we just needed to stay through some difficult times together and there was probably a period of about close to ten years where that was actually a huge benefit in our relationship for male spouses in particular it seemed that for a long time they had been at the receiving end of the benefits of marriage and now for the first time in their life were engaged deeply in their offering of benefits i think its enhanced my life overall actually by being so close to the center laughing rather than out on the periphery somewhere receiving all these benefits laughing a male spouse experienced pride in caregiving i think that as a caregiver your role as benefitting somebody that cant do it themselves gives you a little bit of pride to say hey i can do this im capable of doing this and i shouldnt reject it another spouse offered insights about new lifeenhancing learning that had resulted from caregiving …a lot about housekeeping laughing like how to do laundry and learning a bit about how to cook and prepare meals out of necessity women too learned to do things that their husbands always took care of i know ive learned things like how to take taps off and fix them and all those kind of things laughing certainly household skills theres nothing i cant do around the house anymore i know i take care of everything now and im very proud of it a male participant is convinced that caring for his wife and staying active improved his health ive never been in better health laughing as far as energy and you know alertness and stuff because now i have to structure that part of it before the caregiving commences actually discussion recognizing the diversity of caregivers who participated in the study a number of commonalities were shared first caregivers shared the many common challenges of caring for a relative with mcc ranging from pharmaceutical interactions through to the lack of intraprofessional communication amongst health care specialists further all participant caregivers experiences contributed to the understanding of the three phases of the caregiver trajectory themes 2 3 and 4 all highlight the many differences experienced by the family caregivers interviewed these differences bring to light the importance of social location which refers to either a groups or individuals placelocation in society at a given time based on their intersecting demographics 12 13 14 15 certainly as determined by the findings from the 40 interviews of caregivers caring for patients with mcc a number of these axes of diversity were found to be comparatively more important than others these include gender age education employment status ethnicity and degree of social connectedness for example the findings clearly highlighted the gendered aspects of caregiving men were primarily responsible for technical aspects of care while women performed personal care the issue of deteriorating health was particularly visible in older caregivers implicating age as a unique challenge for these individuals there was some evidence that immigrant status played an important role in social connectedness due to lack of time for leisure and selfcare waning social connectedness was visible in most of the caregivers however immigrants were more vulnerable to loss of social network than those born in canada ethnicity and geography were two other axis of diversity implicated in caregivers experiences employment status intersected with gender to marginalize women more than men marital status was another axis of diversity in fulfilling caregiving roles religious andor spirituality emerged as an important element of caregiver wellbeing furthermore gender and ethnicity intersect powerfully in the aforementioned quote its a culture thing boys take care of parents and girls…its not their responsibility… so i have a lot of already a lot of expectations on me but my parents sometimes dont remember that like im not a machine this division in labour confirms the traditional gendered roles in society where men manage and women due to their nurturing traits carry out the hands on care newman et al 79 convincingly argue that 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 while the central role women play in family caregiving is well known mens entry into caregiving work challenges the primacy of gender this calls us to further explore gender in the caregiving experience in order that we may be better able to understand the caregiving impacts on paid employment finances and health while fostering gender equality in caregiving work when contemplating those who are most vulnerable to caregiver strain and burnout it is equally important to gather an understanding of how gender intersects with other determinants of health to shape caregivers experiences for instance in the current study a male chinese participant is expected to take care of his parents yet even though he wants to he is not able to give his mother a massage we agree with chappell et al 80 with respect to the importance of examining the relationship that the caregiver has with the care recipient as our results show that most spouses considered providing care to their partner as an integral part of the marital vows they had taken and so provided care willingly this willingness to provide care to an ill spouse as a means to fulfill marital vows is similar to the findings by hammondcollins peacock and forbes 81 wherein participants spoke about finding meaning and strength through their caregiving roles particularly among husbands however child caregivers experienced stress and conflict with parents andor their other siblings some women in our study occupied more than one caregiver role providing informal care to the spouse children and parents conclusion chappell et al 80 persuasively argue for using the intersectionality framework for understanding cooccupancy of more than one status much of the caregiver research has offered valuable insight into the impact of gender on caregiving intersectionality analysis has the ability to illuminate the unique experiences resulting from the intersection of diverse variables of diversity it is clear from the current study that multiple and overlapping axis of diversity influence the caregiving experience intersectionality can help to move beyond the focus on one disease at a time to gaining an understanding of intersecting and overlapping factors and concerns that individuals with mcc may experience such insight into the contextspecific factors that are creating challenges is needed to help people their health and manage their chronic conditions certainly such results have implications for service provision in that the needs of the most vulnerable can be prioritized there are several factors influencing this study the first is that the sample was taken from a quantitative study which meant that additional participants were not sampled to further inform the findings as well they were mostly white with only a few that represent different ethnic groups further all lived in urban areas in order to challenge inequities and promote social justice it is integral that we understand within group differences and between group differences within a particular ethnic group and or between different ethnic groups or between caucasian and noncaucasian participants 15 although such an analysis would have deepened the understanding of caregiving of older adults with mcc 15 it was not possible due to the lack of ethnic and geographic diversity across participants future research using an intersectionality framework must include participants representing different ethnic and cultural groups and those who live in rural areas such a multilevel analysis of intersecting factors is important to gather a comprehensive understanding of caregivers experiences and reveal the nuances of their complex lives specifically intersectionality analysis in caregiving research offers the possibility of gaining critical insights of how caregiving issue are framed and informed by diversity further as religion andor spirituality were utilized as a coping mechanism it would be worthwhile to explore the role of faith communities in supporting individuals and families dealing with mcc abbreviations mcc multiple chronic conditions cgtm constructivist grounded theory method psws personal support workers competing interests the authors declare they have no competing interests

background a littlestudied issue in the provision of care at home by informal caregivers is the increase in older adult patients with chronic illness and more specifically multiple chronic conditions mcc we know little about the caregiving experience for this population particularly as it is affected by social location which refers to either a groups or individuals placelocation in society at a given time based on their intersecting demographics age gender education race immigration status geography etc we have yet to fully comprehend the combined influence of these intersecting axes on caregivers health and wellbeing and attempt to do this by using an intersectionality approach in answering the following research question how does social location influence the experience of family caregivers of older adults with mcc methods the data presented herein is a thematic analysis of a qualitative subset of a large twoprovince study conducted using a repeatedmeasures embedded mixed method design a survey subset of 20 survey participants per province n 40 total were invited to participate in a semistructured interview in the first stage of data analysis charmazs 2006 constructivist grounded theory method cgtm was used to develop initial codes focused codes categories and descriptive themes in the second and the third stages of analysis intersectionality was used to develop final analytical themesthe following four themes describe the overall study findings 1 caregiving trajectory where three caregiving phases were identified 2 work family and caregiving where the impact of caregiving was discussed on other areas of caregivers lives 3 personal and structural determinants of caregiving where caregiving sustainability and coping were deliberated and 4 finding meaningself in caregiving where meaningmaking was highlightedthe intersectionality approach presented a number of axes of diversity as comparatively more important than others these included gender age education employment status ethnicity and degree of social connectedness this can inform caregiver policy and programs to sustain health and wellbeing

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some cases is fatal it has been established that exposure to abuse results in physical mental and behavioral health consequences maltreatment is a common and significant burden on the health care system that can produce sequelae both short and long term in fact the negative health consequences can persist long after the abuse has stopped a traumatic event such as abuse leads to potentially irreversible changes that may increase vulnerability to poor health over the life course we know that early exposure to violence can produce longterm consequences for the victim many years later victims may develop at least one mental disorder such as depression anxiety posttraumatic stress substance abuse and chronic physical complaints studies among women who were abused at any time after the age of 15 showed that they are significantly more likely than other women to report overall poor health chronic pain memory loss and problems in walking and carrying out daily activities studies have also found that women with a history of abuse are later more likely than other women to report a range of chronic health problems such as headaches chronic pelvic pain back pain abdominal pain irritable bowel syndrome and gastrointestinal disorders in addition abuse may have an impact on the victims life expectancy and longterm healthrelated quality of life the linkage between abuse and perceived qol has not attracted great attention however existing studies suggest that abuse or neglect experiences are associated with lower qol in most domains furthermore a study has shown that people who have experienced violence for instance reported significant losses in healthrelated qol in adulthood compared with people who did not experience maltreatment also in that study it was shown that childhood maltreatment had a yearly loss of 003 quality adjusted life years or 11 days per year nevertheless there are few studies on the relationship between abuse and perceived qol particularly lifetime abuse and among older people a further examination of the topic may be useful to assess the burden of abuse on health this information may help policymakers and health planners in the development of effective interventions to target abuse and improve qol among victims of abuse based on data collected in a multinational study on abuse and health in seven european countries we intended to assess the subjective perception of qol among people between the ages of 60 and 84 years who have experiences abuse during their lifetime method measures abuse abuse was assessed with 52 questions based on the revised conflict tactics scales and on the uk survey of elder abuse and neglect psychological abuse subscale comprised 11 questions of which six consisted of severe acts physical abuse 17 questions of which 10 consisted of severe acts physical abuse with injury seven questions of which four consisted of severe acts sexual abuse eight questions of which five consisted of severe acts financial abuse nine questions of which five consisted of severe acts each abuse act may have occurred once twice three to five six to 10 11 to 20 or more than 20 times after the age of 18 for each subscale lifetime abuse was defined if participants positively reported the occurrence of these acts at least once during adult life when questions were answered this has never happened the respondent was coded as noncase and if they answered yes as a case cronbachs alphas across countries for each violence type as assessed by the scale were 82 for psychological abuse 80 for physical abuse 70 for physical abuse with injury 90 for sexual abuse and 81 for and financial abuse the present study focused on lifetime abuse that is exposure to any of the abovementioned abuse from the age of 18 years which does not include child abuse qol qol was assessed with the world health organization quality of lifeold module it contains 24 items with responses graded on a likerttype scale ranging from 1 not at all to 5 extremely we transformed the scale scores to between 0 and 100 making it possible to express the scale score in percentage between the lowest and highest possible value to obtain the transformed facet score the manual instructions of the scale administration have been taken the following transformation rule was applied transformed scale score 625 × the items can be summed into a total qol and divided into six domains with four items in each autonomy fear of death or dying intimacy past present and future activities sensory abilities and social participation higher scores indicate higher qol cronbachs alpha for qol across the included countries was 92 statistical analyses in the present analysis analysis of variance was used to compare means of each domain of qol according to each type of lifetime abuse experience seven multiple linear regressions were computed to scrutinize the associations between the dependent variables and each form of lifetime abuse models were adjusted for country of residence age gender living with partner marital status education occupation financial support financial strain social support smoking alcohol drinking body mass index and presence of disease associations were expressed as unstandardized βs and their 95 percent confidence intervals to assess multicollinearity in our regression analysis we calculated the variance inflation factors for estimates in each model results showed vif values lower than 5 which indicates that regression coefficients were not poorly estimated due to multicollinearity as no significant statistical interaction by gender in the association between lifetime abuse and qol was found data for men and women were analyzed together 1 455 percent of the participants reported at least one experience of abuse during their lifetime with psychological abuse as the most common type the prevalence of lifetime physical abuse was 115 percent injury 43 percent sexual abuse 5 percent and financial abuse 185 percent significant statistical differences were observed in the prevalence of lifetime abuse according to gender women tend to report more frequently experiences of lifetime injuries and sexual and financial abuse table 2 shows the prevalence of severe episodes of abuse according to country age and gender severe episodes of physical abuse and financial abuse were reported in higher numbers in portugal results as shown in table as shown in table 3 the mean and standard deviation score of total whoqolold was significantly higher among the nonabused compared with those who reported psychological abuse during their lifetime this difference was also observed for physical abuse physical abuse with injuries and sexual abuse in addition lifetime psychological abuse was significantly associated with lower levels of autonomy past present and future activities social participation and intimacy similar results were found for physical abuse physical abuse with injuries and sexual abuse financial abuse was significantly associated with lower levels of autonomy past present and future activities and social participation furthermore victims of physical abuse physical abuse with injuries or sexual abuse reported lower levels of sensory abilities although differences were not statistically significant for sexual abuse however the relationship of sensory abilities with psychological or financial abuse showed opposite results that is higher scores of sensory abilities were observed among victims of psychological and financial abuse the death and dying domain was not associated with abusive experiences during the course of a lifetime table 4 shows the results for the linear regressions considering each domain of qol after adjustment for potential confounders it was observed that experience discussion almost half of the participants reported at least one type of abuse during their lifetime psychological abuse was the most frequent form although less attention has been given to emotional abuse compared with other forms it is known that such abuse may have a high negative impact on peoples wellbeing psychological abuse over time may lead to depression fear anxiety and low selfesteem and ultimately to a high incidence of suicide and suicidal attempts our study showed that people who experienced abuse during their lifetime had lower scores in qol dimensions compared with people who did not experience any type of abuse a previous study also showed that people who experienced abuse early in life have a marginal decrease in at least two years of undiscounted qualityadjusted life expectancy compared with people who did not experience abuse it seems that lifetime experiences get under the skin and may have a negative impact on individuals later qol after adjustment for potential confounders it was observed in our study that sensory abilities and social participation were significantly associated with lifetime physical abuse with injuries having had an abusive experience decreased the score of sensory abilities by 414 and of social participation by 286 lifetime abuse seems to have had a negative influence on the ability to have personal and intimate relationships over time feelings like worthlessness powerlessness hopelessness unhappiness and insecurity can be instigated by abuse experiences and then incorporated in the individuals health and qol even the experience of psychological abuse was related to lower levels of autonomy intimacy and past present and future activities it has been previously shown that psychological abuse may be more damaging than other forms of abuse moreover it has been suggested that if the abuse was perpetrated by someone close to the victim it may be highly stressful for the individual particularly in terms of intimacy m abused m not abused m abused m not abused m abused m not abused m abused m not abused m abused m not abused m abused m limitations the strength of this study lies in its large sample and multicountry approach in addition it explores a research topic that has been little studied in europe however there are some limitations that should be discussed the crosssectional nature of this study did not allow conclusions about causality information was collected retrospectively which may have resulted in recall bias in our study we used the whoqolold which is the most appropriate instrument to assess qol among older people although there are other instruments available however whoqol allowed a crosscultural comparison and also comprises a generic measure of qol making it ideal for adaptation to the assessment of qol in older adults with good psychometric performance the reliability of older age groups in selfreporting events that may have occurred many years ago can be questioned however there is evidence suggesting that the unreliability of retrospective reports of trauma is overstated in fact traumatic events tend to be memorable furthermore in older age when the maltreatment has ended there is an increased likelihood of disclosure on the other hand we are aware that some cases of abuse have not been selfidentified as an abusive experience practice implications this study showed that experiences of violence have a negative impact in qol and also seem to affect the aging process first this study highlights the importance of screening for violence early in life when these experiences have a negative impact in qol the identification and assessment of interpersonal violence experiences is a difficult process because this is not a visible problem and the disclosure of such experiences is very dependent on the individual intention therefore an appropriate setting is required to gather this type of information social workers are the professionals with appropriate training to identify and assess interpersonal violence experiences in different second to improve qol and wellbeing has increasingly become an essential issue for societies social workers and other professionals should work closely together to assess population needs particularly those of vulnerable populations such as older people to define appropriate actions to reduce the impact of abuse for qol conclusion our results provide evidence that older people exposed to abuse during their lifetime have a significant reduction in qol with several qol domains being negatively affected by an abusive experience further research should be conducted to better understand violence phenomena among the population particularly vulnerable population groups and to define interventions to reduce the impact of traumatic experiences on qol hsw

few studies have evaluated the impact of lifetime abuse on quality of life qol among older adults by using a multinational study authors aimed to assess the subjective perception of qol among people who have reported abuse during the course of their lifetime the respondents n 4467 2559 women were between the ages of 60 and 84 years and living in seven european countries germany greece italy lithuania portugal spain and sweden lifetime abuse was assessed by using a structured questionnaire that allowed to assess lifetime experiences of abuse qol was assessed with the world health organization quality of lifeold module after adjustment for potential confounders authors found that to have had any abusive experience decreased the score of sensory abilities psychological abuse was associated with lower autonomy and past present and future activities physical abuse with injuries significantly decreased social participation intimacy was also negatively associated with psychological abuse physical abuse with injury and sexual abuse the results of this study provide evidence that older people exposed to abuse during their lifetime have a significant reduction in qol with several qol domains being negatively affected

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background social mobility the movement of an individual between social classes over hisher life course is an important sociological concept in health research but also has implications for societal cohesion equity economic stability and happiness 1 socioeconomic differentials in health have been identified for a wide range of health outcomes although the widest health gradient is generally seen between the socially static 2 at either end of the social scale the socially mobile tend to show levels of health at an intermediate level compared to their original and destination social class so that those who move upwards are healthier than those they leave behind but not as healthy as the group they join in most 2 3 4 but not all studies 5 mortality rates have also been shown to differ by social mobility trajectory in a similar way to morbidity 67 however it has been debated whether increasing social mobility reduces 8 or widens 2 health inequalities if upward social mobility can improve health and general wellbeing then this could have important policy implications with resources targeted to help people move up the social scale or to design health promotion strategies tailored towards those groups which are immobile at the bottom however in order to target resources there is a need to determine the factors which are most important in facilitating mobility and also those factors that may act as barriers to mobility it has been suggested that social educational material cultural and physical factors in childhood and early adulthood may influence the chances and direction of social mobility 9 education has been implicated as a predictor of upward social mobility in men in a number of studies 9 10 11 other factors postulated to influence or act as barriers to social mobility include childhood cognition 12 achieved adult height 3912 number of siblings 912 and changes in economic conditions 13 inconsistent findings in the previous studies suggest that further research on social mobility in longitudinal birthcohorts where study members experience economic changes at the same time is needed this study investigated factors in early life childhood and early adulthood that may be drivers of and barriers to intragenerational and intergenerational social mobility within the newcastle thousand families 1947 birth cohort methods the newcastle thousand families study began as a prospective longitudinal study of 1142 children born to mothers resident in the city of newcastle upon tyne in northern england in may and june 1947 14 the health growth and development of the cohort were followed in great detail up to age 15 years all families were visited both on a routine and on an ad hoc basis by the study team which consisted of health visitors and paediatricians the cohort underwent a major followup at age 4951 years 14 participants at that time were members of the cohort who were either traced through the national health service central register or contacted the study team in response to media publicity between october 1996 and december 1998 health and lifestyle questionnaires were sent out for completion and return and participants invited to attend a clinical assessment 14 the study received ethical approval from the appropriate local research ethics committees and all study members gave their written consent measurement of early life experience information on early life was recorded prospectively for all study members 14 social class at age 5 years was measured using the registrar generals definition of occupational social class of head of household with social class split into six categories ranging from i ii iiin iiim iv to v housing conditions were recorded by the city public health department in 1952 based on four measures of living standards that assessed whether participants lived in households that were a overcrowded b lacked hot water c shared a toilet or d where the house was damp or in poor repair a composite housing condition variable recorded the number of adverse housing conditions suffered from 0 to 4 as low numbers were found in some categories this variable was dichotomised to no housing problems or some housing problems adverse events suffered in the first five years of life was a composite variable examining deficiency of care and social dependence using five measures of family life standards consisting of a serious parental debt b parental divorce or separation c parental incapacity through chronic illness d parental criminal activity or cruelty e death of a parent again as low numbers were found in some categories this variable was dichotomised to no adverse events or some adverse events in 1958 study members took the 11plus examination consisting of written papers involving tests of verbal reasoning and two standardized tests of english and arithmetical ability 1516 the total iq score was derived as the average of the four test results at that time in england the 11plus examination was a standard test used in educational establishments at the age of 11 years often to determine the type of secondary school at which a child was to continue their education measurement of adult socioeconomic position social mobility and other adult data social class was prospectively derived at age 4951 years and retrospectively derived for age 25 years from the health and lifestyle questionnaire using occupational details of the main wage earner in the household coded according to the 1990 uk registrar generals standard occupational classification again with i assumed to be the most advantaged and v the least advantaged due to the small numbers in some occupational social classes social class was collapsed into four groupsgroup 1 consisted of occupational social classes i and ii group 2 of social class iii group 3 of social class iii and group 4 of social classes iv and v intergenerational social mobility was measured between ages 5 and 25 years and between 5 and 4951 years and intragenerational mobility between ages 25 and 4951 years within these three timescales four potential socioeconomic trajectories categories were created a stable manual those remaining in social class group 3 or remaining in social class group 4 b stable nonmanual those remaining in social class group 1 or remaining in social class group 2 c upward mobility any move upward from a lower to higher social class group and d downward mobility any move downward from a higher to lower social class group highest achieved education level ascertained from the health and lifestyle questionnaire at age 4051 years was grouped as follows a no formal qualifications b o levelsapprenticeshipclerical qualifications c a levels hncother similar level qualification and d degree or postgraduate qualification achieved adult height in centimetres was as measured at the clinical assessment at age 4951 years 14 statistical analysis representativeness of the participants in this study compared to those of the original cohort not included was assessed using t mann whitney and χ 2 tests as appropriate twins were excluded from all analyses due to their potential lack of independence in statistical models all analyses of socioeconomic trajectory were done over three timescales achieved adult height and childhood iq were treated as continuous variables the other variables as categorical multivariable logistic regression was used to examine the potential associations of childhood iq education level achieved adult height housing conditions at age 5 years adverse events in early childhood and sex with upward and downward mobility likelihood ratio tests were used to assess the significance of each variable the odds of upward and downward mobility were examined with upward and then downward mobility compared against all other possible trajectories ie those who were not upwardly mobile odds ratios and corresponding 95 confidence intervals are reported for upward mobility between 5 and 25 years and between 5 and 4951 years those who were in social class 1 at age 5 were excluded as they were unable to experience upward mobility and likewise those in class 4 at age 5 were excluded for downward mobility similar exclusions were applied at age 25 years for mobility between ages 25 to 4951 years in addition to combined analyses upward and downward mobility were also examined separately for men and women over each timescale as sexspecific effects of social mobility on health have been previously reported for this cohort 41317 regression analysis was performed for all potential factors simultaneously to produce a multivariable model for each timescale to take account of potential confounding factors as adult height was measured at the clinical assessment and thus not available for the entire sample models were established without height at first and then adjustment for height tested on the smaller sample for which height was available potential interactions were tested within the regression modelling framework the statistical software package stata was used for all statistical analyses results table 1 shows sociodemographic characteristics of the study population at baseline and at followup 789 participants had social class data at age 5 574 participants completed questionnaires at age 4951 years and 457 had social mobility data from age 5 to 4951 years table 2 summarises the descriptive data for each potential driver of social mobility by social mobility trajectory between 5 and 4951 years and for the cohort overall there was no significant difference in terms of social class at age 5 years between those included in this study and the remainder of the cohort a significantly higher proportion of women were included in this study than in the remainder of the cohort those who remained in the study had significantly higher median childhood iq than those who did not and those who had housing problems in childhood were underrepresented upward mobility childhood iq and achieved education level were both significantly and independently positively associated adjusting for adult height made very little difference to these results in men higher childhood iq and achieved education level were significantly associated with increased odds of upward mobility between ages 5 and 4951 years at the univariable level however only iq remained significant in a model containing both variables for upward mobility between ages 5 and 25 years in men iq and education level were significant in women higher childhood iq and achieved education level were significantly associated with increased odds of upward mobility from 5 to 4951 years at the univariable level although only iq remained significant in the multivariable model as all upwardly mobile women had a universitylevel education this resulted in infinite odds in women therefore universitylevel education was associated with upward mobility but education level itself was not because the universitylevel women were excluded from the model due to a lack of variation in the mobility outcome data for these women for upward mobility between ages 5 and 25 years childhood iq and education level were significant at the univariable level but only education level was significant in the multivariable analysis this remained the case when those with universitylevel education were excluded from the analysis for upward mobility between ages 25 and 4951 years only childhood iq was significant in a model with education although again all upwardly mobile women had universitylevel education downward mobility whilst childhood iq and education level were significant predictors of downward mobility between ages 5 and 4951 years at the univariable level only low childhood iq retained significance in the multivariable model when examined by sex only childhood iq was significantly associated with downward mobility for men for women childhood iq was significant at the univariable level but lost significance in the adjusted models no women with a university education were downwardly mobile and so were this group was excluded from the analysis due to a lack of variation in outcome data lower childhood iq was significantly associated with increased odds of downward mobility between 5 and 25 years in the unadjusted analysis but lost significance in the adjusted analysis the same pattern was seen when restricting the analysis to just women but for men no significant associations were seen lower childhood iq and lack of higherlevel qualifications were significantly associated with increased odds of downward mobility between ages 25 and 4951 years at the univariable level however only iq remained significant in the adjusted model low childhood iq was significantly associated at the univariable level with an increased odds of downward mobility for both men and women but remained significant for only the men in the adjusted analyses discussion in this cohort childhood iq and achieved education level were both positively associated with increased odds of upward mobility between the ages of 5 and 4951 years however only education level was significantly associated with upward mobility between 5 and 25 years and only childhood iq was significantly associated with upward mobility between 25 and 4951 years lower childhood iq was associated with increased odds of downward mobility as previously noted in studies of social mobility and health in this cohort 41317 most mobility was in an upward direction this reflects changes in occupational social class patterns found throughout the uk 9 where there was a considerable amount of absolute intergenerational social mobility over this period economic and social change meant that there was more room at the top 1 for the newcastle thousand families birth cohort all born in 1947 in a city in the north of england 14 their career and educational opportunities are likely to have been far greater than that experienced by their parents as although manufacturing has declined there has been a massive growth in the service sector leading to a much larger middle class and the size of the unskilled manual labour force has decreased in this study higher achieved education level was a significant driver of upward mobility education has been described as the main engine of social mobility 18 and as a means to escape from childhood disadvantage 19 education has been associated with social mobility in men in a number of previous studies 91012 measured either as number of years of education or as level of education but only one of these studies also measured iq in that study high iq was associated with upward mobility at the univariable level but the association was lost in the multivariable model when education height and number of siblings were included 12 however men who were in an advantaged social class in adulthood had the highest childhood iq scores irrespective of their fathers social class suggesting that iq may be important for upward social mobility 12 in the current study whilst higher childhood iq and education level were significant predictors of upward mobility between 5 and 4951 years at the univariable level in men only iq was significant in the adjusted model although this may have been due to the low numbers of men investigated high childhood iq was significantly associated with upward mobility between ages 5 and 4951 years and between 25 and 4951 years in this cohort our findings in relation to childhood iq and social mobility support previous evidence suggesting that iq level is more strongly associated with social class attained in middleage rather than early adulthood and that people with high iqs eventually move up the occupational ladder regardless of their educational qualifications 12 however education does appear to be important for early mobility as only education level was significant for early social mobility between the ages of 5 and 25 years as in previous studies 11 iq and educational achievement were correlated higher childhood iq has been associated with higher age of leaving education for men 12 who are therefore likely to obtain higher level qualifications but this may also depend on the social circumstances of the family in a meritocracy individuals should be able to improve their circumstances through ability and effort there is a split in the literature between those who believe that the uk is to a large extent a meritocratic society 20 where iq plus effort can allow someone to advance up the social scale and those who argue that children from more disadvantaged origins need to show substantially more merit 21 in order to reach the same levels results from this study suggest that higher iq in childhood is associated with upward mobility supporting the meritocracy theory that iq plus effort does indeed allow upward mobility however in the descriptive analyses the highest iq levels were found in the stable nonmanual group rather than the upwardly mobile a pattern that has been reported elsewhere 22 therefore it appears that those from more disadvantaged backgrounds in this study do not need to exhibit more merit than those who originate from a higher social class in order to reach the same broad level on the social scale however we cannot say anything about finer stratification within each occupational social class where evidence still suggests that those from more privileged backgrounds tend to occupy the more lucrative and prestigious professions 23 low childhood iq 12 and low achieved education levels 1012 have previously been associated with downward mobility in men although only one study considered both 12 in the current study those with a lower childhood iq were significantly less likely to be upwardly mobile and more likely to be downwardly mobile suggesting that low childhood iq is both a barrier to upward mobility and a driver of downward mobility education level was not significantly associated with downward mobility previous studies have largely focused on men and social mobility in women has not been explored in this study childhood iq was significantly associated with upward mobility between 5 and 4951 years and between 25 and 4951 years for women university education also appeared to be important for women in achieving upward social mobility as all women in this cohort who had a universitylevel education were upwardly mobile education level but not childhood iq was significant for upward mobility in women between ages 5 and 25 years it was found that for each level of education women had a higher median iq than men therefore it appears that women in this study who were as intelligent as men did not achieve the same level of education members of this cohort were teenagers in the 1960s when only a small percentage of the population went to university and there were still high levels of inequality between the sexes it is possible that the observed sex differences are due to the social values of the time where education was not considered as important for women however for those women who did go on to higher education this allowed them to progress up the social scale or maintain their high social position as university degreelevel or postgraduate qualifications were only found in stable nonmanual or upwardly mobile women it has been suggested that educational success might not necessarily result in upward mobility if many disadvantages have been suffered in childhood 19 however very few data are available on the influence of childhood social circumstances on social mobility in this current study where it was possible to examine this adverse circumstances and poor housing conditions in childhood did not significantly affect the chances of social mobility in either direction in children who experience deprivation those who are most advantaged in terms of social capital are more likely to be upwardly mobile 24 social capital can be measured in material psychological and cultural terms 25 conditions in childhood which result in low levels of social capital might also contribute to shorter stature 25 so that height can be used as a proxy measure of childhood circumstances as inadequate nutrition contributes to attained adult height 12 achieved adult height has been directly linked to social mobility in men 3 with taller men who were born between 1905 and 1935 9 and who were born in 1921 12 showing upward mobility with downward mobility seen for those who were shorter in the current study with participants born in 1947 height was not significantly associated with social mobility there is a lack of published data relating to height and social mobility in women here no association was found between height and social mobility in women it is possible that due to the postwar conditions that the cohort grew up in with rationing still in place until 1954 potential height differences by social class were reduced resulting in nonsignificant differences in height between socioeconomic trajectories as found here for both men and women the main strength of this study is the prospective nature of the data and the extensive follow up covering 50 years which allows analysis of both intergenerational and intragenerational social mobility the study examined social mobility in women as well as men something that has not been done before although numbers were low when the sexes were examined separately some retrospective data were obtained to determine social class at age 25 years but all childhood and age 50 data were prospectively collected thus reducing the possibility of recall bias the wide ranging available data meant that the indirect selective effects of social biological and educational factors on social mobility could all be examined simultaneously however whilst the range of data examined allowed confounding to be taken into account the possibility of residual confounding having a role in interpreting the findings remains as data on social factors such as adverse circumstances and housing conditions in childhood were available it was possible to examine whether those who lived in more deprived circumstances achieved their educational potential and whether this influenced social mobility iq data were collected prior to educational attainment and the influence of both was evaluated which allowed consideration of whether those from lower social class backgrounds need to show more merit than those from more privileged households in order to obtain similar adult socioeconomic standing as the cohort members were aged 4951 years at the time of data collection for this study it was possible to collect details of educational attainment achieved later in life social class at age 5 years rather than at birth was used with the uk recovering from war in 1947 many of the occupations at the time may not have truly represented the head of households true standing taking social at age 5 years is likely to give a more accurate picture of the individuals childhood socioeconomic circumstances than using birth data loss to followup can be an issue in longitudinal cohort studies and is not always randomly distributed here there was no significant difference in childhood social class between those included in this study and the remainder of the cohort a significantly higher proportion of women were included in this study than in the remainder of the cohort but the sexes were examined separately the problems inherent in assigning a ses based on occupation to women should also be acknowledged particularly when using the highest occupational social class in the household which for many women in this cohort resulted in them being assigned the ses of their male partner however the use of husbands occupation to determine social class for women can also be regarded as a strength as it is debateable how relevant a womens own occupation actually is as a reflection of socioeconomic status as this tends to be compromised by motherhood 8 becoming a mother can often result in apparent downward social mobility for women 10 as they move from an employed to a caring role we did not have data on the number of women in this cohort for whom this was the case but it is likely that many of these women did not work or gave up work when they had children 17 therefore the husbandpartners ses is more likely to truly reflect the ses of the household those who remained in the study had significantly higher median childhood iq than those who did not low childhood iq in this cohort has been associated with an increased risk of early mortality 16 which might partially explain why those who remained had higher iq low iq has also previously been associated with increased risk of morbidity 26 and with adverse health behaviours 26 although this study was able to include some adverse social and material circumstances in childhood the fact that these markers of deprivation and adversity were not associated with social mobility in this cohort might suggest that other measures of social support that we were not able to determine may play a role in limiting some of the adverse effects of socioeconomic disadvantage in childhood this could be an area for future research in this cohort conclusions this study has shown associations between both childhood iq and achieved education level and the odds of upward and downward mobility material factors such as poor household living conditions and adverse psychological experiences in childhood were not associated with mobility in this cohort and those who experienced childhood adversity were still able to move up the social scale due to aptitude and ability the factors that influence iq and educational attainment may be the type of social capital measures that are also likely to result in upward mobility although there is some debate as to whether iq level is alterable 2728 iq may have some genetic heritability but the environment also appears to play a role 28 and factors such as parental childrearing style and the number of books in the home have been shown to influence iq in young children 29 likewise the value placed on education the availability of books in the home and parental support and encouragement to stay on at school have all been suggested as factors that might determine whether someone is able to achieve their educational potential 19 iq and educational attainment are likely to influence employment prospects and thus adult ses 16 upward social mobility has been associated with better health as well as more general benefits to society in terms of population happiness equity and equality of opportunity 118 as both high iq and education level are associated with upward mobility supportive measures to improve childhood circumstances that could result in increased iq and educational attainment may have longterm population health and wellbeing benefits list of abbreviations ci confidence interval iq intelligence quotient or odds ratio author details 1 institute of health and society newcastle university baddiley clarke building richardson road newcastle upon tyne ne2 4ax uk 2 departments of medicine and paediatrics dalhousie university halifax nova scotia canada 3 institute of health and society newcastle university sir james spence institute royal victoria infirmary newcastle upon tyne ne1 4lp uk declaration of competing interests the authors declare that they have no competing interests

background it has been suggested that social educational cultural and physical factors in childhood and early adulthood may influence the chances and direction of social mobility the movement of an individual between social classes over hisher lifecourse this study examined the association of such factors with intragenerational and intergenerational social mobility within the newcastle thousand families 1947 birth cohort methods multivariable logistic regression was used to examine the potential association of sex housing conditions at age 5 years childhood iq achieved education level adult height and adverse events in early childhood with upward and downward social mobility results childhood iq and achieved education level were significantly and independently associated with upward mobility between the ages of 5 and 4951 years only education was significantly associated positively with upward social mobility between 5 and 25 years and only childhood iq again positively with upward social mobility between 25 and 4951 years childhood iq was significantly negatively associated with downward social mobility adult height childhood housing conditions adverse events in childhood and sex were not significant determinants of upward or downward social mobility in this cohort conclusions as upward social mobility has been associated with better health as well as more general benefits to society supportive measures to improve childhood circumstances that could result in increased iq and educational attainment may have longterm population health and wellbeing benefits

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introduction despite progress in the past 15 years levels of child stunting and maternal undernutrition in ethiopia remain unacceptably high 1 the levels reported in the 2011 demographic and health survey showed slight improvement compared with previous dhs 2 but were still very high by world health organization standard 3 a minidhs survey in 2014 reported a 404 prevalence of child stunting in ethiopia a small improvement over a five year period 4 maternal undernutrition however had not changed since the first dhs in 2000 125 maternal and child undernutrition has been a local and global public health concern with farreaching consequences ranging from poor health outcomes to loss of economic gains and productive citizens due to morbidity and mortality associated with poor nutrition research has estimated over 3 million child deaths annually due to undernutrition and suboptimal care for young children 67 undernutrition in mothers has been identified as a major risk factor for poor health outcomes in offspring such as poor fetalgrowth lowbirthweight and poor development in the first two years after birth resulting in stuntedgrowth and poor health later in life 689 child undernutrition particularly stunting is a major problem stunting is linked with some serious consequences such as poor cognitive development lower school performancehence loss of income and productivitywhich further perpetuates intergenerational undernutrition due to the subsequent poor economic capacity to provide adequate care for ones offspring 10 realizing the grave consequences of malnutrition local and international governments as well as humanitarian agencies have sought ways to mitigate the problem of undernutrition through implementation of various health and nutrition programs since 2008 the ethiopian government has implemented a national nutrition program that aimed at improving the nutrition of women and children 11 the nnp set a specific target for reducing undernutrition in children but not for women for this and other concerns the nnp was revised few years into its implementation to reflect a lifecycle approach in improving nutrition of women and children and relaunched in june 2013 12 the revised nnp had specific targets of reducing child stunting and undernutrition in women of reproductive age nationally by 2015 the programme sought to achieve these objectives through strengthening nutrition service delivery within the health sector and nutritionsensitive interventions across sectors however dhs reports in 2014 and 2016 showed these targets were not met for child stunting 413 this implies the need to strengthen andor put in practice more comprehensive approaches to solving the problem of undernutrition one of such areas is recognizing that health is determined by more than individual factors such as genetic predispositions and behaviour or lifestyle choices 14 ones social and economic status such as gender housing conditions education income access to services age and sanitation collectively known as social determinants of health are factors that need to be considered 14 nutrition is a vital component of health that affects and is affected by these factors women and young children are among the most at risk for poor nutrition particularly in ethiopia where economic and social disparities tend to be greater even when food is available women tend to be malnourished because of their gender status 15 women shoulder triple roles including their biological role of bearingrearing children productive and social responsibilities 16 these roles add significant workload on women increasing their risk for poor nutritional status undernutrition in women is also known to increase the risk of poor nutritional status in children 717 the national nutrition program in ethiopia focused on improving nutrition for women and children through nutrition specific and sensitive activities such as food security diet diversification therapeutic feedings supplementation and fortification the nondietary factors such as gender and socioeconomicdemographic factors and their importance as underlying causes of maternal and child undernutrition were not emphasized in the program although the united nations childrens fund conceptual framework of malnutrition outlined the underlying causes research that examined the effects of such factors on motherchild undernutrition was limited in our study setting 1819 moreover the impact of the nnp in improving undernutrition in mothers and children at regional levels have not been adequately assessed either the purpose of the current study was to estimate levels of maternal and child undernutrition in selected rural communities of ethiopia five years into the implementation of the nnp and to explore the association of maternalchild undernutrition phenomenon with gender socioeconomicdemographic factors accessutilization of health services and nutrition related knowledgepractices of mothers during pregnancy and lactation we hypothesized that levels of maternalchild undernutrition as well as the socioeconomic factors affecting it would differ in the selected rural communities participants and methods setting participants and ethics the baseline data reported here was collected as part of a communitybased intervention study in three purposively selected rural kebeles kebeles are the smallest administrative units in the government structure and may contain about 500 households each two of the three communities were selected from rural halaba a woreda in southern nations nationalities and peoples region the woredadistrict is located 85 kilometers northwest of hawassa the capital of snnpr it is known for growing pepper and pulses which are considered cash crops for the farmers the third rural community was selected from adamitulujidokombolcha district near zeway town in the regional state of oromiya it is located about 160 kilometers southeast of addis ababa ethiopias capital maize teff wheat barley and different oil seeds are the major crops produced in the district the area is characterized as dry land with both irrigated and rainfed crop productions the study communities were part of a larger ethiopiacanada project between hawassa university and the university of saskatchewan that sought to improve agricultural productivity and human health in south ethiopia 20 in all the three communities the study population were mothers and their 5yrs of age children hence the inclusion criteria were households in the community with mothers and children 5yrs of age the sample size was determined using formula for crosssectional studies in each community 21 n o ¼ z 2 1à a 2 pð1 à pþ h i d 2 and n n o n n o where n o n stand for sample sizes before and after applying finite population correction factor respectively z 196 p probability of expected prevalence n total population of interest and d margin of error in this study prevalence of maternal undernutrition was taken as expected prevalence p 027 with a margin of error of 5 for calculation of the sample size the calculation yielded 200 households with motherchild pairs per each community adding a 5 contingency a total of 630 motherchild pairs were required sample size in halaba was higher as two of the selected communities from this district were merged for this analysis the selection of additional community in halaba was needed for a subsequent interventioncontrol study selection of individual households was carried out by first obtaining a list of all eligible households from the local health post and applying simple random sampling in this study a household was defined as one that had a mother and at least one under five years of age child and was served by the local healthpost regardless of whether polygamy was practiced or not whenever households had more than one eligible child the youngest was considered the study was approved by the university of saskatchewan behavioral ethics board as well as the regional health bureaus of snnpr and oromiya all mothers gave oral consent to participate in the study due to the low literacy rate in rural ethiopia obtaining written consent was not feasible oral consent was the most and culturally appropriate way of obtaining informed consent the consent information was written in simple and easytounderstand manner which was also translated into the local language consent forms were attached on a coded interview questionnaire for each participant female data collectors read and explained to each participant the purpose of the research as outlined in the consent form once participants gave oral consent to participate in the study the data collectors wrote the participants full name on the consent form to indicate consent this was then signed by the principal investigator detached from the interview questionnaire and stored in safe locker the obtaining of oral consent was approved by the ethics committees the study was carried out in marchjune 2013 data collection tools variables information on the characteristics of participating households was collected by a questionnaire adapted from previous national and local surveys in the region 22 23 24 we collected information on household size number of children 5yrs of age marital status polygamy education of mothers and their husbands household headship usual occupation ownership of domestic animals cultivable land ownership of various household assets housing characteristics sanitation facility access to drinking water persons responsible for fetching water and time required to fetch water womens access to their own farm land person in charge of agricultural produce and some other variables the questionnaire also contained a section that assessed access and utilization of health nutrition services as well as dietary habits of mothers during their most recent pregnancy and lactation these items were adapted from the baseline survey for national nutrition program 22 information on access and utilization of healthnutrition services included whether mothers had visited any healthcare facility type of healthcare facility visited number of visits place of delivery of the youngest child and whether mothers had received ironfolate supplement as well as if mothers had received any healthnutrition education duringafter their most recent pregnancy additional questions asked include whether mothers abstained from eating certain foods during pregnancy for cultural reasons including the type of foods avoided this way what their eating pattern was like during pregnancy and lactation as well as whether mothers knew what balanced diet was from the data collected we created a set of variables to reflect gender economic and demographic structures of the study households difference in years of formal schooling between husband and wife was used as a proxy measure for empowerment index for the household the use of years of formal schooling to measure empowerment is supported in literature 2526 we also used the length of time required to fetch drinking water as a proxy measure to estimate work burden on women whounicef recommend that drinking water should be accessible within 30 minutes of round trip from ones residence 27 thus if time required to fetch water took 30 minutes or longer this would significantly increase work burden womens access to ownpiece of farm land control over agricultural produce and polygamy were also variables used to reflect the gender dimensions of participating households likewise we used information on cultivable land size per household and number of persons per household to calculate physiological density and which provided information on how much land was available to produce food for the family we then placed participating households into two categories and explored associations with nutritional status of mothers and children ownership of livestock is another important resource for agricultural communities in ethiopia we used the number and type of livestock information to calculate tropical livestock units for each household and divided the households as having low average or high tlu one tlu is estimated as the equivalent of 250 kg livestock 28 a wealth index was also developed for each participating household to classify households based on socioeconomic status to achieve this we used various assets owned by households and other housing and sanitation related characteristics the assets include ownership of radio tv mobile phone bicycle horsedonkey cart motorcycle handheld torch and oxen housing characteristics include roofing structure flooring materials presence or absence of windows crowding as well as presence or absence of an improved sanitation facility the use of assetbased approach to determine households socioeconomic status is also common in dhs surveys at national level 129 it is usually used for poor countries where large proportion of the population does not have regular income various methods can be used to weigh each item and calculate the actual index 30 each household received a score of 1 or 0 depending on whether it owned a particular asset we then weighted each binary variable by the inverse of the proportion of households that owned the particular asset or had the particular characteristics 30 this method assumes that if assets are owned by just the few it is an indication that those few are wealthier than those that do not own the asset hence they are given greater weight after calculating wi for each household households were grouped into low medium and high wi categories trained female data collectors who fluently spoke the local languages administered the interview questionnaire at participants residence data collection was supervised by the principal investigator and bsc nutrition graduates who also spoke the local language fluently anthropometric measurements of mothers and their children were carried out at the nearest health facility local school campus or outside the local kebele office on separate dates participants living near to any one of these locations were invited to attend the anthropometric measurement sessions those who could not attend were visited at their residence one person conducted all anthropometric measurements for both mothers and children to avoid intermeasurer errors child anthropometry included weight using electronic scale height recumbent length using adultinfant lengthstature measuring board head circumference using a flexible nonstretch tape midupper arm circumference using colored insertion tape for children and triceps skinfold thickness using skinfold caliper mothers anthropometry included weight height and muac all measurements were taken in duplicate and averages were considered when the duplicates were similar if the values were not similar a third measure was taken to obtain the average of the two similar values standardized procedures were employed when taking body measurements 323 birthdates for children were determined from immunization cards while age of mothers was asked verbally data analysis questionnaires were inspected daily and errors or inconsistencies were corrected at the field level information from questionnaire was entered in spss computer package and cleaned by running simple frequency distributions univariate and bivariate analysis was performed for the descriptive statistics bivariate and multiple variable regression analysis were performed to explore associations of gender and socioeconomicdemographic variables with maternal and child undernutrition ie body mass index 185 kgm 2 and lengthor heightforage z score 2 standard deviation respectively using chi square tests and multiple classification analysis only variables that were significant in the bivariate analysis were included in the mca maternal bmi and child lazhaz as continuous variables served as main outcome variables and results were presented with the associated eta and beta values indicating the bivariate and multiple variable coefficients of variation respectively who anthro 2011 was used to analyse all anthropometric data for children mean lengthor heightforage zscore weightforlengthheight zscore weightforage zscore muacforage zscore head circumferenceforage zscore triceps skinfold thicknessforage zscore and bmiforage zscore were calculated differences were tested using ttest for independent samples prevalence of stunting wasting and underweight were also calculated body measurements from mothers were directly entered in spss spreadsheet and average muac weight height as well as maternal short stature were calculated 3 bmi of nonpregnant mothers and severity of maternal undernutrition were estimated per who classification of bmi since muac is relatively stable during pregnancy 31 all mothers in the study were grouped as undernourished or normal using muac 23 cm as a cutoff point for comparison purposes and where possible results were presented along with findings from nationalregional studies statistical significance was set at a pvalue of 005 results household structure socioeconomic and demographic characteristics individual and household related background characteristics are presented in table 1 similar demographic characteristics were observed in both study areas no significant difference was observed between the communities in median maternal age household size and in the proportion of 5yrs of age children per household the average household size reported was larger than the national average almost all mothers were married polygamy was a common practice particularly in halaba where one in four mothers had polygamous husbands compared with one in ten at the national level compared with the national report school attendance was much lower among the women however their husbands particularly in zeway attended some primary and postprimary education table 1 also shows that maleheadship was very prominent in the study areas ninety percent of the women were not involved in any income generating activities farming was the main occupation of their husbands standpipepublic tap and wells were the main sources of water for households fetching water was primarily womens responsibility maternal and child anthropometry and levels of undernutrition tables 2 and3 present information based on maternal and child anthropometric measurements mothers in halaba were taller than those in zeway but had similar average muac as zeway mothers excluding pregnant mothers and those who had babies within the two months preceding the measurement the average maternal weight was not different while average bmi was slightly lower in halaba than zeway mothers prevalence of maternal shortstature was 1 to 5 comparable to the national prevalence of 4 maternal undernutrition was 22 in halaba and 14 in zeway most of the mothers had normal bmi when muac was used to estimate proportion of undernourished mothers 27 of halaba and 24 of zeway mothers fell in the undernourished category however no significant differences were observed between communities in proportion of undernourished mothers using either bmi or muac mean zscores of various anthropometric indicators of halaba children particularly the ones measuring heightlengthforage and weightforage were as low as 21 and 16 abbreviations gs gubasherero hk holagobakukie eq edoqontola sd standard deviation muac midupper arm circumference bmi body mass index edhs ethiopia demographic and health survey a edhs 1 b significant between communities at p 005 c excludes i pregnant mothers ii pregnant and lactating mothers and iii mothers who had babies within the last two months prior to the anthropometric measurement respectively and significantly lower than the respective values for zeway children prevalence of undernutrition in 5yrs of age children particularly stunting and underweight were very high in halaba communities the respective findings in the zeway community were 42 and 21 still very high but significantly lower compared with halaba children the prevalence estimates for zeway children were lower than those reported at national level whereas stunting and underweight in halaba were 20 and 26 respectively higher than the national estimates gender disaggregated prevalence of child undernutrition showed no significant difference in prevalence of stunting wasting and underweight between males and female children within communities however more stunted and underweight female children resided in halaba than zeway among male children significantly more wasting and underweight were found in halaba than zeway access and utilization of health services dietary habits and food taboos during pregnancy and lactation table 4 presents findings on access and utilization of health services dietary habits and food taboos during pregnancy and lactation during their most recent pregnancy most mothers attended their antenatal care at a health post or health centre health post is a component of primary healthcare unit that provides basic preventive promotive health services mostly for the rural ethiopia population whereas health centre also part of primary health care unit severs as a referral for health posts and provides curative services to common diseases higher proportion of zeway mothers had greater number of anc visits but also visited a health centre hospital use for anc was very minimal or nonexistent in both halaba and zeway delivery of babies at a healthcarefacility was very minimal particularly in halaba more mothers in halaba than zeway reported receiving ironfolate supplement during pregnancy however 77 zeway and 41 halaba mothers did not get healthnutrition education before or after delivery of their youngest baby food taboos were more common in halaba than zeway most common foods mothers avoided during pregnancy were animal source foods such as dairy liver meat fish and plant source foods such as banana avocado kale sweet potato and yam majority mothers said they ate the same as usual or less than usual during their pregnancy in a followup question poor appetite and feeling nauseatedsick followed by inability to afford desired food were mentioned as reasons for not eating more during pregnancy whereas increased appetite due to lactation was mentioned as a reason for eating more during lactation in halaba only one in four mothers knew what a balanced diet was compared with two in four in zeway associations of gender household structure access and utilization of health services and diet related variables with maternal and child undernutrition table 5 presents chisquare associations of various gender and household structure related variables with maternal undernutrition and child stunting empowerment index significantly associated with child stunting but not with maternal undernutrition womens access to their own piece of land did not significantly associate with either maternal or child undernutrition slightly more stunted than nonstunted children were observed in households where only men controlled agricultural produce but the difference was not significant other gender related variables such as workburden of women presence or absence of polygamy in the home and headship of household did not show significant association with maternal and child nutritional status having a household size of 6 or 6 persons significantly associated with maternal undernutrition and with child stunting physiological density also significantly associated with child stunting but not with maternal undernutrition households economic structure variables did not significantly associate with either outcome maternal dietary habit during pregnancy significantly associated with child stunting and underweight but not with maternal undernutrition mothers knowledge of balanced diet did not associate with undernutrition in either group however residing in halaba or zeway significantly associated with both maternal undernutrition and child stunting access and utilization of healthnutrition services food taboos and knowledge of balanced diet did not significantly associate with either maternal undernutrition or child stunting but abstinence from certain foods during pregnancy significantly associated with child wasting multiple variable analysis of determinants in maternal and child undernutrition in a followup multiple variable regression analysis of variables that were significant in the bivariate analysis geographic location of households ie being in halaba or zeway and household size ie 6 or 6 membershh in order of importance remained independent predicators of maternal bmi after adjustment for other factors in the model the overall model was significant and predicted a small variation in maternal bmi likewise household size men vs women control of farm produce and physiological density in order of importance remained independent predictors of lazhaz in children while dietary consumption pattern during pregnancy and geographic location of households were near significant the overall model was highly significant and predicted a small variation in lazhaz of children discussion we found an alarming level of child stunting in our study communities54 in halaba and 42 in zeway the levels of maternal undernutrition ranged from moderate in zeway to high in halaba communities we also found that 95 of halaba and 85 of zeway mothers reported dietary consumption patterns that were same as usual or less than usual during their most recent pregnancy compared to times of nonpregnancy or lactation the practice of food taboos by mothers was up to 61 in halaba and 18 in zeway communities gender and socioeconomicdemographic factors such as imbalance of power physiological density household size and dietary habits during pregnancy showed significant associations with maternal and child undernutrition targeting the nutrition of most vulnerable groups such as pregnantlactating mothers adolescent girls infants and young children is one of the strategies to break the cycle of chronic undernutrition with emphasis to the first 1000 days of life 6732 in agreement to this ethiopia launched a national nutrition program in 2008 the nnp was later revised with the intent to accelerate progress and achieve the millennium development goals 1112 reducing stunting from 46 to 37 was set as part of the countrys five years growth and transformation plan 33 to deliver the service from nnp ethiopia took advantage of the already in place national health extension program implemented to improve access to basic health and nutrition services at grass root levels 34 nutrition specific and nutrition sensitive programs have been put in place through initiatives such as communitybased nutrition and agricultural extensions programs as a result of these and other related initiatives ethiopia has experienced reduced prevalence of stunting wasting and underweight as well as lowbirthweight babies over the past few years 35 despite these encouraging pronutrition environments our findings indicated existence of undernutrition that is of serious public health concern the prevalence of maternal undernutrition we reported though lower than the 27 national prevalence 1 presents a continued challenge for the particular region level of maternal undernutrition in ethiopia in 2011 dhs were nearly twice as high as those reported for neighbouring country of kenya or uganda in recent dhs 3637 maternal undernutrition along with maternal shortstature is known to increase obstetric risks and maternal morbidity even in the presence of adequate medical services 38 in addition it is a known risk factor for intrauterine growth restriction and subsequent lowbirthweight babies with increased risk of neonatal mortality or stunting 7917 in the current study motherchild malnutrition phenomenon was observed in 10 and 8 of households in halaba and zeway respectively this means a stunted child was present in nearly 50 or more of the households with undernourished mothers an insult during fetal or embryonic development per the theory of fetal programing of chronic diseases has also been linked to adultdiseases such as coronary heart disease hypertension type2 diabetes and high cholesterol 83940 the alarmingly high levels of child stunting found in our study are 50 80 higher compared with levels in neighbouring countries 36374142 the prevalence of underweight in halaba was 70 higher than the level found in zeway community both stunting and underweight levels for halaba children were not only higher compared with values reported in 2011 dhs at national level 1 but also higher than values from dhs 2005 regardless of what the baseline prevalence in 2005 may have been in these communities the levels reported here signal a serious warning for nutrition program implementers in the region research has already established that stunting compromises both the physical and mental productivity of a countrys future labor force 104344 hence the level of stunting reported here should raise a serious concern for future labor force in the region the fact wasting was relatively low indicates that stunting was major contributor to the observed high or very high level of underweight among children stunting reflects poor nutritioncare suffered for a long period of time as opposed to wasting which reflects acute situation of poor nutrition from primary or secondary causes addressing wasting in children need not be neglected but health and nutrition programs need to be specific enough to address stunting previous similar studies in younger children from adjacent regions of south ethiopia also reported high levels of child stunting but not as high as what we reported here 234546 high levels of stunting were also reported among adolescent girls in halaba area in a recent communitybased study 24 the lack of significant difference between boys and girls in the gender disaggregated data for stunting wasting and underweight may indicate that both boys and girls were equally vulnerable to poor nutrition at early age and there was no differential vulnerability based on gender however stunting tended to be higher in boys than girls in the zeway community poor nourishment andor health may be the obvious causes of maternal and child undernutrition however women and young children are surrounded by a host of underlying and basic factors in their physical and social environment that play key role in their nutrition and health these factors often referred to as social determinants of health 14 may greatly impact the growing environment of children access and utilization of healthnutrition services may affect maternal and child nutritional status as most mothers in ethiopia live in rural areas where informationservices on nutritionhealth are limited children are more vulnerable to effects of suboptimal growing environment because they depend on adults mostly women for necessary care hence the adequacy of care women provide to children is affected by their own socioeconomic statusgender related factors such as their level of empowerment accesscontrol of important resources and the workburden they shoulder in addition household level factors such as number of people in the household wealth and ownership of livestock are also factors capable of modifying healthnutrition environments for children and women the socioeconomic and demographic characteristics we presented in table 1 follow similar trends as in dhs and other local studies 1224547 many of these factors presented in table 5 did not show significant associations with maternal nutritional status however household size and location of households were independent predictors both in the bivariate and regression analysis larger family size may exacerbate the pressure on women as they carry out their biological role of bearing and rearing children empowerment index significantly associated with child stunting in the bivariate but not in the multiple variable analysis the proportion of stunted children was the smallest and mean lazhaz was the least in households where the difference in empowerment was the least this might imply that imbalance in empowerment affects decision making and communications in the household which in turn negatively influence childcaring practices in addition child lazhaz mean scores where better in households where women controlled farm produce indicating the importance of ensuring womens control of important resources to better position them for improved child care likewise high physiological density may mean less food produced to feed members of the household hence implication to child nutritional status either or both large family size and smaller farmland holding contribute to high physiological density this challenge can be mitigated by population policy and a strong agriculture policy that improves productivity in a small plot of land both physiologicaldensity and household size have shown significant association with markers of child stunting in bivariate and multiple variable regression analysis in our study dietary consumption pattern during most recent pregnancy was another important variable that showed significant association with child stunting in bivariate analysis this association was weaker when lazhaz was used as continuous outcome variable in the mca model but was nearly significant diet during pregnancy affects maternal health and child development at early stages earlier studies looked into factors dictating human growth process in infancy childhood and puberty and documented that growth in infancy and early childhood is nutritiondriven while growth in the later stages is hormonedriven 48 some also added that growth at the early stage of infancy is simply a postnatal continuation of fetal growth 49 maternal undernutrition and poor dietary habit during pregnancy was a known risk factor for intrauterine growth restriction and poor pregnancy outcome both of which were shown to be major risk factors for childhood stunting 7 50 51 52 53 besides abstaining from consumption of certain nutritious foods during pregnancy a large majority of mothers in our study reported consuming as usual or less than usual during this critical period our finding on poor dietary practices during pregnancy was not only consistent with the national report in 2009 22 but also was an indication to the lack of improvement five years after the launch of the nnp though we were unable to connect poor diet during pregnancy and birthweight in our communities the alarming levels of child stunting and moderate to high levels of maternal undernutrition indicate the poor growing environment available for the children to thrive these findings again call for more focused nutritionhealth services to and improved utilization by mothers and children in our study communities and similar settings if the country is to sustain progress in the reduction of undernutrition toward achieving the new sustainable development goals 54 the strength of this study was that it investigated motherchild undernutrition levels five years into the implementation of the nnp phase1 and explored a set of gender specific or gender sensitive as well as socioeconomicdemographic variables affecting maternal and child undernutrition in rural ethiopia selection of the study communities was purposive which may limit the external validity of the findings however applying our results to other rural communities given the similarities in health and agriculture services physical infrastructure local government etc could still be applicable and warranted conclusion in this study we have reported very high levels of child stunting and underweight we also report moderate to high levels of maternal undernutrition gender as well as socioeconomic and demographic factors such as empowerment imbalance control of farm produce physiological density household size and dietary habits during pregnancy showed significant associations or trends with maternal and child undernutrition in bivariate and multiple variable analysis we were also concerned with the poor dietary habits including existing food taboos of the women during pregnancy our findings stress the need for health program implementers to provide nutrition education before during and after pregnancy as the health of mothers is critical to the health of both the mother and fetus overall this crosssectional study provides important information to nutritionhealth service providers in rural communities in evaluating and strengthening existing health programs targeting women and children and in the development of new programs attention should be focussed on womens education access and control of resources as well as better reproductive health services to improve womens balance of power in the household and ensure optimum family size for better nutrition all data underlying the study are within the paper and its supporting information files supporting information s1 data anonymized raw dataponed1647012r2ftc data curation getahun ersino gordon a zello formal analysis getahun ersino gordon a zello nigatu regassa funding acquisition carol j henry investigation getahun ersino gordon a zello methodology getahun ersino gordon a zello carol j henry nigatu regassa project administration getahun ersino gordon a zello carol j henry resources carol j henry supervision getahun ersino gordon a zello carol j henry writing original draft getahun ersino gordon a zello writing review editing getahun ersino gordon a zello carol j henry nigatu regassa

addressing maternal and child undernutrition is a priority for the national nutrition program of ethiopia in a crosssectional design we selected motherchild pairs n 630 from halaba south ethiopia n 413 two communities and zeway oromiya region n 217 one community these communities were previously included in a project to improve agricultural practices we aimed to estimate the level of maternal and child undernutrition in the two study sites and compare findings to regionalnational reports we also examined associations with gender householdstructure and nutritionhealth related variables households were selected using simple random sampling based on list of households obtained from local health posts mothers were interviewed via questionnaire anthropometric measurements were taken from motherschild pairs maternal undernutrition bmi 185 ranged from moderate 14 zeway to high 22 halaba in the children stunting and underweight were very high 54 and 42 stunting 36 and 21 underweight in halaba and zeway respectively up to 95 of halaba and 85 of zeway mothers reported same as usual or less than usual consumption patterns during their most recent pregnancy compared to periods of nonpregnancy mothers reported 61 in halaba 18 in zeway abstaining from consumption of certain nutritious foods for cultural reasons gender and socioeconomicdemographic structure of the households including imbalance of power control of farm produce physiological density household size and dietary habits during pregnancy showed significant associations with maternal and child undernutrition p 005 the levels of child and maternal undernutrition particularly in children were unexpected and of concern given that a national nutrition program has been in place since 2008 the study provides insights for policy makers to improve womens education reproductive health services for better family planning and strengthen nutritionhealth programs designed to target vulnerable segments of the population in these and other rural communities and districts with similar structure and demographics in ethiopia

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challenging students are often associated with poor student health and emotional and behavioral disorders and create a lot of problem for teachers and schools kaiser and rasminsky define challenging behavior among students as behavior that interferes with a students cognitive social or emotional development is harmful to a student his peers or adults and puts a student at high risk for later school failure social maladjustment and physical and mental health problems in contrast to a confined biomedical model as well as an individualpsychological model as a researcher my understanding of challenging students is in line with socioecological and critical sociological perspectives from a critical sociological view the school system constructs most of the challenging students as a result of takenforgranted norms and discourses embedded in the politics and institutions of the society according to erevelles how educational personnel approach students with disabilities or severe school problems is mediated by a societal perspective that labels those students as outside the norm this normalizing practice of schooling occurs because public education has used the concepts of difference deviance and disability synonymously to justify the exclusion of certain student populations in addition according to a socioecological perspective childrens development behavior health and wellbeing are a function of complex interactions between biological components psychological states and processes as well as the processes and characteristics of the environments in which they function a function of the quality of relationships among individual family and institutional systems hence to conduct effective interventions practitioners have to take advantage of coordinating and involving the many human resources and competences around the target student such as teachers parents special educators school psychologists and so on furthermore research from other fields has shown that close and welldeveloped collaboration between individuals from different professions has many advantages as compared to when individuals work solve problems and make decisions and interventions on their own independently and in isolation from each other moreover implementation of multiprofessional schoolbased health care services has shown to have positive effects on students academic achievement reduce absence from school and reduce aggressive as well as substance use behaviors among students nevertheless research on multiprofessional teams and collaboration in school settings has shown a lot of pitfalls or problems • the problems of professional boundaries mistrust and professional outgroup devaluation especially teachers suspicions skeptical attitude or rejection of nonteaching professionals who in turn are aware of this suspicion and potential hostility and thus avoid engaging with teachers • teachers who feel threatened when encouraged to question their own practice and to try working in other ways • nonteaching professionals are not comfortable with offering consultation to teachers regarding issues of classroom practice • insufficient teacher involvement or participation in the process and lack of respect for teachers by some nonteaching workers • teachers generally cited lack of time and scheduling difficulties as reasons for their inability to become involved • low degree of treatment integrity in how teachers cope with teamrecommended interventions and • weak or insufficient parent involvement and participation in the process as well as lack of respect for parents hence further research on multiprofessional collaboration and meaningmakings of actors involved in such processes is urgent to better understand and cope with pitfalls and problems that tend to occur or develop in the process the aim of this study is to investigate multiprofessional collaboration as well as collaboration between professionals and challenging students and their parents in which the focus for these collaborations is on handling the challenging students academic and social behavior the analysis resulted in a grounded theory of collaborative synchronizing of human resources in relation to challenging students method i used qualitative methods guided by a grounded theory approach to investigate the processes and sensemakings of collaboration between different professionals parents and challenging students according to meyers truscott meyers varjas and smith collins qualitative research is appropriate for studying the process variables in the context of particular settings it offers the opportunity to develop a deeper understanding of participants perspectives qualitative methods facilitate study of issues of depth and detail and are capable of discovering important discourses and nuances of social processes and actors meanings that might be less visible in largescale studies constructivist position of grounded theory constructivist grounded theory approach assumes that neither data nor theories are discovered but are constructed by the researcher as a result of his or her interactions with the field and its participants data are coconstructed by researcher and participants and colored by the researchers perspectives values privileges positions interactions and geographical locations data as well as analysis are created from shared experiences and relationships with participants and other sources of data this position takes a middle ground between the realist and postmodernist positions by assuming an obdurate reality at the same time as it assumes a relativist epistemology multiple realities and multiple perspectives on these realities social realities are mutually constructed through interaction and are therefore subject to redefinition and are somewhat indeterminate the grounded theory generated in the current study is built on social constructed dataacts of interpretation of participants meanings and narrativesand it is situated and located in a particular context in line with the constructivist grounded theory tradition i have tried to understand the participants beliefs purposes experiences the actions they take and reasons for their actions and inactions from their perspectives and based on their narratives conceptualized a grounded theory background consultations are common in swedish schools in which school psychologists school counselors or special educators from schoolbased multiprofessional studenthealth teams act as consultants and teachers as consultees consultation is usually a onetoone relation or one consultant to a couple of teachers team discussions are not recognized as part of the consultation and typically the teachers are not present the result of the team discussion might be an offer to a teacher to consult with one of the members of the team nevertheless in their problemsolving discussions studenthealth teams rarely contextualized the problems as responses to what had happened in the classroom or as a consequence of the pedagogical arrangements in the class but mostly focused on the target students biological and psychological deficiencies which in turn limited the consultation possibilities with teachers the resource team initiative in the current study was a pilot project it was set up funded and organized by the local government in a mediumsized swedish town to counteract the prevalent withinchild explanation trend and instead initiate a more socialecological model and a social inclusion approach hence external teamslike the resource teamwhich work toward schools around particular cases of challenging or hardtoteach students to analyze the problem with a socialecological perspective offer school consultation promote change of school and classroom contexts and enhance inclusive education are still rather rare in relation to the swedish school system it is significantly more common in sweden to treat challenging students in line with biomedical and individualpsychological models as well as considering students families as possible roots of the problem rather than analyzing how teachers practices and other contextual factors within the school and the classroom might create or contribute to the problem the resource team initiative began in december 2006 in two districts comprising six elementary schools in a mediumsized swedish town five of the six schools were involved in the resource team initiative whereas three of the schools involved were located in a socially disadvantaged district the other two were located in a socially mixed district on average there were about 250 students in each school the resource team project was designed to provide immediate assistance to challenging students with psychosocial problems and their parents to employ problem solving and collaborative consultation with teachers to develop interventions and changes in school that address the needs of the students and their teachers and thus to help maintain atrisk students in the regular classroom and curriculum during the first period team building and development were conducted and information about the resource team was distributed to the six schools in the area during the spring of 2007 the team started to work with specific student cases the resource team consisted of four memberstwo trained social workers and two special educators the principal in each school could apply for resource team assistance regarding individual student cases a special committee organized by the local government decided which applications the team would work with the committee was not made up of school professionals but consisted of administrative personnel from the local government the team handles 6 to 10 students at the same time they offered them intensive support for a limited time period at the time of conducting the study the team had completed 15 student cases and was working with additionally 7 student cases that were completed after the study had been conducted generally the cases involved both academic and behavioral problems some of the students had also received an adhd diagnosis in each student case two team membersone trained social worker and one special educatorworked in cooperation and one of them visited the school and interacted with the target student and the teachers for an extended period the team members began their work on individual cases by acquiring data for the three first weeks they also initiated relationship building with the student and his or her parents as well as with the contact teacher the contact teacher was the class teacher or the mentor of the student and functioned in the specific case as the main contact person between the resource team and the school data collection i conducted four focus groups a focus group with the principals a focus group with 5 teachers a focus group with 3 teachers and a focus group with the resource team focus groups are group interviews in which a moderator guides the interview while a small group discusses the topics that the interviewer raises according to morgan focus groups are used to generate a rich understanding of participants experiences and beliefs participants do not only interact with the researcher but more so with each other which gives the researcher the opportunity to learn the participants own language instead of imposing the researchers language on them resulting in a greater access to their perspectives and conceptual worlds based on ethical considerations regarding the students and parents in the study i chose individual qualitative interviews instead of focus groups the individual interviews with the students ranged in duration from 13 to 21 min five parent interviews were held individually the sixth parent interview included a parent couple that is a mother and a father of the same child the parent interviews ranged in duration from 16 to 44 min qualitative interviews enabled the students and parents the opportunity to present their individual understandings and experiences and for me as a researcher to follow up their narratives with explorative questions all the focus groups and interviews were recorded with a minidisc recorder and then transformed into mp3 files data analysis coding and analysis were conducted directly on the audio data by using nvivo 8 grounded theory methods that is coding constant comparison memoing and memo sorting were used to analyze data based on a constructivist position the following main steps were taken initial coding in which codes were constructed by comparing data segments and using analytical questions such as what is this data a study of what does the data suggest what happens in the data from whose point of view what category does this specific datum indicate initial coding involved naming words lines and segments of data focused coding in which the most significant and frequent codes from the initial coding were compared to each other to synthesize the large amounts of data theoretical coding in which the previously developed codes or concepts were integrated into an analytical story that had coherence in line with a constructivist grounded theory approach i have used and constructed theoretical concepts as interpretive frames that offer an abstract understanding of relationships and these relationships are not based on observational data on multiprofessional collaboration but on the participants representations and descriptions of interaction patterns relationships and effects to readers who are unfamiliar with grounded theory research it is important to recognize that the study was not a quantitative one in which numbers have been investigated this is a too small sample to make meaningful statistical inferences the main idea of the study was not to describe numerical tendencies and differences as a qualitative case study with a grounded theory approach the main idea was to generate a grounded theory which is to construct concepts and conceptualize hypothetical relationships between these concepts grounded in data by grounded theory methods furthermore i have used a broad social psychological framework with a focus on peoples representations of social situations as a starting point which has given me a loose frame to the interest of this study consistent with blumers depiction of sensitizing concepts grounded theorists often begin their studies with certain research interests and a set of general concepts these concepts give you ideas to pursue and sensitize you to ask particular kinds of questions about your topic hence i did not force preconceived ideas and theories directly on data but used these as lenses and tools that helped me to focus the attention on certain phenomena aspects and nuances the social psychological framework of the grounded theory peoples conceptions or representations of a particular type of social situation influence and guide their perceptions interpretations and actions when they are involved in such social situations an individual does not react and act as a consequence of what another person in the situation says or behaves but as a consequence of how he or she perceives and interprets the person and his or her actions how we interpret or define situations interactions and other people depends on our representations or conceptions which we perceive as a takenforgranted reality that we act on these statements have a broad scientific social psychological support based on research and theory development this has been claimed by the traditions of social cognition symbolic interactionism and social representation theory with this broad social psychological perspective in mind it is reasonable to assume that those social and mental representations that teachers principals team members students and parents had about themselves and others about different forms of interactions between one another about the resource team activity and about the school and the home mattered and influenced how they approached thought about and behaved in different forms of interactions to understand their actions and interactions it is therefore urgent to examine their meanings and representations of the social situations in which they act and interact a grounded theory of collaborative synchronizing for the recognized social psychological reasons above and grounded in the analysis of the data i have constructed a grounded theory of collaborative synchronizing in relation to challenging students in school human resource synchronizing a core category generated in this study is human resource synchronizing which refers to processes that included and coordinated different people so that they integrated and interacted together in a way resulting in positive development of the target student the grounded theory is illustrated in figure 1 the left side represents phenomena in the interaction between resource team and school that seemed to contribute to human resource desynchronizing in other words that counteracted the integrating and coordinating of human resources the right side contains phenomena in the interaction between resource team and school that contributed to synchronizing of human resources the concept of human resource has its origin from the area of organizational and management literature in which it refers to the staff that operates an organization in the current analysis this concept has been used more loosely as a sensitizing concept in the generated grounded theory human resource refers to peopleprofessional workers such as teachers and school counselors as well as students and parents it is important to emphasize that the two concepts desynchronizing and synchronizing in this grounded theory are two ideal types ideal types are hypothetical constructions which contain fixed reference points that are useful tools to examine evaluate and compare real situations these are not expected to occur in a pure form in real life but should instead be viewed as analytical tools synchronizing and desynchronizing are two opposite poles and those interacting processes that took place between resource team individuals and school personnel from the different schools were expressions of intermediate forms in which some were closer to synchronizing whereas others were closer to desynchronizing hence according to the grounded theory and based on the participants narratives the more synchronizing the less desynchronizing and vice versa a critical process that appeared to influence the degree of human resource synchronizing was the process of goal setting and negotiation among those who were expected to collaborate this is establishing collaboration between school and home as well as other adequate partners counteracting professional coordinating professional cultures cultures unclear and poor communication low clear and open communication high accessiaccessibility us and them thinking bility us thinking ie high integration ie disintegration between resource between resource team and school personal team and school personal negative see each others as valuable resources multisocial representations on the others professionalism and a will for mutual undernarrowminded professional thinking standing considering multiple perspectives and acting professions and professional professionals and professional cultures are cultures clash available to everyone to make an active and effective collaboration possible aversive relations positive relations negative attitudes negative focus positive and constructive attitudes positive students and parents as antagonists to focus students and parents as partners to school personnel aversive approaches school personnel positive approaches and and methods negative and infective methods positive and supportive relations relations destructive conflict managing constructive conflict managing goal setting the conversations with the resource team as well as the teachers and principals indicated that they often had different or conflicting goals which of course counteracted effective collaboration this in turn pointed to the important process of goal setting the analysis shows two types of goal setting static versus dynamic static goals easily created desynchronizing because they were not open to negotiation were not sensitive to the particular situations of different student cases and did not consider teachers professional judgments if they were not gained approval with and supported by the teachers but were instead viewed by them as unrealistic then there was a high risk that negative expectations among teachers as well as goal conflicts between the teachers and the resource team aroused and thus resulting in re goal setting responsibility professional cultures relations source desynchronizing goal dissonance was indeed a core process in human resource desynchronizing unfortunately according to teacher and principal reports as well as the attitude expressed in the resource team focus group static goals were typical in the resource team activity for example the official and nonnegotiable goal of inclusive education held by team members in every single student case in their approach to the school often collided with what teachers thought and wanted in many cases teachers often wanted the target students out of their classroom and were skeptical about the very idea of inclusion i think that in some way you actually have to listen to the teachers and trust that we actually have some knowledge in this case the teachers were not against inclusion per se but were critical because social inclusion seemed to be a holy cow and not open for discussion and evaluation after all we have to sit down but what does it look like in this situation is this idea really the best goal dissonance or conflicts between teachers and team members created negative attitudes and expectations among the teachers and counteracted effective collaboration and consultation in contrast dynamic goals were shared sensitive open to negotiation and selfevaluating during the ongoing intervention process and achievements the starting point and main focus in dynamic goals was on social inclusion but through systematic data collection dialog and continual evaluation team members teachers and principals together discussed and judged to what degree inclusive education was reasonable and realistic or if the goals had to be revised one important aspect of the goal issue appeared to be a need for revision of the present priority principle of student selection according to the school staff the present order of primarily targeting the most acute and severe student cases was problematic because it resulted in unrealistic goals of inclusive education considering the limits of the resource team intervention period and the resources available such incredibly hard cases which are too difficult the resource team shouldnt deal with them criminal kids the resource team staff cant do anything about them with their very limited time instead the resource team should intervene in cases where we see that if nothing is done now it will become messed upnot when it already has been messed up some teachers argued that there were other challenging students with difficulties but who were not as problematic and hard cases as the most extreme cases often involved in the resource team activities which would be more realistic to work withto keep them in the regular classroom and general education deciding which students were best suited for resource team activity of course was not an easy judgment call which in turn pointed to the necessity of dynamic goals and being prepared to handle cases that first proved to be too difficult during the intervention period or unsuitable to reconcile with an inclusive education the goals had to gain approval with and be supported by the teachers so that they worked toward the same goals in contrast to static goals dynamic goals appeared to be an important strategy to gain acceptance among the teachers this was not about abandoning the idea of inclusion but in an active way working and interacting to gaining approval for this intention through dialog with teachers and together investigating and considering the possibilities of inclusive education in every real case responsibility responsibility transferring was another phenomenon that seemed to result in desynchronizing responsibility transferring means that actors disclaimed responsibility or had responsibility taken away for the target students positive development according to many teachers and some principals a lot of teachers had an attitude and behavior which expressed a desire for relief that is to transfer all responsibility to team members instead of sharing the responsibility with the team member and collaborating to promote the students progress according to the team members accounts the perspectives and attitudes varied however to some degree across different schools or teachers there are teachers who say please take him out but another teacher might ask what do you think we should do i can see there is a problem here and then we have a dialogue some teachers were more focused on trying to help keep the target student in the regular classroom whereas others were more focused on relief by removing the target student from the classroom when the team members met the latter group of teachers which they said that they mostly did they experienced that effective collaboration was much more difficult to accomplishwhereas they were working with direct interventions with students and parents consultation with these teachers did not work or take place at all responsibility transferring involved making the teachers role and work with the target student passive with team members taking over the whole responsibility this means that the team members themselves conducted most or all interventions thereby the teachers did not become involved in the intervention work by consultation neither were other professionals from organizations or institutions beyond school involved because the responsibility of conducting the intervention work to such a large degree rested on the team members at least two risks could be identified loss of effectiveness because the professionals around the target student were not synchronized and did not actively collaborate toward shared goals in the particular case and shortterm effects that is a risk that good results would depend on the team members presence at school which means that when the resource team intervention period was over there was an obvious risk that the target student returned to the problems or developed similar problems because no one else around the student continued to shoulder the processes that the resource team had initiated many teachers and some principals talked about this dependency on team member presence teacher they behave themselves when team members are there they take care of themselves but afterwards they do not behave themselves researcher it sounds almost like these students become dependent on the presence of the person from the resource teamteacher right researcher to work and when they arent there it goes wrong again teacher this has happened to us too teacher well it hasnt been like that for us teacher it was like that for us with our troublemaker who s no longer in the school he worked at least quite well when someone sat rightnext to him and said now do this and that these experiences started off worries among teachers and principals about what would have happened when the resource team intervention period regarding the target student was over what happens afterwards when the resource teamwhen they arent there any more can you trust that new networks are in place taking care of the problem in other words the issue is whatll happen then so that everything doesnt just collapse then notice that the teacher still expressed responsibility transferring but in this case to future new networks instead of the resource team in the excerpt responsibility sharing was a phenomenon that according to the grounded theory was necessary for synchronizing responsibility sharing means that team members as well as school personnel took responsibility for initiating processes that aimed to support and assist the student to develop in a positive direction the project in other words was in these cases a shared project and not one persons job one of the teachers who was satisfied with the collaboration and its outcomes expressed a clear involvement in the resource team process we the teacher and the team member had regular meetings weve been able to see each other when the students have gone and been able to sit down for a while every week to discuss the student token economy and things like that and how to organize the work instead of making all the interventions by themselves responsibility sharing means that the team members worked more actively as consultants to involve and assist the teachers in the intervention work in addition the team members involved trained professionals from other organizations or institutions outside the school by consultation as well as active crosssector networking together they all created conditions for maintaining the process of supporting the target students positive development after the team members have finished their intervention period furthermore responsibility sharing also means that the professionals shared responsibility with the target student and his or her parents as well they were involved as active participants in the process by working toward shared responsibility and full participation from all parts from the outset of the intervention period the conditions for the development of appropriate expectations from all parts increased professional cultures counteracting professional cultures means that professionals and professional cultures came into conflict with each other and more or less cancelled each other out us and them thinking had developed in which individual stuck together in their own group while looking at and judging the other group with suspicion and skepticism the resource team and teachers had negative representations about each other and viewed their own professional culture as better and more competent it often happens that we kind of talk about us and them they the resource team represent one idea and we the teachers represent another idea about how we want things to be we want to have good order in the classroom we want a classroom situation that works and im sure it will work if this student is not there in the focus group with teachers many attacked the resource group by labeling their members as incompetent not knowing how the school worked not understanding learning goals in different school subjects and so on we dont expect someone who knows everything but someone who actually has an enormous competence in this stuff it hasnt felt that he was better than us in the levelin the level of competence in the focus group with the resource team team members criticized teachers for not using evidencebased methods and not approaching hardtoteach students in a competent way as well as being unwilling to replace nonconstructive habits and strategies with constructive ones they claimed that many teachers were not interested in listening to them because they just wanted to get relief by removing the target student from their classrooms such negative social representations of each other appeared to counteract and undermine the motivation for collaboration across the professional cultural boundaries they resulted in isolated and narrowminded professional thinking and acting they enacted professional selfdefense and protectionism instead of multiprofessional collaboration and consultation obscurity and lack of communication as well as lack of accessibility to collaboration as a result of lack of time appeared to promote and maintain the problem of counteracting professional cultures in addition the manifestation of counteracting professional cultures seemed to motivate a further lack of communication and lack of accessibility to collaboration moreover counteracting professional cultures could be linked to the change resistance of the school culture and team members lack of legitimacy visàvis the teachers principal but i think that this isnt a new problem that here the thing about people from outside coming in and trying to get some kind of legitimacy in the school principal its not easy principal school people are a bit prickly to deal with in some way howeverresearcher what do you mean principal well about someone from outside coming in as an expert thats something i think thatprincipal the teachers play a waiting game principal weve had the attitude for a long time does this person really know anything about these things in a skeptical tone hence the school and teacher cultures appeared to have a strong tendency to categorize professionals from outside the school in terms of them or outgroup members and attribute negative stereotypes to them when these professionals came to the school this pattern easily led to the development of counteracting professional cultures the resources became more or less desynchronized in relation to school personnel in contrast coordinating professional cultures means that the various professionals and professional cultures coordinated and were made available to each other to have active collaboration by their distinct and specific competences they complemented and developed each other in their interaction and collaboration the other group was not viewed as deficient or a threat but as a valuable resource there was an us thinking across the professional borders focusing on the shared project of promoting and supporting the positive development of the target student good integration between resource team and school personnel was created and resulted in a team spirit we could communicate very well and worked together to improve the situation for the student in the school and we really complemented each other in this work there was a striving for mutual understanding in which different perspectives and expertise were combined to create better opportunities for seeing and considering the whole student problem to improve problem solving and to broaden the repertoire of interventions a real multiprofessionalism had been developed consultation was not about team members knowing everything and transferring this knowledge to the teachersan initial expectation among many teachers instead the team member functioned as a sounding board by actively listening cothinking and giving the teacher opportunities for reflections with regular consultation the team members could offer teachers other perspectives and methods and together formulate how the teacher or teachers would work further on with the target student there was a fruitful giving and taking in which the different competences actively contributed to the whole in this way the human resources became synchronized unfortunately according to the reports from teachers principals and team members effective coordinating professional cultures seldom took place we havent reallyor i think that the teachers havent understand that this is something that we have to solve together thus the word together is in fact a key word that hasnt really been spread but you the teachers think that someone from outside school should come and fix it nevertheless in some instances interaction patterns similar to coordinating professional cultures were reported and often team members explained this in terms of teachers openness and willingness to collaborate relations in the grounded theory developed here relations refer primarily to those interaction patterns and relationships that took place not only between grownups and the target student but also between professionals and the parents of the target student if the relationships and interaction patterns were aversive and negative a desynchronizing of human resources seemed to occur aversive relations mean that the interaction pattern and relationship between the grownup and the student were perceived as unpleasant by the student in which both parts had a negative attitude and approach to each other and primarily focused on the students deficits and negative behavior which in turn tended to reinforce and emphasize the aversions in the interaction according to some students their teachers negative attitudes and expectations of them demotivated them and turned into a selffulfilling prophecy student they the teachers just thought how can i put it well saw me as disruptive and stuff researcher they saw you as disruptive student yeah researcher what do you think about that that they saw you as disruptive student well so by then i didnt think it was particularly fun to go to school in aversive relations conflicts often occurred and these were typically handled with destructive and hostile behavior in such processes teachers and other grownups tended to use aversive methods and approaches visàvis the target student a negative spiral took place in which grownups and the student developed negative expectations of attitudes to and behavior toward each other desynchronizing had occurred the relationships were negative and infected the students in the study described histories of aversive relations with their teachers and how such relations counteracted their academic motivation and inspired them to behave badly or inappropriately in school the students expressed a feeling of not being seen liked and understood by their teachers researcher when you were rowdy like that what do you think caused that during the time before you met kim the team member student no one noticed me at school no one understood me and when i was rowdy and stuff it was perhaps a cry for help or stuff furthermore parents reported how they repeatedly received negative messages from teachers about how bad or problematic their children were at school they just called at home and there were complaints all the time they never received any positive information about their children only negative this in turn resulted in resistance from some of the parents which counteracted effective collaboration between home and school because you thought it cant just be robins fault you opposed them right from the start and it can still be like this because i know it isnt just robins fault one of the parents in the study also reported how this narrowminded negative reporting from school undermined her selfesteem as a parent they often called me and then you felt useless as a parent according to some of the parents when as a parent you heard all the time from teachers that your child had done bad things or doesnt do any work and only negative things like that then you developed a negative attitude to the dialog with teachers or school they did not perceive this as a constructive starting point in aversive relations professionals viewed students and parents as antagonists or opponents school personnel who were primarily involved in aversive relations with marginalized students would inevitably remain desynchronized with them as well as with the team members who consciously strove to avoid and break aversive relationships and interaction patterns in contrast positive relations led to enhanced synchronizing between adults and the target student between professionals and parents and between school personnel and resource team it was about interaction patterns and relationships in which adults had a positive attitude and approach to the target student as well as to his or her parents and which mainly focused on the target students strengths and positive behavior students and parents were viewed as partners or coplayers the professionals worked consciously with developing positive and supporting relationships with the target student and his or her parents they mainly used positive constructive and pedagogical methods and approaches the professionals tried to handle conflicts that occurred with constructive strategies that is everyone listening to each other and together trying to find solutions that all sides are happy with the students and parents in this study reported experiences of positive relations with the team members which in turn resulted in trust and motivation to collaborate with them and as they saw as a clear contrast to their relations with the teachers student i quickly got some confidence in john a team member researcher how did that come about student i dont know i felt that he was a good person and that i could talk to him about a lot of stuff researcher how did you recognize that he was a good person student he helped me a lot talked to mei was able to talk about serious things with him and he cares researcher and he cares what do you mean by that that he cares student well he supports me he doesnt give up so easily some of the parents associated the positive effects of the resource team on their childrens academic and social achievements with the positive and supportive relationships between team members and their children they team members are responsive and nice and explain everything to jonathan and dont just say now you have to do that and that now you have to do this and this but they might explain now you have to do this because and stuff like that which the teachers didnt do before one of the parents told me that the main reason why the collaboration worked so well and why her son made many positive achievements was because of this trust that sonny her son and i have in kathy a team member the parents also perceived that this positive and supportive approach differentiated team members from teachers as well as explained why they and their children had confidence in team members but not in teachers hence positive relationships and interaction patterns between professionals and students as well as their parents synchronized professionals parents and target student in their work of enhancing the target students development and achievement discussion multiprofessional collaboration has a lot of advantages in making a more effective problemsolving and interventiongenerating process compared to isolated individual achievements and my findings confirm this by pointing to advantages when such collaboration functions well nevertheless my findings also confirm other research that indicates that problems and pitfalls easily might arise when teachers and other professionals interact with each other and with students and their parents by analyzing teachers principals nonschool situated resource team members challenging students and parents reported experiences and representations about their interactions and collaborations i have developed a grounded theory of collaborative synchronizing in relation to challenging students in school the current study contributes to the already existing literature a set of concepts generated from the analysis of the participants perspectives on collaboration according to the grounded theory in the current study goal setting responsibility professional cultures and relations are core elements in how well human resources are synchronized to conduct a movement toward the target students healthy and positive development and outcomes it indicates that human resource synchronizing is associated with dynamic goal setting responsibility sharing coordinating professional cultures and positive relations whereas resource desynchronizing is linked to static goal setting responsibility transferring counteracting professional cultures and aversive relations involving teachers principals parents and the student himor herself in the ongoing process of formulating and decision making of goals appears to be a highly relevant strategy for special educators school counselors trained social workers school psychologists or other professionals who are assigned to change a negative and unhealthy pattern linked to a challenging or atrisk student in fact the grounded theory in the current study actually indicates that goal dissonance was a core process in desynchronizing all the significant people around the target student including the student should be treated as members of a team with the shared project of making life and life opportunities better for the student when many people are involved in a shared project there is always a risk of what social psychologists call free riding social loafing and diffusion of responsibility the grounded theory in the current study points to the pitfall of responsibility transferring in which teachers seek relief instead of collaboration and so transfer all responsibility to the resource team members who in turn take over the student this leads to resource desynchronizing consultation loss diffuse and passive teacher role and delayed and less effective interventions this can also be associated with research showing insufficient teacher involvement or participation in the process as well as teachers perceptions of having limited skills and preparation for working with challenging students another pitfall that the grounded theory of collaborative synchronizing in relation to challenging students highlights is counteracting professional cultures which means that professionals and professional cultures are being put into conflict with each other and counteract each other whereas the process of counteracting professional cultures identified in the study promoted cohesion and belongingness within the resource team as well as within teacher groups it blocked or undermined professional collaboration between team members and school staff here an us and them thinking had been generated in which each professional group had negative social representations or stereotypes about each other the problems of professional boundaries mistrust and outgroup devaluation in multiprofessional collaboration in school settings have also been shown in other studies nevertheless and in contrast to responsibility transferring and counteracting professional cultures my grounded theory indicates that responsibility sharing and coordinating professional cultures are core elements in the productive process of resource synchronizing this means that the work is viewed as a shared project in which everyone takes responsibility that teachers have a significant and active role that all parties see each others as valuable resources are welldisposed to mutual understanding considering multiple perspectives and are available for each other to make an active and effective collaboration possible there is a team spirit and an us thinking across the professional borders focusing on the shared project of promoting and supporting the positive development of the target student nonteaching or nonschool professionals have to be prepared to and consciously cope with the discrepancies of professional cultures and the change resistance of the school culture to avoid counteracting professional cultures and instead efficiently coordinate and synchronize the different professional competences to maximize the intervention effectiveness another main theme in the grounded theory of the current study is the significance of relations whereas positive relations are associated with resource synchronizing aversive relations are associated with resource desynchronizing it is especially clear that aversive relations desynchronize professionals with target student and parents whereas team members in my study strive to establish and maintain positive relations with target students as well as with parents in many cases the relations between teachers and target students as well as between school and home appear to be more aversive typically focusing on negative issues while using aversive strategies and interaction patterns according to the students and parents reports in this study this difference has a significant influence on their attitudes motivation and involvement and explains why they listen to and trust the team members and engage in the interactions with them in contrast to how they approached the teachers and the school settings in the past many studies have shown that positive teacherstudent relationships are linked to students academic achievement social adjustment and mental health peer relations and are especially beneficial to atrisk students and students growing up in socially disadvantaged neighborhoods nevertheless interactions between goodintended teachers and challenging students might vary depending on student and teacher characteristics selfdefinitions beliefs and the influence of support staff as kennedys indepth study illustrated furthermore the professionals positive relations with parents as a core element of resource synchronizing in the current grounded theory can be linked to metaanalyses which indicate that parental involvement positively influences academic achievement of students growing up in socially disadvantaged neighborhoods nevertheless the findings in my study illustrate some pitfalls in the relation work between school and home as well as between teacher and student and hence help to make professionals conscious about them to avoid them and focus on positive and supportive relationships instead finally the findings also indicated the practice of doing student problem cases among teachers and principals in schools that is talking about and dealing with problems in everyday school or classroom life in terms of particular student cases which produced or manifested a dominant discourse of deficient students identified problems were understood and explained as deficiencies or pathologies within the students who had been addressed as problem cases in addition the resource team members displayed a rather ambivalent approach to this discourse on one hand they wanted to challenge how teachers and principals talked about and understood the problems with these students by applying a socioecological perspective on the other hand in their communication with teachers and principals and by their taking over of the student problem cases the team members actively participated in the dominant discourse of deficient students the very talk of challenging student in school can easily lead to withinstudent explanations of the problem nevertheless from a socioecological perspective challenging students in school are understood as an ecological phenomenon that is established and maintained as a result of the complex interplay between individual and contextual variables thus challenging students have to be understood across individual family peer school and community contexts because the dominant discourse of deficient students produces biomedical and individualpsychological interventions and silences contextual interventions this very discourse counteracts the process of resource synchronizing and therefore has to be exposed and challenged limitations and generalizability several limitations to the grounded theory and the conclusions drawn in this study should be noted first it is important to recognize that this is a study with a small and nonprobability sample for example other parents students or teachers involved in the resource team project might have reported other things moreover the sample from a particular practice in a particular area of sweden might or might not be similar to the context in which and people with whom the readers primarily work second the grounded theory of multiprofessional collaboration and resource synchronizing is built on analyses of experiences representations and conceptions that team members teachers principals parents and students expressed in their conversations in this study it is not built on direct observations of collaboration and its effects thus it is important to recognize that the links were not identified by statistical methods of observational data of multiprofessional collaboration but identified by indepth analysis of the participants narratives about their multiprofessional collaboration third this study did not gather data on students academic and social achievements in the form of grades school subject tests established behavioral check lists and psychological tests to statistically investigate the effects of the resource team intervention projectonly narrative reports from target students parents team members teachers and principals fourth the rather homogeneous group of challenging students described as student cases in the resource team activity has hindered my analysis of how different types of student problems might affect the human resource synchronizing fifth school differences due to the school context between considering attitudes and approaches visàvis the resource team did not emerge when i analyzed the data perhaps a study with a larger sample including a lot more schools might have identified such differences thus the small sample of schools and the rather homogeneous student sample in the reported student cases have hindered me from more fully analyzing student challenge and school context variations as possible factors instead of statistical generalization built on the logic of mathematics in qualitative research generalization has been discussed as an interpretation work in terms of for example generalization through conceptualization generalization through recognition of patterns and generalization through context similarity in which the reader not the researcher judges the generalizability according to glaser a generated grounded theory is not accurate facts and not description it is just straightforward conceptualization integrated into theorya set of plausible grounded hypotheses that has to be tested by further research which is always the case in inductive and abductive investigations moreover in line with a constructivist position the grounded theory in the current study should be viewed as an interpretative portrayal of patterns and connections rather than an exact picture of simple linear reasoning interpretative research like this study is concerned around how the social world is experienced and understood by a particular group or set of participants and to uncover how people think and feel about the world or a particular practice and make sense of their lives or social interactions from their particular vantage points conclusions and implications in accordance with the logic of extrapolation the grounded theory presented in this study can be used to analyze multiprofessional collaboration and consultation in school settings and as a basis for discussion in local evaluation and developmental work of multiprofessional collaboration studentteacher relations schoolhome collaboration and school consultation the dichotomized ideal types human resource synchronizing and human resource desynchronizing and their subprocesses of goal setting responsibility professional cultures and relations offer looking glasses or analytic tools to practitioners and researchers as well at least two main conclusions of the grounded theory in the current study could be made first to create good conditions for effective collaboration and consultation an inclusive participation has to be obtained in which teachers principals other involved professionals parents and students are invited into the processes of formulating and making decisions about goals actively participate in problemsolving processes and are perceived and valued as significant resources who can contribute by their different knowledge and experiences with a more comprehensive view and effective changes and interventions developing positive relations with students and parents is an important strategy to motivate and involve them in the work of enhancing the students development and achievement all the parties are concerned with the target students positive development a desynchronizing process that passivates and devaluates the target student the parents or the teachers has to be counteracted therefore involved individuals have to avoid goal dissonance and responsibility transferring high resource synchronizing requires that all parts participate and are focused on how they can contribute to a positive change of the students situation second there has to be an acceptance of multiprofessionalism as a superior ideology to do a more effective job by surmounting professional barriers and taking the advantage of professional differences there has to be an acceptance of the multiplicity of professionals and professional cultures multiprofessional collaboration cannot be imposed by force being preoccupied with defending ones own profession combined with an inability or unwillingness to consider other professional perspectives results in counteracting professional cultures negative social representations of other professional groups make the professionals draw attention to and exaggerate other professionals deficiencies whereas their strengths and merits are belittled ignored or rationalized away if actors seriously see the benefits of multiprofessionalism then they also have to seriously accept and affirm multiprofessionalism as a superior ideology instead of ending up in professional territorial thinking and acting disagreements and diversity of opinions perspectives and methods between different professionals are then not perceived as threats but as starting points for significant and fruitful discussions aiming to expand the field of view and together develop comprehensive and effective interventions

the aim of this study was to investigate multiprofessional collaboration as well as collaboration between professionals and challenging students and their parents in which the focus for these collaborations was on handling the challenging students academic and social behavior a grounded theory study of collaboration between a prereferral resource team and teachers principals challenging students and their parents was conducted qualitative interview and focus group methods were used the findings presented a grounded theory of collaborative synchronizing in relation to challenging students around two ideal types human resource synchronizing and human resource desynchronizing

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introduction nursing has a long history of nurses campaigning or advocating on behalf of a cause and going beyond what is routine including activism regarding suffrage black rights birth control as fowler writes nursings social ethics has driven nursings concerns for addressing structural injustices affecting…all socially marginalized vulnerable voiceless stigmatized persons or groups watson considers that nursing has a global covenant with humanity to sustain human caring healing health and wholeness for humanity drawing upon a philosophical and social justice perspective watson identifies sacred activism as informed moral action by nurses to address moral and social injustices it is necessary nursing work in doing so nurses like other activists may become normtransgressors within their role and organisation the environment is an important determinant of health globally nurses care for people whose health is affected by toxins pollution global warming or poor air quality disadvantaged populations are most at risk despite this the uk national health service fiveyear plan has no environmental strategy despite 264769 live years being lost in 2010 in england alone because of pm25 air pollution which is costing up to £186 billion a year in the uk climate change has been removed from the american national security strategy funding to the us environmental protection agency has been reduced many nurses express concerns about environmental health issues in their practice and community their environmental stewardship is evident the international council of nurses identified nurses as having universal and fundamental responsibilities to promote health to prevent illness to restore health and to alleviate suffering in 2018 the icn issued a position statement that it strongly believes that nurses have a shared responsibility to sustain and protect the natural environment from depletion pollution degradation and destruction background environmental ethics holds that anticipatory action must be taken to prevent future harm salazar a highlyrespected nurse environmental activist encourages nurses to take anticipatory action yet few studies have explored nurses activism macdonnell buckmcfadyen explored activism in forty ontario nurses activism addressed issues like women abuse homelessness birth control…that were considered part of nurses professional role or responsibilities there is little literature regarding nurses as environmental activists cezarvaz bonow sant anna pereira rocha verde de almeida santos da silvas integrative review found that public health nurses merely need to understand environmental health impacts and be partners in promoting sustainability dunphy reported australian nurses are gravely concerned about sustainability kangasniemi kallio pietiläs review concluded that nurses have a critical role observing and highlighting environmentally responsible health care polivka chaudrys scoping review identified that the primary focus of nurses environmental research was disastersdisaster preparedness occupational health and the home environment with only six studies on climate change and four on sustainability despite two decades of discussions over environmental threats to health nurses sense of its importance has varied in the early 21st century public health nurses talked of a lost legacy of environmental health and the need to reincorporate it into practice nurses in a 2002 survey saw clear connections between environmental health and patient health however nursing curricula vary regarding its inclusion the uk nurse education standards do not mention sustainability or environmental health the term nursing the environment disappeared from nursing literature an explanation may lie in macdonnell buckmcfadyens research which indicated that being identified as a professional nurse was good but being a political activist was bad political activism challenges perceptions of the public face of nursing thus even though internationally nurses are increasingly concerned about environmental risks to health environmental activism might seem roletransgressing theoretical framework this study investigates the emotional labour and impact upon nurses who extend their role beyond patient care to environmental activism hochschild argues that emotional labour requires one to suppress feelings in order to perform the role expected because of socially constructed feeling rules that govern what is acceptable feelingsuppression is an antecedent to feeling burdened by the emotional labour of the workers role wettergren reminds us that emotions structure and drive social action and that according to hochschild people hold onto their ideologies with emotional anchors nursing practice carries a significant burden of emotional labour which is associated with interacting with patients families and colleagues and addressing ideological and organizational demands differences and conflicts tension between their role as envisaged by employers and the nurses own emotionallyanchored ideological beliefs can cause distress the study aim to investigate the emotional labour associated with environmental activism and impact upon nurses who see their role as caring for the environment as well as for patients design an ethnographic approach with qualitative methods was selected to facilitate the understanding of the beliefs attitudes and behaviours of participants the lead researcher is a nonnurse nonactivist providing an outsider perspective contrasting with the insider perspective of the coresearcher a registered nurse with over 40 years of activism mostly on environmental issues like coombs osborne our partnership enabled us to stand on both sides of the insideroutsider hyphen thereby facilitating challenge and biasminimisation collecting data on two continents separated by an eighthour time difference was challenging we triangulated data sources incorporating participant observation plus focus groups and interviews with nurses whose practice included environmental activism in the form of political legislative or civic engagement policy formation research or campaigning at a local national or international level sampleparticipants purposive sampling was employed to find informationrich participants ie registered nurses actively engaged with environmental health issues potential participants were identified through personal knowledge of their activism publications and those whose environmental activism meant they were listed as luminaries on the health care without harm luminary project website forty nurses agreed to participate whose experience covered twelve states in america plus england wales and scotland some had worked in european and developing countries twentytwo had specialist communitybased qualifications eighteen were hospital nurses data collection it was important to witness emotional responses in situ during two weeks in march 2017 the lead researcher shadowed the coresearcher in her occupational health and activist practices including witnessing to state legislature in may 2017 the coresearcher visited the uk for two weeks and further observations were made a uk participant was observed for a day by the coresearcher the observations in both countries provided some mirroring there were destination shopping centres staterun terroristtarget sites with the potential to cause devastating environmental damage a first nations village and a uk ecovillage as well as meetings with environmental activists and activist organisations to gather selfreports we held four audiorecorded focus groups during the two observation periods the lead researcher facilitated all focus groups the coresearcher observed in march 2017 ten us participants attended focus groups in may 2017 six uk participants attended focus groups they lasted 4689 minutes the focus group questions were to obtain deeper insights and expanded geographic spread we invited others who had not attended focus groups to take part in individual interviews between mayoctober 2017 the same topic guide as for the focus groups was used with the interviewer seeking richer responses and probing regarding emerging insights thirteen individual interviews were carried out with participants in america of eleven uk interviews nine were conducted by the lead researcher by telephonevideo call and two were facetoface one being done jointly with both researchers this was not audiorecorded at the persons request notes were made immediately after average interview length was 46 minutes the lead researcher transcribed her reflective research diary and field notes were also data sources ethical considerations ethical approval was obtained from both employing universities consent was obtained if any participant indicated distress the interviewer would halt and provide support the participant could decide whether to continue the research purpose of any observation visits was identified in advance to others who might be present it was made clear that nothing they said or did would be recorded data analysis social constructivist discourse analysis was employed to understand the personal social and political significance hidden in participants narratives observational data and field notes this helps explicate impact upon individual people as part of society audiorecordings transcripts and other data were kept on a passwordsecured website accessible only to the researchers analysis was done manually a published da tool drawing on gee but designed to address risks of underanalysis in da helped us understand how nurses environmental activism impacts upon them we explored cognitions and emotions words used tonal expression and visual indicators like facial expression stories identities and interactions during observations we witnessed interactions and emotions in situ field notes made during focus groups and skype interviews captured some visuals analysis required seeking to understand participants narratives about themselves what they valued what identity was imposed on them and how they acted interacted or reacted the two researchers met virtually via skype for debriefing after data collection during analysis and writingup stages these discussions produced consensus we are confident we achieved data saturation despite it being a challenging claim for qualitative researchers to make the final synthesising stage facilitated agreement regarding the three main themes rigour the consolidated criteria for reporting qualitative studies 32item checklist was employed in designing and reporting this study triangulation of methods and settings enhanced completeness using a peerreviewed published da tool keeping a reflexive diary auditing how insights emerged being insideroutsider researchers and providing rich quotes enhances credibility dependability transferability and confirmability reliability was secured by having another researcher independently analyse four transcripts revealing no major differences our dual aspects provided a holistic perspective together we explored the complexity and richness of the space between the three main themes were subsequently corroborated by some of our participants when presented at two conferences findings participants activism related to a variety of contexts their clinical practice and healthcare setting local community state country global environment and the planet it impacted on their roles and identities within their families nursing and community activism commenced when their nursecentred concern at threats to human and planetary health were irreconcilable with not acting this was sacred activism for participants nursing practices advocacy and the championing of patients one intriguing finding materialised some participants saw the planet as a living entity almost a patient in its own right if you think about about rocks as a life force…its a really important view of environmental justice he felt outraged at the harm mother earth was experiencing three themes emerged outrage at preventable harms the emotional toll of sacred activism and handling negative emotions each is discussed in turn outrage at preventable harms associated discourses included the role of the nurse regarding environmental determinants of health with expressed anger frustration and fear for future generations and the planet nature is sacred as nurses they felt embedded responsibility for improving peoples health and when their outrage reached tippingpoint they became driven to act uki11 explained how she had always had an interest in holistic nursing but became an activist when she read about the health impacts of climate change and the death and destruction that we are doing as humans most framed environmental damage such as pollution and climate change in terms of health injustice to the poorest or least powerful in society global warming is not just about polar bears its about our communities being destroyed like other employees nurses health is affected by workplace pollutants one participant had to stop nursing because of exposure to toxic chemicals by 2003 i couldnt take responsibility for patients anymore was evident the behaviour of corporations was a source of significant outrage one participant was involved in the aftermath of the bp oil spill we demanded that the environmental protection agency released the chemical ingredients so we could understand what people were being exposed to there were people with rashes that infectious disease docs had no idea what was going on people with asthma whod had it under control that was completely out of control people with diabetes whod had their blood sugar managed that was no longer managed we talked to teachers who had closets full of nebulisers another participant was outraged by adverts for household cleaning products …if you dont use this noxious spray all over your babys tray youre killing your baby actually you are killing your baby because they are inhaling all this nasty noxious stuff fears for future generations were common the population is growing…this worldwide population we have these developing countries who are polluting china and india and polluting big time now during one of the observation periods the person being observed expressed her outrage at how the us legislature seemed more interested in lining their pockets from the lobbyists than the risk to their children of all the toxins in the environment participants outrage drove them to take action …if it is something i am really passionate about i will fight for it being a nurse and an activist were embedded into their identity i probably even after retirement will be the little old lady on the street holding the sign saying i am a nurse and this is what i believe the need to act was hardwired into them we cant continue to destroy our earth…we have to stand up and fight the failure of the nursing profession to embrace environmental issues as a valued aspect of the nurses role caused outrage its made me really angry at nursing for not recognising and stepping up to be an advocate for their skill sets in other places another commented on how hard it is to get colleagues to maintain sustainable practices the recycling bins get mixed up with all the rubbish were not retrofitting the existing nursing workforce in any way…on environmental problems…weve just had a heatwave there must have been additional deaths in that heatwave that were preventable and i want to know why theyre not doing anything about it participants were driven to action by their sense of sacred activism that tackling environmental threats to health is an urgent and vital part of the nurses role emotional toll of sacred activism taking action took an emotional toll discourses of sadness and grief were common the campus buildings were built with an environmental footprint in terms of heating and air cooling and yet we waste so much in every other aspect sighed when their beliefs were threatened or dismissed it affected them deeply …when it taps into the emotional burden or toll for me is…i always rely on science and evidence which apparently is questionable…when theres compelling evidence and argument that is sound and then theres no action grief evident in voice …thats where i think the emotional burden is you pour not just your heart into these arguments but…your mind and your knowledge into it and those two things hand in hand are still not able to convince people to act and do things different feelingsuppression was evident some participants felt they needed to suppress their response to workplace practices that were environmentallyunfriendly such as poor waste management so there you are at home being as environmentallyfriendly and green as possible then you go to work for twelve hours and do the opposite during a factory visit in her capacity as an occupational health nurse the coresearcher was observed tailoring her responses whilst advocating for employee health later her suppressed feelings emerged in a diatribe against low income migrant workers being taken advantage of a discourse of fearforthemselves was evident organisationallyconstructed feeling rules that govern what is acceptable meant that there were differences between the two groups in how they reacted to potential political sensitivities american participants freely spoke about social justice but their uk counterparts suppressed such language for fear of how their employers might react one uk nurse academic related recently i was teaching on some sort of public health module…and i didnt once use the words social justice i really scared to i was scared to not that anybody says dont its not about that but its very much about jumping the line to politics this same participant referred to someone elses experience affecting what she published her equivalent research was banned…if it doesnt agree with current public policy position they dont want to know…it wont get you promoted…i was fearful…i didnt publish part of my phd because of the sensitivities around the issues in contrast american participants seemed more prepared to transgress those feelingrules it has been quite ugly…people being told they cant use the term climate change…i had a conference for nurses…because we were using grant money they needed to check to make sure that it was okay that we used that term and i thought listen im using it the emotional toll of us participants extended to receiving litigation threats to stop their activism on behalf of population health risks the urban town where i work has a large wood smoke pollution problem…the hearth products industry and the rental and the real estate industry came lawyered up and said…you have to allow people the right to burn wood in their homes the combination of feeling outraged at environmental threats to human health the need for feelingsuppression as employees and the disparagement of their emotionallyanchored ideological beliefs meant that negative emotions could become overwhelming discourses of isolation were common i feel like i im a bit of a lone voice feelingsuppression occurred in interactions with family and friends i feel that my message isnt getting through…it starts to affect relationships i back off…it does drain you isolation could be exacerbated by bullying one participant spoke of how having participated in a press conference about the links between health and air quality he was subjected to a bullying letter campaign in the press orchestrated by one of the corporations opposed to the legislation the very next day in the newspaper…there were no less than about ten letters to the editor directly criticising me…saying some really mean things about me…i was gut shot how can people think this of me uk participants found holding onto hope challenging speaking with great sadness in her voice one said i have no expectation that we will prevent to any degree global warming…so in a sense emotionally what i have done is i have done my grieving on it one participant referred to the prison diaries of antonio gramsci ive never been depressive ive never had those tendencies but i have to say this issue has taken me to some dark places…its been hard to maintain a degree of optimism i think it has been attributed to antonio gramsci who talked about having pessimism of the intellect but optimism of the will as two emotions within oneself ive certainly got the pessimism of the intellect…have i got optimism of the will sighed laughed its hard despite the emotional toll participants kept fighting for their beliefs when america pulled out of the paris accord on climate change the observee noted this is perhaps where those nurses who are committed to supporting environmental health have to fight even harder handling negative emotions how they handled negative emotions was where us and uk participants differed markedly discourses related to hope support companionship and the need to develop emotional resilience the more resilient held onto hope through taking action environmental health is like the stages of death and dying denial anger bargaining acceptance laughter but id add a fifth to it that is action because i would be so angry and frustrated and paranoid if i didnt feel like there was something i could do about it …you can feel a sense of being overwhelmed a sense of despair…i tend to go between those two emotions…it seems too easy to lose hope and be overwhelmed so responsible environmental advocacy means holding out hope and helping nursing students and others see ways that they can help improve the environment not trying to take on too much helped participants maintain emotional resilience im an operating room nurse and we generate truly obscene amounts of waste in the operating room…things that impact water pollution air pollution landfill gaseous fumes all kinds of things that our hospitals generate…i began to get this creeping suspicion that healthcare institutions on a level are contributing to the very diseases and health problems that we are ostensibly in business to treat sighs …i felt very overwhelmed but decided that one thing i could do was…try to make a difference with recycling finding sources of support and solace aided survival us focus groups participants identified support networks and individual nurses who mentored their activism it was clear that american nurses had stronger support mechanisms than uk participants these helped them start fighting and continue fighting activist organisation taught me how to advocate practical steps… nurse taught me how to get laws in place support could come from outsiders too im working with a group of mexicanamerican mums who have kids with asthma…im drained before i go and meet with them but i come out after my meeting with them realising that theres core elements inside humanity that rise above the challenges and can be committed to greater ideals discussion smith in her seminal work on the emotional labour of nursing used hochschilds emotional labour as a framework to explore what people jobs require of workers and their labour this study shows that being a nurse activist for sustainability and the health of the environment is emotional labour nursing practice involves influencing through advocacy planning and acting although there are wellknown examples of activism such as fighting for womens rights to birth control for most nurses their practice does not cross the border into political activism participants in this study expressed powerful emotions which seemed to underpin and sustain their environmental activism this mirrors jacobsson lindbloms finding in relation to animal rights activism nussbaum identifies that a persons emotion relates to a particular object towards whichwhom the person has developed an intentional relation and has formed beliefs about the objectperson all participants believed like nightingale that nurses should be acting upon environmental threats to human health this fits with watsons sacred activism as informed moral action by nurses to address moral and social injustices participants recognition of the risks to human health was accompanied by shock and outrage words were used like pillaged and destroyed the greater the shock the stronger the perceived risk when threats go to the heart of a persons identity and what they hold sacred feelings of outrage emerge as benski explains outrage at violation of what people hold sacred turns into righteous anger that is directed at violators and their actions tackling determinants of illhealth to improve community or population wellbeing is a key tenet of nursing and participants felt betrayed by their professions failure to show more effective environmental leadership as nurses their global covenant with humanity is a deeplyembedded ideological position for which they were willing to roletransgress and shoulder the associated burden our participants displayed the human caringecocaring for which watson calls participants suppressed feelings about the need to take action on environmental threats to protect relationships with colleagues employers or family suppressing feelings is an antecedent to feeling burdened by the emotional labour of the workers role negative consequences of emotional labour identified by badolamenti et al include emotional dissonance worker dissatisfaction and emotional exhaustion some of our participants exhibited these some believed it is too late to take effective action nonetheless suppressed their feelings of being overwhelmed and exhausted to continue fighting environmental activism creates a huge emotional burden for those who see it as integral to their identity as a nurse smith in revisiting her seminal work noted it is interesting to see nursing language returning to an emphasis on health and illness prevention participants in this study felt that caring for the environment is underrecognised within nursing as a means of illnessprevention this was part of the emotional toll of their sacred activism american participants had read the climate science special report which clearly states the threats to us citizens they foresaw the risks to worker and community health with the reductions in legislative protection yet found colleagues and employers belittling their concerns their distress was accompanied by feelings of isolation thus compounding the emotional labour involved in their environmental activism environmentallyengaged nurses may feel a tension between supporting their employers interests and the wider good of the community or planet because health activism invariably involves a challenge to the existing order even though the american nurses association code of ethics calls for nurses and nursing associations to advocate…for social justice participants worried that their activism could affect their employment or risk their research being suppressed for american academic participants tenure provided some freedom although litigation threats remained real the uk academic participants were on permanent contracts but feared reprisals more than their us counterparts this was clearly a deterrent to their environmental activism and willingness to be a lone voice worldwide others have reported similar concerns environmental activism can leave nurses feeling unsafe and at risk of being bullied in relation to providing good patient care smith has argued that the staff who care for patients must also feel safe and cared for the support of likeminded nurses and the holding onto hope is vital to counter negative feelings and prevent burnout the us participants had much stronger support networks than the uk nurses and their focus groups revealed strong bonds between participants positive consequences of their emotional labour were evident in the way participants embraced caring for the planet and fought to counter environmental threats to patients communities and future generations their nursing background possibly helps activists not to be overwhelmed by devastating scenarios this differentiates them from the nonnurse participants in oneill and nicholsoncoles study for our participants environment activism raised similar emotions to caring for dying patients which smith describes as the ultimate emotional labour the kublerross five stages of bereavement were sometimes referred to and caring for the planet seemingly invoked even deeper emotions than caring for dying patients participants perceived the planet as criticallydiseased and killing people often the most vulnerable yet believed even small actions are helpful nurses can be formidable instruments for social justice when people have constructive hope regarding the possibility of countering climate change they believe they can influence matters the critical passage from hope to implementation of change depends on the willingness of institutions to alter course our participants were willing to challenge their employing organisations and external institutions what emerged strongly is participants selfconstructed identity as strong nurses who control their negative emotions and turn them into action they shoulder their emotional burden hold onto hope and fight for patients communities limitations this study only recruited from the uk and usa as we lacked scope to include nurses in other countries observational data was limited but this aspect of the study is unique in allowing the witnessing of emotions in situ of a nurse environmental activist conclusion this study reveals for the first time that nurse environmental activism is emotional labour the initial trigger is outrage on recognising risks to human health the more nurses engage in activism the greater the risk of feeling isolated and overwhelmed with encouragement and support from others particularly fellow nurses they can hold onto hope and be formidable fighters for patient community and planetary health conflict of interest statement no conflict of interest has been declared by the authors indepth comparison and meetings to obtain agreement over major themes and key discourses with coresearcher and two critical friends as part of steps taken to ensure rigour member verification provided by some participants when the study findings were presented at conferences in the uk and usa synthesis once agreement obtained over the content of the completed discourse analysis sheets the compendium of these is analysed with recourse to primary data as required people what identities are present how do they represent their own identityidentities are there hidden identities they seem unaware of how do these identities impact their relationships with others their practice the environment what interactions are present what do the identities interactions and relationships reveal researchers a and b separately complete the six elements of the discourse analysis tool for each primary source using diary as needed independent researcher completes discourse analysis tool for 2 focus groups and 2 interviews as part of steps taken for rigour areas of concordance convergence and disagreement scrutinised in depth

aim to investigate the emotions associated with environmental activism among nurses background nursing has a long history of political activism in relation to social justice issues some nurses are environmental activistsmethods focus groups and individual interviews were triangulated with additional observational data the 40 participants united states of america 23 united kingdom 17 were nurses actively engaged with environmentalsustainability issues data collection was from march october 2017 data were analysed using discourse analysisthe trigger for nurses environmental activism was a strong emotional response to recognising risks to human health their activism results in an additional emotion burden above that which they routinely experience in caring for patients many feel overwhelmed by the magnitude of the issues nurses in america feel more supported and empowered to be activists than uk nursesthis study reveals for the first time that advocating for the environment is emotional labour additional to the previouslyrecognised emotional labour associated with caring for patients encouragement and support from others particularly fellow nurses helps nurse environmental activists continue to fight for the health of communities and the planetwhat problem did the study address  the environment is an important determinant of health this study is the first to investigate the emotions associated with environmental activism and impact upon nurses who see their role as caring for the environment as well as for patients outrage at threats to human health triggers nurses environmental activism  environmental activism creates an additional emotional burden above that routinely experienced in caring for patients  nurses in america feel more supported and empowered to be activists than uk where and on whom will the research have impact  nurses whose practice embraces environmental activism need practical and emotional support from other nurses

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introduction children who become street children can be motivated by the parents work which describes the familys economic conditions adopted parenting patterns and patterns of violence against children from familysisters who want to be economically independent child abuse is any form of illtreatment verbal or nonverbal of physical emotional or sexual abuse neglect commercial exploitation or any other form of exploitation that harms the childs health survival development and dignitycarried out within the framework of a relationship of responsibility trust or power the violence and abuse that children experience while in the home environment encourage children to seek attention outside the home especially on the streets children who have wandered on the streets for a long time will find comfort and escape from the problems they face at home as a form of escape or compensation street children spend most of their time doing daily activities on the streets including in markets shops and other crowded centers street children are often defined as teenagers who do not have a permanent place of residence various factors make teenagers become street children including family background mental health and living situations these very complex factors drive a child to prefer to take to the streets and become street children factors that influence street children to take to the streets or become street children are the family environment social environment and community in terms of family environmental factors these street children do not get attention and affection from their families so their parents or family neglect them street children are among societys most vulnerable and marginalized members often without access to food shelter health care security and education adolescents whom their peers influence are more likely to participate in premarital sex than adolescents whom their peers do not influence the study finds this study also found that adolescents their peers influenced were 1825 times more likely than those their peers did not influence to participate in premarital sex research by puspita et al also shows that teenagers prefer spending weekends with friends rather than family they are sometimes more comfortable talking about sex with friends than with other people and sometimes watch pornographic picturesvideos because friends see them statistical results show that there is a relationship between the role of peers on premarital sex at risk of sig 0001 aprianti et al also stated that the friend factor is the dominant factor in premarital sexual behavior where friends who play a negative role are 2743 times more likely to have premarital sex than those who play a negative role in addition adolescence has a considerable sexual attraction to the opposite sex which leads adolescents to premarital sexual behavior the development and sexual urges that are felt are considered biologically normal because of curiosity to try new things and great curiosity according to the research results of hartmann et al states that being on the street can intensify risky sexual behavior while it cannot be said that sexual initiation took place in a street context 40 had sex before the age of 12 the prevalence of unsafe sex in this study was 619 in line with research that found a high prevalence of unprotected sex among people living on the streets about 655 of the 165 people in the study reported that regular partners did not use condoms this proportion was reversed among individuals who reported not having a regular partner as 627 reported using a condom the main reason for not using a condom between regular and nonpermanent partners is not having a condom at the time of intercourse indicating difficulty accessing a condom research by do et al states that the factors associated with risky sexual behavior among vietnamese youth are gender level of education and use of alcohol and drugs the novelty of this research is that the sample is not only children who work on the street but also punk children who live on the streets they spend more time with their community members on the streets no handlers yet n specifically regarding the health of street punk children the number of ngos in pekalongan city is limited and they only deal with economic welfare problems and legal problems faced by street children examination of sti symptoms in street children has not been carried out because street children are not a risk group which are included in the risk groups namely fsw pps waria msm idus spouses and customers based on this phenomenon the researchers studied the factors associated with sti risky sexual behavior in street punk children research methods this type of research is a quantitative study with a crosssectional approach this research was conducted from march to april 2022 in the batang district pemalang district pekalongan district and pekalongan city the population used is street punk children in the four districtscities with an unknown number sampling using incidental sampling with a total sample of 100 children the independent variables are gender recent education and the behavior of drinking and drug use with the dependent variable sti risk behavior data was collected in batang district with nine respondents and in pemalang district with 16 respondents and pekalongan district with 45 respondents and pekalongan city with 30 respondents the research data was tested using the chisquare test each variable that has a pvalue 005 is considered significant the researcher stated that all research procedures had been carried out according to ethics and the diponegoro university ethics commission had issued an ethical clearance based on the table above most respondents were male had a low educational background graduated from elementary and junior high school and had healthrisk behavior namely drinking alcohol and drugs 42 based on the table above it shows that the majority of street punk children have risky sexual behavior namely 62 and those who do not have sex have an sti risk of 38 the bivariate analysis results for gender obtained a pvalue of 0203 and the respondents education obtained a pvalue of 0821 meaning there is no significant relationship between sex and recent education with sexual behavior at risk of stis meanwhile for the variable behavior of drinking and drug use a pvalue of 0000 was obtained which means that there is a significant relationship between sexual behavior at risk of stis research result discussion most street punk children in batang district pemalang district pekalongan district and pekalongan city have sexual behavior at risk of stis which is 62 risky sexual behavior in question is having had sexual intercourse without using a condom or having experienced sexual harassment or having had sexual intercourse in turns or having had sexual intercourse orally the results showed that the number of street children encountered was more male namely 88 people and the number of female street children was 12 people this happened to each group where it was found that in one group there were mostly men the number of women in one group was only one or two people this is also related to the data on street children in the 2021 ppks and psks data distribution book for central java province which states that the number of street children recorded in the batang district is 13 people consisting of 6 males and seven females in pekalongan district as many as three people and all male in pemalang district there were ten people consisting of 8 men and two women and in pekalongan city there were 158 people consisting of 101 men and 57 women whereas in research on ordinary street children usually the numbers are not much different between male and female street children in research in medan there were 55 male respondents and 450 female respondents most studies in southern and west africa report that girls experiences of street violence are more severe than boys on the other hand street girls were found to be more amenable than street children to being recruited into institutions living with relatives recruited into sex work and tricked into falling into relationships with older male sugar daddies making them less visible on the streets than boys men however the results of the bivariate test from this study obtained a pvalue 0203 no relationship exists between gender and sexual risk behavior for stis in street children both men and women have risky sexual intercourse this is in line with a study by whitton et al on adolescents in kampala uganda which stated that overall there was no significant difference in the prevalence of risky sexual behavior in women and men regarding stirisky sexual behavior punk boys are more active and aggressive in having sex supported by female characters who have attention affection and deep feelings that ultimately want to have risky sex according to the respondents narrative if they have had sex it is not uncommon for girls to want to have sex first so from this description it can be concluded that boys and girls are both at risk of having sex at risk of stis based on the results of the study it was shown that the majority of respondents were elementary school graduates namely 63 who were included in the low education level however some respondents never attended or did not finish school at the elementary level namely 2 however 7 of respondents namely high school graduatesequivalent are highly educated dropping out of primary school is also a common characteristic among street children although some have never attended school at all the last reason is that families cannot afford school fees and most children come from polygamous and large families with an average of 4 to 9 children per household the results of the bivariate test between the respondents last education and sti risk behavior obtained a pvalue of 0821 so there was no relationship between the respondents last education and sti risk behavior in street children according to research findings by syafitri et al adolescents with lower levels of education are more likely to participate in premarital sexual behavior than adolescents with higher levels of education adolescents with a low level of education are 182 times more likely to participate in premarital sexual behavior than those with a higher level of education the lack of information about sexuality and reproductive health causes adolescents to want to try having sex without knowing the consequences the higher the education the easier it is to receive information from various sources and the better the knowledge so the lower the education the more difficult it is to receive information from various sources and the lower the knowledge obtained vice versa low education will hinder youth from receiving information and lower the knowledge obtained the higher the education level of street punk children it should prevent them from having sex at risk of stis because their ability to absorb information about the adverse effects of free sex will be better than those with low education however this study found that 5 out of 7 punk kids who were highly educated had sex at risk of stis in this case it can be assumed that education level has no significant relationship with sti risk behavior the health risk behaviors in this study were the behavior of consuming alcohol the behavior of sticking to drugs and the behavior of consuming drugs based on the univariate test it can be seen that 42 of respondents are at risk 82 of respondents consumed alcohol 100 of respondents admitted that they never drank and 43 of respondents took drugs respondents who consumed liquor said they had consumed beer 2561 1220 had consumed winevodka 6951 had consumed traditional alcohol and 5488 had consumed mixed types the lowest age of the respondent who drank alcohol for the first time was nine years and the highest was 18 years based on the frequency most respondents started drinking at 13 2439 while the least was at 18 122 respondents who drink liquor daily as much as 2805 sometimes 6829 very rarely 366 the amount of liquor the respondent drank at one time was 13 glasses 4024 510 glasses 2195 12 bottles 1220 and 35 bottles 2561 respondents who consumed drugs said that the types of drugs they had consumed the most were comix in large quantities 5116 dextro pills 3721 hexamer 3023 but green pills 1628 extra 698 submarine pills 233 cannabisgeek 233 and ctm 233 the lowest age of respondents taking drugs was six years and the highest was eight years when viewed from the number most are aged 13 years equal to 3256 respondents who consume drugs daily 465 sometimes 8605 and very rarely 930 some street punk kids have the principle that they are drinkers but not drug addicts in general they get the drug from their friends komix is the type of drug consumed the most but now it is starting to be challenging to get comics in large quantities because shopkeepers and pharmacies already know that street children abuse komix according to research by ayenew et al in ethiopia which involved 312 street children 308 of respondents currently use substances 391 of respondents used at least one substance in their life 626 used khat 115 used alcohol 467 used cigarettes and 459 used mastic the results of bivariate tests show a relationship between health risk behavior and sexual risk behavior for stis this is to the results of research by aprilia et al in semarang which showed a relationship between consuming alcohol and using drugs with sexual practices at risk of stis street children explained that they drink alcohol and take drugs to relieve stress and it is a habit in their group in this unconscious state risky sexual intercourse often occurs the research results on street children in brazil stated that years of living on the streets hours on the streets sleeping on the streets lifelong drug use having regular partners in the past year and having unprotected sex under the influence of drugs were significant they were associated with risky sexual behavior those who reported having used illicit drugs in their lifetime were 219 times more at risk conclusion gender and recent education were not significantly related to stirisky sexual behavior but healthrisky behavior was significantly associated with stirisky sexual behavior in street punk children suggestion there should be further research regarding the relationship between sti risk behavior and sti symptoms experienced by street children bibliography andini t m sulistyowati t alifatin a sudibyo r p suharso w hidayati d s kurniawati d hayatin n rahadjeng e r ekowati d w

this study aims to analyze the factors associated with stirisk sexual behavior among street children in batang district pemalang district pekalongan district and pekalongan city the method used is quantitative research with a crosssectional research design the results showed that 62 of street punk children had stirisk sex and 58 did not have stirisk sex the bivariate analysis results showed no relationship between sex and recent education and sexual risk behavior for stis still there was a relationship between health risk behavior drinking and drug use and sexual risk behavior for stis in conclusion gender and recent education were not significantly related to stirisk sexual behavior still healthrisk behavior was significantly associated with stirisk sexual behavior in street punk children

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introduction risky behavior among adolescents is a recognized worldwide phenomenon 1 that is even more relevant during times of crisis such as the end of 2019 when the coronavirus started to spread studies indicate various effects on adolescents since the onset of the pandemic including a significant increase in mental distress alcohol use screen addiction student dropout decreased physical activity and reduced involvement in community activities 2 3 4 5 covid19 pandemic and whether the pandemic influenced the prevalence of these risky behaviors furthermore this study examined whether there are links between different risk behaviors during covid19 among adolescents in israel and which characteristics can predict risk behaviors in adolescents materials and methods design this was a crosssectional design participants and procedure the study participants consisted of 1020 israeli youth aged 15 to 18 data were collected between the first and second lockdowns in israel through ipanel ipanel is an online sampling service that allows fast responses striving for a representative sample based on the populations sociodemographic characteristics such as age gender and health status this 100000member panel is the largest panel survey in israel and holds highquality research codes from the european society for opinion and marketing research 25 26 27 an introductory email was sent to 2187 potential candidates via the ipanel database system explaining the research objectives in detail and their rights such as the right to withdraw at any time from the research the survey directions emphasized anonymity and confidentiality data collection resulted in 1020 full questionnaires representing a response rate of 466 measurements the present studys measurements were adopted from the health behavior in schoolaged children organizations protocol the hbsc is a schoolbased survey of adolescent health behaviors and psychosocial determinants carried out among representative samples of school aged children every four years in more than 50 countries using an international standardized methodological protocol 28 29 30 involving standardized procedures for the sampling and translation of items 28 outcome measures sociodemographic characteristics the hbsc includes items describing participants sociodemographic characteristics participants reported their selfidentified sex age and socioeconomic status using the revised family affluence scale 2829 family support two separate scales assessing family support were used in the first scale answers ranged from 1 to 5 and in the second scale from 1 to 7 for each scale all items were summed in order to create a total family support score higher scores represent greater family support the scales cronbachs α 094 since the pearson correlation between the two scales presented strong correlations between the two scales an average score was calculated 2830 friends support friends support was measured using the multidimensional scale of perceived social support 3031 answers to each question were given on a 7point likert scale ranging from strongly disagree to strongly agree items scores were summed in order to create a total score the scales cronbachs α 092 emotional health the hbsc 8item emotional health symptom scale symptom checklist was administered to each participant 32 and has been used in all previous hbsc surveys the scale is flexible in that statistical analyses are meaningful both on the singleitem and sum score level 3334 accordingly a total score was calculated with a higher score representing lower emotional health 35 health during covid19 pandemic participants were asked to describe their health during the covid19 pandemic using the question how would you describe your health during the covid19 pandemic with answers ranging from 1 not good to 4 excellent physical activity level physical activity level was measured using the question how often over the past seven days have you been physically active for a total of at least 60 min per day answers were given on an 8point scale the measure has reasonable validity with fiveday accelerometer data 36 and acceptable testretest reliability when used as a dichotomous variable 37 moderatetovigorous physical activity was also assessed with the following item how many hours a week do you engage in your free time in physical activity that makes you get out of breath or sweat with scores ranging from 1 to 6 covid19 restrictions participants were asked whether they were asked not to engage in any of the following behaviors during the covid19 pandemic social gatherings public transportation isolation due to exposure to someone who might be positive for covid19 isolation on account of exposure to someone positive to covid19 and a family member hospitalized on account of covid19 answers were either yes or no a total score of the number of restrictions was calculated outcomes assessing risky behavior four different risky behaviors were assessed risky behavior during the covid19 pandemic tobacco smoking habits alcohol consumption and cannabis use risky behavior during covid19 participants scored the prevalence of eight risky behaviors as either 0 or 1 a total score reflecting the number of risky behaviors was calculated the total score was dichotomized to those not presenting any risky behavior and those presenting one or more risky behaviors tobacco smoking habits the hbsc questionnaire includes mandatory question items investigating tobacco consumption in the current study the question that examined the frequency of tobacco smoking habits was how often have you smoked tobacco in the past 30 days with response options ranging from 1 to 30 or more answerers were further dichotomized into participants who never smoked and those who smoked at least once 38 alcohol consumption the hbsc instrument was used to collect information on alcohol consumption 39 binge drinking was assessed via the question in the past 30 days how many times have you drank five drinks of alcohol or more within a period of a few hours in addition a dichotomous variable was created to identify adolescents not involved in alcohol use 39 cannabis use cannabis use was measured based on a series of questions asking respondents how often they had used cannabis in their lifetime the last year and the previous month cannabis use experiences were coded 0 abstinence 1 experimental use 2 regular use as the prevalence of experimental and regular users was small a dichotomized variable was created data analysis descriptive statistics as well as chisquare tests were used to describe participants main sociodemographic characteristics the prevalence of each risky behavior was dichotomized into those presenting and those not presenting the risky behavior chisquared tests were used to examine differences in the prevalence of those presenting and not presenting the risky behavior associations between the four risky behaviors were also examined using spearman rank correlation coefficients changes in risky behavior during the pandemic comprising eight different risky behaviors were further analyzed the prevalence of those who stopped started decreased increased or did not present any changes in their risky behavior during the pandemic were reported differences in independent variables between participants presenting and not presenting risky behaviors were examined using chisquared or independent ttests variables significantly different between those presenting and not presenting the risky behaviors were entered into four separate binary logistic regression models in order to determine the extent to which the independent variables were predictive of the risky behaviors in that respect the dependent variables were coded as 0 not presenting and 1 presenting the risky behavior all independent variables were checked for multicollinearity using the variance of the inflation factor the criterion for inclusion in the model was an alpha level of 005 the data were analyzed with ibm spss statistics 19 in all statistical analyses pvalues lower than 005 were considered statistically significant ethical considerations the study protocol was approved by the ethics committee of ariel university confirmation number auheart20210610 participants were voluntarily recruited and informed of the research goals volunteers signed an informed consent form before answering the questionnaire and were assured that they had the right to withdraw from the research at any time that their answers would be kept confidential and that the questionnaires would be analyzed anonymously results study participants characteristics this study included 1020 youth aged 15 to 18 years old participants were recruited from throughout the country however most study participants were from the center of the country for additional information refer to table 1 notes † the socioeconomic status scale scores range from 6 to 19 with higher scores representing higher status a significantly different than north of the country b significantly different than south and coastal plain c significantly different than center of the country d significantly different than east of the country e significantly different than central coastal plain sd standard deviation risky behavior characteristics the most prevalent risky behavior in the sample was binge drinking with 338 of the sample reporting experiencing binge drinking in the past month the next most prevalent risky behavior was tobacco smoking in the last 30 days with approximately 10 of the sample reporting this risky behavior in addition the four measures of risky behavior were significantly correlated in addition the four measures of risky behavior were statistically significantly correlated the highest correlation observed was between tobacco smoking in the last 30 days and total risky behavior during the pandemic and the lowest was between cannabis use in the last 30 days and total risky behavior during the pandemic for additional information refer to table 3 the measure of risky behaviors during the covid19 pandemic comprises eight independent behaviors the mean number of risky behaviors per participant was small and ranged between 0 and 8 most of the participants did not change the frequency of their risk behavior during the pandemic however more than 20 of the sample started to or increased their frequency of smoking cigarettes smoking electronic cigarettes antianxiety medications and smoking cannabis in addition 144 of the participants started or increased the frequency of drinking alcohol on the other hand 20 decreased and 267 stopped using other illegal drugs during the pandemic 159 reduced alcohol consumption and 189 reduced cigarette smoking most of the participants did not change the frequency of their risk behavior during the pandemic however more than 20 of the sample started to or increased their frequency of smoking cigarettes smoking electronic cigarettes antianxiety medications and smoking cannabis in addition 144 of the participants started or increased the frequency of drinking alcohol on the other hand 20 decreased and 267 stopped using other illegal drugs during the pandemic 159 reduced alcohol consumption and 189 reduced cigarette smoking factors related to and predicting risky behavior all independent variables except for friends support physical activity volume and covid19 restrictions significantly differed between participants engaging vs those not engaging in risky behaviors for example in all risky behaviors assessed the mean family factors related to and predicting risky behavior all independent variables except for friends support physical activity volume and covid19 restrictions significantly differed between participants engaging vs those not engaging in risky behaviors for example in all risky behaviors assessed the mean family support among those not presenting the risky behavior was significantly higher than those presenting risky behavior similarly in all risky behaviors as well as in total risky behavior during the pandemic score those with higher emotional health scores presented greater risky behaviors than those with lower scores the regression model showed that tobacco smoking in the last 30 days was related to age and emotional health similarly older age and greater emotional distress predicted binge drinking male sex was also a significant predictor of binge drinking in contrast cannabis use was only predicted by family support with greater family support predicting abstinence total risky behavior during the pandemic was predicted by older age emotional distress and low family support health during the pandemic and socioeconomic status were not significant predictors of any of the risky behaviors evaluated notes † significant differences in prevalence between males and females significant betweengroup differences sd standard deviation discussion the coronavirus pandemic has profoundly impacted adolescents lives 1114 this study examined the factors influencing risky behaviors among adolescents in israel two months after the first lockdown in 2020 in addition we examined the possible links between different risk behaviors in the prevalence of risk behaviors and which factors could predict risk behaviors in adolescents during covid19 our findings show that all risky behaviors during the pandemic were moderately correlated these results are consistent with many other studies showing associations between risky behaviors such as illicit drugs marijuana alcohol and ecigarette use 40 41 42 43 44 however the analysis of risk behavior prevalence during the pandemic yielded mixed results approximately 50 of those engaged in risky behaviors did not change their behaviors during the pandemic alcohol consumption was somewhat decreased with 30 reporting cessation or reduction of alcohol consumption whereas 15 reported starting or increasing consumption the observed decline may be due to the imposed lockdown and restrictions limiting the adolescents access to alcohol decreased ritalin consumption during the pandemic may be attributed to the forced transition to remote learning in contrast there was an increase in antianxiety drug use similarly to other studies reporting an increase in antianxiety drug use among adults during covid19 moreover international and noncollege data demonstrate shifts in drinking behaviors related to the covid19 pandemic 4546 analysis using a regression model revealed that all collected independent variables except for friends support physical activity volume and coronavirus restrictions significantly differed between participants engaging vs not engaging in risky behaviors in all risky behaviors assessed the mean family support was significantly higher among those not presenting the risky behavior than those presenting it this result is in line with multiple studies that point to the importance of parental support in preventing risky behaviors such as reducing adolescent substance use 4748 indeed more involving parents are more successful in protecting their adolescents from problematic drug use 49 furthermore setting clear rules and boundaries open communication and a good parentchild relationship are all associated with reduced use of illicit substances among adolescents 50 in addition in our study emotional health was found to predict all risky behaviors with the chance of engaging in risky behaviors increasing with increased emotional distress being younger and female also reduced the likelihood of engaging in risky behaviors consistent with previous studies 51 52 53 interestingly the present study found that socioeconomic status was positively correlated with risky behaviors during the pandemic this may be because upperclass adolescents had more resources and access to illegal substances during the quarantine compared to lowersocioeconomic adolescents in addition they may have enjoyed greater personal space in their homes allowing them to continue engaging in risky behaviors without being caught indeed hanson and chen 54 found a link between low socioeconomic status and cigarette smoking but no clear alcohol consumption or marijuana use pattern future research should examine how resource availability affects different kinds of risky behaviors during routine and in times of crisis additionally peer support and physical activity did not correlate with any risky behaviors while being a protective factor peer support may also encourage risktaking actions and their attitudes towards experimentation with substance use may be positive 55 the opposite potential effect of peer support may explain its lack of contribution to predicting risky behaviors in the present study yet another possible explanation is that the covid19 restrictions had impaired social connections thus lessening their protective essence 56 57 58 although previous studies have linked physical activity with adolescent health risk behaviors 5960 the present study did not find evidence for such association possibly due to an overall decrease in physical activity owing to covid19 as found in a recent report on young spanish adults 61 one of the strengths of the present study is the large response rate of participants that answered the online questionnaire however a few limitations must be observed first the measures in this study were limited to adolescent selfreport without further testing therefore several tools are needed to increase data reliability and prevent biases such as a personal interview second the sample was not probabilistic and included a group of adolescents looking to participate in this type of online research therefore is not necessarily representative it is crucial to make a representative sample of all adolescents across israel to increase data reliability third data were collected between the first lockdown in israel and the second lockdown thus it should be taken into consideration that the results and the implications for adolescents use of substances may have been different if given later during the pandemic hence it is recommended to conduct research sampled at several points in time to find a systematic longitudinal research setup conclusions our findings suggest that family support is one of the most influential factors in preventing risky behavior during the pandemic emphasizing the importance of familybased interventions with children and adolescents it is necessary to allocate state budgets to deal with covid19 consequences such as strengthening and encouraging adolescents who have not started or who have increased risky behaviors during this period and providing educational and therapeutic responses to adolescents who have used substances in addition targeted and tailored intervention programs for the adolescent population who drink alcohol are necessary future research should examine the characteristics of adolescents who started or increased the use of substances compared to those who stopped or reduced data availability statement not applicable

we investigated the prevalence of risk behaviors among israeli adolescents tobacco smoking alcohol consumption drug use during the covid19 pandemic associations between different risk behaviors were examined and so was whether specific characteristics could predict risk behaviors in adolescents the study consisted of 1020 israeli adolescents aged 1518 study subjects completed an online survey between the first and second lockdowns in israel april 2020 to september 2020 participants reported the frequency at which they engaged in four different risky behaviors general risky behavior tobacco smoking alcohol consumption binge drinking and cannabis use the most prevalent risky behavior in the sample was binge drinking 338 the four measured risky behaviors were significantly correlated among participants who had previously engaged in a risky behavior assessed most did not change the behavior frequency during the pandemic all independent variables sociodemographic characteristics family support and emotional health excluding friends support physical activity volume and coronavirus restrictions were significantly different between participants engaging vs not engaging in risky behaviors our findings suggest that family support is one of the most influential factors in preventing risky behavior during the pandemic and they emphasize the importance of familybased interventions with children and adolescents from elementary to high school

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introduction since international business machines corporation put forward the concept of a smart earth in 2008 with the spatial application of information and intelligent technology the term smart city has gradually become synonymous with the future development of the city in 2012 china promulgated the notice on carrying out the national smart city pilot work which marked the beginning of the specific practical work of chinas smart city construction chinas smart city construction has experienced more than ten years of development at present the relevant themes need to be grasped as a whole so as to summarize the development law enrich the theoretical framework and provide corresponding guidance for specific practical problems smart city construction promotes the optimization of urban ecosystems with intelligent perception and interconnection integration from five aspects concept strategy social development economic development spatial planning and infrastructure so as to provide corresponding methods and strategies to solve the problems faced by urban development 1 learning from the sustainable big data and other diversified smart city models shaped in the construction of global smart cities could promote the coordination of smart city governance personalized urban services for people and the comprehensive aggregation of technology applications releasing the dividends of corresponding policies and systems and then grasping the new trend of smart city construction 2 it is clear that smart cities are of significant value to the current problems and challenges encountered in urban development and a large number of research results have emerged the technological revolution has led to changes in traditional production and lifestyles profoundly altering the way society is organized and the way urban space operates shaping a whole new pattern of human urban social systems smart cities driven by digital and intelligent technologies have emerged and the development of smart city construction relies on the interaction process between modern intelligent technologies and urban development needs however the specific objectives and action plans of smart city construction are applied piecemeal in the field of urban construction and rely excessively on the technical sphere forcing people to experience unsatisfactory results and other real problems that need to be addressed accordingly based on this this paper analyzes the state of smart city research in china further explores the evolution of smart city research paradigms tracks research frontiers and research hotspots and provides reference and guidance for future smart city practice and theoretical research literature review from the specific practice of smart city development it has become mainstream to build and develop smart cities around technology support governments around the world are focusing on smart city projects to achieve diverse goals such as sustainability citizen engagement and improved services 3 the development of smart city applications involves the improvement of the quality of life of residents in society and the use of cloud computing for the sensing infrastructure data calculation to achieve the application of allowing the process of activity to unfold through the encryption of computing methods to achieve data privacy protection and to help the development of smart city applications 4 from the perspective of the theoretical development of a smart city the theoretical connotation of a smart city and its technical support framework have undergone changes in specific practice smart city version 10 is a smart urban solution promoted by technology companies smart city version 20 is a local government solution leading the improvement of residents lives and sustainable lifestyles smart city version 30 is a community collaboration model which includes the best strategic solutions for citizens policy makers enterprises and other subjects 5 the development of smart city theory cannot be separated from the logic of specific technological developments where technologies such as the internet of things big data and artificial intelligence have become the underlying framework supporting and influencing the connotative development of smart city theory here including the theoretical categories of sustainability innovation and governance geotwitter provides information on the perceived experience of smart cities in australia where sydney melbourne and brisbane are the leading smart cities by providing appropriate decisionmaking information for smart city development at a community level 6 the conceptual goals of a smart city are to provide quality services to city residents and to make the best use of public resources to improve peoples quality of life blockchain technology is applied in the smart city service system using its advantages of decentralization anonymity and security to analyze smart city application areas such as smart transportation smart healthcare and supply chain management 7 the neoliberalism of community citizen participation in smart cities links different forms of neoliberal urbanism by focusing on the practical work of european smart cities and community innovation partners promoting everyday experiences rooted in the public interest such as the right to the city and the idea of sharing thus reshaping the practice of a citizencentred smart city discourse 8 based on smart cities as a global issue involved in local practice the issue of how to develop rationalized standards and norms for smart cities and the dynamic competition between world cities and second and third tier follower cities have become globally engaged issues to some extent the global character of smart cities and the transformative governance issues they represent point the way to future research and policy practice 9 through the construction of threedimensional economic social and environmental indicators 173 countries were examined in terms of their sustainable development 10 ultimately providing a system of indicators for sustainable development little is known about how the norms and perceptions of institutional arrangements influence and shape urban experiments the institutional planning of smart cities in amsterdam hamburg and ningbo was examined to explore how urban experiments are shaped based on local specificities leading to the relationship between urban policy arrangements and concrete urban practices 11 technological rescue and urban crisis as a narrative premise of a smart city have become a sociotechnical imaginary concept breaking the narrative discursive status of the technologydominated smart city imaginary and opening up space for a humanistic urban narrative 12 smart city research in canada revolves around large cities and is very limited in targeting rural and remote development how to establish communication between the development of lagging areas and big cities and how to synergize the smart development of rural remote areas are necessary to bridge the digital divide as well as for scale development 13 the construction of public spaces in smart cities requires the construction of spatial infrastructures that combine virtual and real organically combining the physical tangible space and virtual digital space of the city to further enhance the level of urban services and governance faced with the development needs of an intelligent and humanized city the key to upgrading the construction of urban spatial infrastructure lies in the synergistic coupling of functional mechanisms the use of digital intelligence technology to model and analyze urban spatial realities and the shaping of a comprehensive governance system that is agile and responsive with responsible subjects in place and the effective integration of resources 14 the urban social structure and governance system should be reshaped intelligently and the systematic scientific thinking paradigm should be used to guide the intelligent transformation of urban governance to achieve the goal of good urban governance the logic of intelligent technology governance is integrated with urban governance to explore the role of systematic holistic selforganized and collaborative behavior in urban innovation governance to build an urban intelligent governance mechanism and to adapt to the complexity requirements 15 under the background of new crown epidemic prevention urban smart governance is based on the dual logic of collaborative governance and technological innovation taking the innovation of health code technology as an example combined with the construction of digital governance ecosystems such as government governance and grassroots governance governance innovation has emerged 16 although international research on smart cities started earlier chinese smart city research has just begun in terms of research content chinese smart city research is more focused on technological innovation and infrastructure development while international research is broader covering technology policy and humanities at the same time international research is more concerned with the economic value derived from smart city construction while chinese research is more concerned with its public value many studies have addressed the conceptualization of the smart city itself with one illuminating definition being that a smart city is a system integration of technological infrastructure that relies on advanced data processing with the goals of making city governance more efficient citizens happier businesses more prosperous and the environment more sustainable 17 in view of the current situation that chinas smart city research consists mostly of theoretical overviews qualitative analyses or experience summaries this paper uses bibliometrics as a tool to explore the overall research context existing deficiencies and future research trends to provide theoretical reference for the research and construction of smart cities at home and abroad research design and integrity analysis bibliometrics is a crosscutting science field that uses mathematical methods of mathematical statistics to analyze the literature in a field of interest vosviewer is commonly used in bibliometrics as visual mapping software to structure and visualize the knowledge domain of the literature by extracting data units and constructing a visual spectrum of the relationships between data the spss statistical analysis process includes descriptive statistics general linear models regression analysis loglinear models cluster analysis time series analysis multiple responses etc cooc software is mainly used for literature database deduplication cooccurrence matrix twomode matrix similarity matrix etc bibliometric tools are commonly used in various disciplines of social and natural sciences to achieve a holistic grasp of trends and the current state of research in related disciplines through the processing of large amounts of data from relevant literature this study is a bibliometric approach to data analysis of the literature related to smart cities and the research design is broadly divided into the following sections retrieve smart cityrelated literature from the cnki database and on this basis extract authors keywords time journals and other categories and make a cooccurrence map establish a coword matrix according to highfrequency keywords calculate the correlation coefficient matrix according to the coword matrix as the basis of the analysis and carry out cluster analysis on the prerelation matrix according to the cluster spectrum map to conduct a comprehensive analysis of smart city development ing definition being that a smart city is a system integration of technological infrastructure that relies on advanced data processing with the goals of making city governance more efficient citizens happier businesses more prosperous and the environment more sustainable 17 in view of the current situation that chinas smart city research consists mostly of theoretical overviews qualitative analyses or experience summaries this paper uses bibliometrics as a tool to explore the overall research context existing deficiencies and future research trends to provide theoretical reference for the research and construction of smart cities at home and abroad research design and integrity analysis bibliometrics is a crosscutting science field that uses mathematical methods of mathematical statistics to analyze the literature in a field of interest vosviewer is commonly used in bibliometrics as visual mapping software to structure and visualize the knowledge domain of the literature by extracting data units and constructing a visual spectrum of the relationships between data the spss statistical analysis process includes descriptive statistics general linear models regression analysis loglinear models cluster analysis time series analysis multiple responses etc cooc software is mainly used for literature database deduplication cooccurrence matrix twomode matrix similarity matrix etc bibliometric tools are commonly used in various disciplines of social and natural sciences to achieve a holistic grasp of trends and the current state of research in related disciplines through the processing of large amounts of data from relevant literature this study is a bibliometric approach to data analysis of the literature related to smart cities and the research design is broadly divided into the following sections retrieve smart cityrelated literature from the cnki database and on this basis extract authors keywords time journals and other categories and make a cooccurrence map establish a coword matrix according to highfrequency keywords calculate the correlation coefficient matrix according to the coword matrix as the basis of the analysis and carry out cluster analysis on the prerelation matrix according to the cluster spectrum map to conduct a comprehensive analysis of smart city development data sources the data used in this paper were obtained from the cnki database as of 31 march 2022 the title key words and abstract containing smart city were selected the source categories of journals were searched ie peking university core cssci journals and cscd journals and a total of 2236 documents were retrieved after the literature was processed 1976 documents were finally obtained as sample data data sources the data used in this paper were obtained from the cnki database as of 31 march 2022 the title key words and abstract containing smart city were selected the source categories of journals were searched ie peking university core cssci journals and cscd journals and a total of 2236 documents were retrieved after the literature was processed 1976 documents were finally obtained as sample data research tools coword analysis uses spss cooc vosviewer and other software to analyze the degree of association between words such as keyword clustering second mock examination cooccurrence analysis hierarchical clustering and so on to outline the current situation of smart city research coword analysis shows the relationship between the research objects through data and images then summarizes the relevant literature and discusses the research status and future development trend of smart cities overall research and analysis in this study the year author journal and highfrequency keywords were analyzed through bibliometric metrics specifically the annual publication of chinas smart city research was analyzed vosviewer cooc and other software were used to analyze coappearing authors and keywords and journals and keywords and then the twomodel cooccurrence relationship between related authors journals and keywords was excavated and multilevel clustering analysis and keyword clustering cooccurrence analysis were carried out for highfrequency keywords time distribution analysis according to the time distribution map of smart city research literature chinas smart city research showed a steady increase and an upward trend year by year the historical trend of the number of articles published was roughly divided into three stages in the first stage the number of articles published showed an exponential growth reaching 68 in 2012 in the second stage the number of documents fluctuated around 150 maintaining a stable trend in the third stage the number of documents basically fluctuated at a high level of 200 and reached a historical peak of 282 in 2021 situation of smart city research coword analysis shows the relationship between the research objects through data and images then summarizes the relevant literature and discusses the research status and future development trend of smart cities overall research and analysis in this study the year author journal and highfrequency keywords were analyzed through bibliometric metrics specifically the annual publication of chinas smart city research was analyzed vosviewer cooc and other software were used to analyze coappearing authors and keywords and journals and keywords and then the twomodel cooccurrence relationship between related authors journals and keywords was excavated and multilevel clustering analysis and keyword clustering cooccurrence analysis were carried out for highfrequency keywords time distribution analysis according to the time distribution map of smart city research literature chinas smart city research showed a steady increase and an upward trend year by year the historical trend of the number of articles published was roughly divided into three stages in the first stage the number of articles published showed an exponential growth reaching 68 in 2012 in the second stage the number of documents fluctuated around 150 maintaining a stable trend in the third stage the number of documents basically fluctuated at a high level of 200 and reached a historical peak of 282 in 2021 cooccurrence analysis of authors and keywords there were 54 authors whose frequency was greater than or equal to five times and 51 keywords whose frequency was greater than or equal to 10 times the second mock examination of the cooccurrence of authors and keywords represents the number of simultaneous occurrences the larger the circle in the figure the higher the frequency this visually presents the areas highlighted by the authors research as shown in figure 3 deren li wei liu and others published relevant research in the fields of the internet of things intelligent transportation and digital cities guo hua cheng cooccurrence analysis of authors and keywords there were 54 authors whose frequency was greater than or equal to five times and 51 keywords whose frequency was greater than or equal to 10 times the second mock examination of the cooccurrence of authors and keywords represents the number of simultaneous occurrences the larger the circle in the figure the higher the frequency this visually presents the areas highlighted by the authors research as shown in figure 3 deren li wei liu and others published relevant research in the fields of the internet of things intelligent transportation and digital cities guo hua chengming li feng zhou jing xu zhigang zhao et al have published relevant articles on smart cities and information safety guangbin wang and zhiwei tang have highlighted relevant research on smart city construction new smart cities and so on shengzu gu sisi tang and others have focused on information society and egovernment feng zhen guangliang xi xiao qin and yangwei chai have studied the smart community urbanization and so on ming li feng zhou jing xu zhigang zhao et al have published relevant articles on smart cities and information safety guangbin wang and zhiwei tang have highlighted relevant research on smart city construction new smart cities and so on shengzu gu sisi tang and others have focused on information society and egovernment feng zhen guangliang xi xiao qin and yangwei chai have studied the smart community urbanization and so on analysis of the cooccurrence of journals and keywords the 41 journals have published 10 or more articles in addition the 51 keywords had a frequency of 10 or more times visual analysis of the second mock examination of the cooccurrence between journals and keywords was carried out and the results are shown in figure 4 computer engineering and applications computer science and acta geodaetica et cartographica sinica focus on artificial intelligence knowledge map intelligent transportation data mining deep leaning etc journals such as archives construction and china archives focus on key words such as digital archives smart grid smart city construction etc science and technology management research modern urban research science of surveying and mapping and bulletin of surveying and mapping focus on key words such as smart city sustainable development etc urban planning international human geography and urban planning forum focus on smart city planning spatiotemporal behavior big data and other aspects egovernment focuses on intelligent governance internet etc analysis of the cooccurrence of journals and keywords the 41 journals have published 10 or more articles in addition the 51 keywords had a frequency of 10 or more times visual analysis of the second mock examination of the cooccurrence between journals and keywords was carried out and the results are shown in figure 4 computer engineering and applications computer science and acta geodaetica et cartographica sinica focus on artificial intelligence knowledge map intelligent transportation data mining deep leaning etc journals such as archives construction and china archives focus on key words such as digital archives smart grid smart city construction etc science and technology management research modern urban research science of surveying and mapping and bulletin of surveying and mapping focus on key words such as smart city sustainable development etc urban planning international human geography and urban planning forum focus on smart city planning spatiotemporal behavior big data and other aspects egovernment focuses on intelligent governance internet etc highfrequency keywords the keyword fields of the 1976 documents were measured by cooc 18 software carrying out word frequency statistics and 4977 keywords were extracted including 51 keywords with a frequency ≥10 cooc software was used to generate 51 highfrequency keywords and the cooccurrence matrix of 51 showed some highfrequency keywords due to layout constraints in order to facilitate multiscale analysis and hierarchical cluster analysis the keyword cooccurrence matrix was transformed into a dissimilarity matrix by cooc software cluster analysis the 51 keyword dissimilarity matrix in the cnki database was imported into spss25 software and the pedigree of the word connection is used to cluster the highfrequency keywords into six categories category 1 focused on archived research category 2 focused on embedded research such as artificial intelligence technology category 3 focused on urbanization category 4 focused on smart city planning construction and development governance digitization and other fields category 5 focused on research related to smart cities and big data internet of things and category 6 focused on research related to egovernment urban management and public services the cooccurrence matrix of 51 keywords from the cnki database was imported into cooc software and converted to a net format while the cooccurrence profile was derived from vosviewer software the clustering of highfrequency keywords resulted in five categories category 1 included keywords such as digital twins artificial intelligence convolutional neural network deep learning threedimensional modeling intelligent transportation modeling and intelligent transportation in category 2 the keywords were public service information society digital governance city management internet urban informatization public administration urban informatization public administration egovernment intelligent governance digital economy intelligent society smart community etc the category 3 keywords were new smart city informationalization spatiotemporal behavior smart city planning smart city construction urbanization new urbanization etc the category 4 keywords included smart city big data cloud computing internet of things data mining urban development digital city blockchain evaluation system blockchain evaluation system urban governance sustainable development intellectualization city planning information safety smart grid gis smart tourism etc the key words in category 5 were smart archives toplevel design and digital archives gent society smart community etc the category 3 keywords were new smart city informationalization spatiotemporal behavior smart city planning smart city construction urbanization new urbanization etc the category 4 keywords included smart city big data cloud computing internet of things data mining urban development digital city blockchain evaluation system blockchain evaluation system urban governance sustainable development intellectualization city planning information safety smart grid gis smart tourism etc the key words in category 5 were smart archives toplevel design and digital archives keyword clustering in figure 6 was analyzed which showed that category 4 intersected with categories 1 2 and 3 this was clearly seen from the keyword clustering space in the figure to a certain extent this also confirms that the hierarchical clustering effect of highfrequency keywords in figure 5 is not ideal but this does not prevent us from introducing the relevant research topics in this study we identified the research topic of classification 1 in the cluster diagram as intelligent technology supporting smart city research the research topic of classification 2 was the integration of the social system of a smart city the theme of category 3 was research in the fields of toplevel strategic design and the planning and construction of smart cities the research topics of classification 4 and 5 were the research of smart city construction development evaluation and specific practice identified the research topic of classification 1 in the cluster diagram as intelligent technology supporting smart city research the research topic of classification 2 was the integration of the social system of a smart city the theme of category 3 was research in the fields of toplevel strategic design and the planning and construction of smart cities the research topics of classification 4 and 5 were the research of smart city construction development evaluation and specific practice results and discussion according to figure 6 the five categories are discussed according to four themes the four themes are the research on smart cities supported by smart technologies research on the integration of social systems in smart cities research on the toplevel strategic design planning and construction of smart cities and research on smart city construction and development evaluation and specific practices smart technology to support smart city research the application of the latest technology in the internet of things era has accelerated the construction of urban infrastructure and has realized humancomputer interaction and humanhuman interaction through network transmission bringing convenience to human production and life unfortunately however the contradiction between user privacy and forensic investigation is inevitable how to protect privacy and security based on forensic services requires corresponding solutions to provide a reasonable framework to ultimately ensure the security of data flow across domains 19 data drive results and discussion according to figure 6 the five categories are discussed according to four themes the four themes are the research on smart cities supported by smart technologies research on the integration of social systems in smart cities research on the toplevel strategic design planning and construction of smart cities and research on smart city construction and development evaluation and specific practices smart technology to support smart city research the application of the latest technology in the internet of things era has accelerated the construction of urban infrastructure and has realized humancomputer interaction and humanhuman interaction through network transmission bringing convenience to human production and life unfortunately however the contradiction between user privacy and forensic investigation is inevitable how to protect privacy and security based on forensic services requires corresponding solutions to provide a reasonable framework to ultimately ensure the security of data flow across domains 19 data drive the operation of smart city application systems and the effective mining and development of data in smart city application systems are related to the highquality development of smart cities however these data are usually sensitive and private and the tradeoff between data privacy protection and data availability has become a challenge through privacy computing federated learning and other methods for data mining and the utilization of smart cities data security is finally ensured under the premise of the availability and value of data 20 the application development of the edge computing paradigm provides an efficient computing network system for the development of urban society constructing an open platform for computing storage application capabilities etc providing a technical computing framework as well as a computing service system for the future development of urban wisdom heterogeneous intelligent drones can realize a differentiated framework for monitoring cities and oceans the environment of smart cities and oceans is very different and the monitoring of public transport related to smart cities can be realized through a tight flatbased framework while at the same time a loose hierarchybased framework is developed to realize the monitoring of oceans which provides a technical idea for the smartization of marine cities 21 the underlying technology to support smart cities requires multiinterface access and the signal processing of massive heterogeneous iot devices based on artificial intelligence algorithm technology to achieve performance enhancement and improved processing power to realize the beautiful blueprint of smart cities 22 this could strengthen the risk management and control of smart city network systems using technical means to reduce risks or pass on risk losses through thirdparty network insurance companies 23 there is an innovation alienation trap in the science and technology innovation cycle the irrational perception of the science and technology innovation cycle the purpose of innovation and the relationship between the city and society has led to problems in the process of using science and technology for smart city construction it is necessary to understand the characteristics of the science and technology innovation cycle and its value objectives to accurately grasp the scale of innovation to create a good innovation space to stimulate innovation and to achieve a sustainable model of smart city development 24 the construction of japans supersmart society in the context of innovation system theory is led by government policy with universities cultivating relevant knowledge and talents and the collaborative development of research industry and academia through the industrialization of enterprise technology which provides corresponding guidance suggestions for the construction of smart cities in china 25 there are many security risks in the construction and operation of smart cities such as the lack of toplevel network security design longterm restriction of core technology products insufficient investment in digital network security and a lack of awareness of digital network security protection the construction of a risk assessment model for smart cities will be beneficial in promoting urban risk prevention 26 research on the integration of the social system of a smart city the true wisdom of smart city construction in the new crown epidemic period needs to be peoplecentered and it needs to turn crisis into opportunity individuality and collectivity integration and to create an intelligent governance model of multisubject cogovernance 27 major public health events affect the quality of urbanization development and promote the transformation of urban development from populationspatial expansion to functionecological connotation 28 it is beneficial to change the orientation of local government performance evaluation build a multilevel urban governance system deepen the construction of the social functions of urban agglomerations and smart cities improve the level of highquality urban development and prevent and control public health incidents public emergencies test the level of smart city governance and help the transformation of urban governance from the aspects of big data prediction service capabilities of smart cities urban emergency management coordination capabilities smart city emergency material support capabilities smart city refuge space planning and construction capabilities and the management resilience of grassroots smart communities 29 new infrastructure drives the construction of smart cities from the iterative development of technology to urban space construction changing the urban space network system and innovative practice application scenarios 30 the construction of smart communities in the postepidemic era has played a fundamental role in the urban circulation and peoples livelihood security system 31 and the precise prevention and control of the emergency management system for the prevention and control of the new crown epidemic is inseparable from the transformation of urban public management into the construction of smart cities promoting the sharing of big data and strengthening information security construction 32 research on specific practice areas of smart city society the concepts of industry 40 society 50 and connected industry have gradually become the consensus of modern social development promoted the construction of the national strategic extension framework system of smart cities taken suitability technology comprehensiveness and systematization as the basic requirements for improving the development of smart cities and explored strategic docking and cooperation such as science and technology strategies and industrial enterprises 33 from the manufacturing transformation dimension the design principles of industry 40 include interoperability virtualization localization realtime talent serviceoriented and modular aspects 34 the development of 5g technology provides a basic framework for the underlying framework for the development of smart cities such as the internet of things nanogenerators have become sustainable power sources and selfpowered active sensors which have contributed to smart city applications such as smart transportation and smart healthcare 35 the complexity of smart city assessment indicators affects the decision making process for smart cities and the development of a framework system for smart city assessment will help to promote smart cities 36 the smart city environment monitoring system based on zigbee wireless network forms a dynamic organization network through street lights taxis and other nodes to realize the infrastructure construction of a smart city with wireless network sensors providing comfort and convenience for peoples lives 37 urban social governance is the nerve endings of urban governance and it is indispensable to promote the modernization of urban governance the urban resilience governance model is inseparable from the localization of the social development power mechanism among which institutional resilience economic resilience and social resilience need to be further refined in the construction of urban space 38 the disruptive technologies in the intelligent age have a transformative impact on urban space life shaping urban science theories and the future development trend of smart cities the development of smart cities promotes the modernization of urban governance systems and capabilities realizes smart empowerment and then resolves the contradiction analysis between technical governance and administrative governance coordinates social relations in an orderly manner and solves traditional urban problems 39 research in the fields of toplevel strategic design and planning and construction urban planning and design construction development evaluation systems and other related research smart city construction is inseparable from digital infrastructure and competitive advantages should be ensured in the fields of toplevel design and core technology research and development compared with latecomer countries the us digital infrastructure does not have an advantage 40 and the lessons learned by the united states have reference value for the proportion of chinas new infrastructure structure talent training and urbanrural integration from the macro strategic level the us smart city construction strategy is based on four levels toplevel design institutional mechanism application deployment and project practice so as to provide a reference for chinas smart city construction 41 urban planning in the intelligent era needs to seek changes from passive adaptation to technology to active response actively cater to the impact of intelligent technology on the development of disciplines explore a new development system of urban planning interpret the essence of smart city planning clarify its positioning and development goals sort out the four aspects ie technical support planning scheme operation implementation and system guarantee explore the problems and contents of smart city planning at different spatial scales and promote the intelligent transformation of urban planning 42 the wholeprocess governance strategy consists of source control in advance overall implementation during the event and postevent assessment and evaluation sorting out the functional architecture of the smart city system monitoring system indicators as well as platform simulation calculation and data application in the smart city governance system focusing on the digital support system in smart city planning construction operation and maintenance management realizing the data flow transfer and platform governance of smart cities and providing a reference for smart cities and city brain operation and the maintenance management assessment and evaluation for example the problems existing in the construction of a smart city in guangzhou are analyzed at five levels strategic level social activity level economic activity spatial structure and technical support level and corresponding reference suggestions are provided for planning and design social management peoples livelihood industrial development and the spatial structure layout 43 sustainable urbanization and informatization have become the trends of urban social development and the use of informatization means to promote the sustainable development of urbanization and realize a lowcarbon and sustainable urbanization ecological resilience system 44 urban geography research focuses on urban agglomerations urbanization smart cities and other research fields focusing on regional coordination urbanrural integration green development etc 45 urban development transformation is based on the original urbanization construction should pay attention to infrastructure construction urban functions and new technology integration innovative development green ecological construction urban culture construction and other aspects of upgrading and optimization and finally create a livable innovative green smart and humanistic urban goal construction 46 urbanization development faces many urban problems such as environmental pollution imperfect infrastructure and transportation and the smart city construction process should respond to these urban diseases the boundary of smart city construction is dominated by the value boundary of the city and the value orientation of grasping the law of urban construction is the key to the development of a smart city in the process of urbanization information and communication technology focuses on the individual spatial behavior of urban residents among which social fairness fairness and justice and other issues need urgent attention 47 the development stage governance model construction and management mode service effect and other aspects of the construction of new smart cities have changed and policy suggestions for the development of new smart cities have been put forward and problems have been pointed out 48 research on smart city construction development evaluation and specific practice we need to promote the construction of smart cities and explore the realization path of smart governance based on four dimensions governance concept model system and mode 49 we need to carry out smart city construction pilots improve governance systems and mechanisms vigorously cultivate innovative talents build digital platforms shape a diversified and cogovernance pattern and jointly build a peopleoriented sustainable smart city 50 the digital transformation of cities has become the basic consensus of chinas smart city construction under the background of digital transformation the governance of international metropolises follows the logic of scientific intelligent and refined governance attaches importance to the overall planning of urban public data facilities realizes the sharing of data resources standardizes systems and rules improves governance capabilities and promotes the efficiency of metropolitan governance digital twin generation is a new aspect of smart cities and focuses on the field of digital city governance a digital twin contextualizes traditional urban governance problems intelligent methods simplified processes multiple subjects and realtime interactions but the dilemma brought about by digital twins to urban governance is not limited to technology organization value dilemma etc and it is necessary to explore the system optimization of digital twin urban governance from the aspects of toplevel system design organizational structure optimization and peoples subject value anchoring 51 the smart city theory based on digital twins is helpful to promote the solution of problems faced by urban development and the improvement of urban fine governance capabilities realize the construction of urban data asset management systems and implement digital business scenarios achieving refined governance in urban development in the new era is a key step in the urban governance system which is an important link to promote the governance system regarding the details and depths among which technology empowerment and institutional guarantee provide an integrated framework for urban fine governance ensure the design of smart city systems and the construction of comprehensive administrative law enforcement systems and promote urban fine governance 52 we need to promote the construction of smart cities the digital layout of global scenarios and realize the construction of standardized systems for digital society and digital community infrastructure we need to promote urban digitalization and refined governance solve the problem of community governance application scenarios and drive the development of science and technology industries related to urban construction 53 enterprises are the main body and driving force of urban economic development enterprise intelligent operation innovation and creation precise services etc have become the characteristics of smart enterprises and their development logic can be summarized as an eight selfmechanism and the quality of intelligent enterprise operation and development ultimately creates value for users 54 the theoretical framework of a library smart service uses the diversified services of information technology practice through the logical main line of smart citysmart library serviceuser and constitutes the theoretical framework of smart service from five aspects macro analysis specific element analysis technical equipment service innovation and service landing 55 the functional positioning of traditional comprehensive archives driven by smart city construction is reflected in precise services and accurate demand perception integrating diversified data service functions supporting urban cultural service functions realizing intelligent services for archival information and then constructing a relevant service network framework 56 the highquality development of smart file construction needs to be integrated into the construction of smart cities with the humanistic concept of benefiting the people 57 the digital transformation of urban construction archives is conducive to the planning and construction of smart cities reducing the corresponding approval links through intelligent innovative services improving the legal administration system promoting intelligent administration and intelligent services and achieving the government affairs goal of onenetwork management 58 conclusions in this paper the selected literature data were limited to the cnki database and international databases were not comparatively studied which makes the research data sample too localized and does not truly reflect the international value of chinas smart city research in the next step of our research we should strengthen the use of international databases to promote the international integration of chinas smart city research discourse system smart city research has attracted extensive attention from many disciplines including urban science management science geographic science urban sociology economics and other multidisciplinary fields chinas smart city research focuses on the essential connotation historical development influential factors logical framework industrial application and other fields of smart cities in the future the research on smart city construction should focus on the practical exploration of interdisciplinary system integration urban digital simulation dynamic mechanisms and so on 59 through highfrequency keyword cooccurrence and cluster analysis we visually measured the smart city research literature from 2009 to 2022 reflecting the research status of related topics of a smart city in china the construction and development of a smart city can be summarized by the following aspects first the research theme of chinas smart city shows a tendency of scattered fragmentation to a certain extent there is no unified framework for domestic smart city research which shows that smart city theory is in the initial stage of exploration and its connotation essence has not reached a consensus and the smart city framework under different theoretical frameworks is also different among them the construction of smart cities from the perspective of system theory generates a holistic intelligent system through the coupling of three major systems physical city social city and digital city so as to realize digital sustainable development and creative city construction 60 from the perspective of urban development a smart city is an organic and unified development model such as the economy society and ecology and its development path realizes the development and construction of a smart city through the interaction of urban citizen knowledge environmental intelligence and technological intelligence 61 from the perspective of the urban operation mechanism a smart city is a new concept and new model that uses convergent technologies such as big data cloud computing and artificial intelligence to promote intelligent development such as urban planning construction and services second the law of smart city construction and development needs to be further explored for example urban governance especially the governance of megacities needs to explore a social governance path that conforms to the characteristics of the development laws of megacities pay attention to the construction of a digital and intelligent urban governance system improve the level of urban services and make cities more agile intelligent ecological and livable at present population aging has become a development trend in china how to use big data to drive the precise and intelligent development of the traditional pension model has become a real problem the big data platform can accurately meet the needs of the elderly and guarantee that the flow of data capital and service is coordinated and unified the allocation of resources is optimized and the healthy and orderly development of the aging society is realized 62 third the philosophical humanism and ecological ethics of smart cities need to be systematized the risks encountered in urban governance in the digital era need to be considered from the overall nature of urban society and issues such as technical risks and the nature of human practice should be examined from the perspective of urban ethics to provide reasonable space for the innovation of the coconstruction system of smart city construction 63 the coating theory of chinese scholar professor chen zhong provides a corresponding theoretical framework for humanistic city research and it is of great benefit to avoid alienation and coating formalism 64 urban smart life is the combination of a smart city and an ecological city and it is an inevitable trend of future urban development there is a need for the construction of smart cities to follow the perspective of the ecological environment in the process of the digital transformation of a smart city for example the lowcarbon travel of shared bicycles contributes to ecological environment governance through the analysis of relevant air quality testing data the practical value of a smart and green city is presented 65 fourth the organic life form of a smart city needs to be nourished by theories related to global cities innovative cities and urban innovation the world city a product of globalization is undergoing a transformation into a digital intelligent organic city life form a process that will inevitably bring about structural changes in society which will in turn affect the industrial system of the urban space and issues such as citizen participation the organic and innovative smart city is a system in which innovation agents mechanisms and environments interact with each other with intrinsic dynamic mechanisms driving the sustainable economic social and cultural development of the city finally smart cities may reshape the future of urban development and the technocraticinduced critique of smart cities will become a new model for the vision of neoliberal urban governance with the rise of the critical discourse on smart cities the framework of the smart city vision needs to be redefined and combined with a case study of the smart city in cologne germany to demonstrate social innovation and the future changes of sustainable cities that are genuinely smart 66 smart city ecosystem is a multilevel complex structure how to govern a smart city not only requires digital intelligent technology system as support but also needs to pays attention to the problems and challenges faced in daily life 67 the discourse system of technologydriven smart cities has created the emergence of technological determinism so the critical discourse of humanistic dimensions in specific spaces is conducive to technological innovation in urban development and the creation of the humanistic attributes of urban life 68 data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation author contributions data curation jt formal analysis cz writingoriginal draft yx writingreview editing wl all authors have read and agreed to the published version of the manuscript

smart cities are the future development direction of cities and are a comprehensive expression of the development of the organic life body of cities the organic life form of a smart city relates to viewing the city as an organic life selforganizing system based on the wholeness and systemic nature of the smart city life form itself to construct a holistic spatial linkage of the functions and mechanisms of the city life system and to enhance the overall vitality of the space this study is based on the literature of smart city research in the china national knowledge infrastructure cnki database and the current situation and related themes of smart city research in china are discussed through coword analysis and cluster analysis using software such as spss and vosviewer among which there are four themes in coword cluster analysis namely intelligent technology supporting smart city research research on the integration of the social system of a smart city research on the toplevel strategic design and planning and construction of a smart city and research on the development evaluation and concrete practice of smart city construction four conclusions are drawn from the development of smart city research in china firstly smart city research has attracted the attention of multiple disciplines and the research themes are scattered and integrated across disciplinary systems secondly smart city construction development rules and characteristics need to be further explored and the problems future trends and policy support for the modernization of chinas cities and towns have been focused on engineering and technology with a lack of practical research in nontechnical areas such as humanities and ethics thirdly the philosophical humanism and ecological ethics of smart cities need to be systematized and their construction and development needs to be humanistic systematic and comprehensive thus contributing to the sustainability livability ecology and wisdom of future urban development fourthly the development of the smart city system is supported by theories related to global cities and innovative cities and the world city a product of globalization is undergoing a transformation into a digital and intelligent organic urban life form

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during the rana regime the darkest period of nepal yogmaya confronted many hurdles in her early life like childhood marriage as she was married at the age of 7 to iswar padhyeya koirala from dhollekhani bhojpur after two years she left her home as she could not tolerate the behaviors rendered to her and reached her parents home at the age of 13 she left her home for assam and got married to a kandel after some years she became a widow after that she challenged her social status quo by getting married to a dotel brahmin she bore him a daughter named nainakala after some years she again faced the tragic event ie the death of her husband again then she renounced the family life and came back to her birthplace and began the life of austerity yogmaya gave voice to the voiceless women lower caste people the exploited and the discriminated ones when the entire country cowered to rana rules aziz argues that her words resound the sensitivity of all common folk people have common needs joys and suffering the tears she speaks refer to the laments of men and women bound against their will by societys caste rules aziz remarks that caste rules and laws destine some to be lower and poorer and to thereby suffer much deprivation in a society in which people are strictly and irrevocably distinguished at birth according to the caste membership of their parents this invocation is sheer heresy her ideal of intermingling was possible only if caste differences were abandoned yogmaya called for her people to engage in unfettered reciprocity through nurturing marriage and all other social exchange yogmaya undertook a poignant protest against rana rulers brutal behaviors and activities as well as social evils through her sarvartha yogbani published from assam posthumously she condemned caste discrimination corrupt brahmins money lenders and the rulers through the medium of religious hymns poems and songs neupane established the first organization of nepali women nari samiti in 1918 ad the committee under the leadership of neupane launched its activities against social ills and woes like child marriage polygamy injustice corruption blasphemes gender and racial discrimination and so on in very short time more than 2000 people became her disciples who were committed to her mission within a few years of its activity the committee submitted a 26point petition demands stating womens problems to rana prime minister chandra samsher who later abolished the tradition of sati practice in which a woman who used to burn herself alive on the funeral pyre prepared for her dead husband in 1936 she had pilgrimage to the pashupatinath temple in kathmandu where juddha shamsher came seeking blessing from her she demanded truth dharma rajya alms with him she also warned the rulers that apocalypse was near for them juddha shumsher assured her that the demands would be met but the assurance was not transformed into action and yogmaya along with 240 disciples made plans for mass immolation so as to rock the rulers conscience before they could commit immolation they were arrested and jailed in dhankuta and bhojpur she became the first nepali woman rebel imprisoned on the allegations of misleading people and thereby eroding the fabric of social order after four months of her imprisonment she was released she resumed her protest for social justice and good governance once being very upset by her holy activities the corrupted the feudalists and the conspirators sent five naked yogis to slay her but they got shocked with her immense power of magic and returned without doing any harm to her instead they begged pardon with her admiring her word power because of her mesmerizing and magical power people used to surrender before her regarding her as the goddess of truth humanity and harmony later being harassed from the activities of rana rulers who put deaf ear to her demands of good governance and social reformation yogmaya along with her 68 disciples took jalsamadhi plunging into the raging arun river from a huge rock attached to it at majuwabesi nepaledanda bhojpur on july 5 1941 it was her trenchant protest against social evils prevalent in contemporary society social revolution in sarvartha yogavani yogmayas sacred work sarvartha yogavani holds the mirror of contemporary society as it depicts different social evils like the oppression and suppression of woman including child marriage polygamy deceptions black mailing corruption racial and gender segregation and discrimination social injustice untouchability and so on through the medium of hymns religious songs and lyrical poems yogmaya attacks corrupt brahmins money lenders sellers of rudrakshya iron rules of rana regime common folks who are obsessed in hoarding wealth through foul means her yogavani aims at making social reformation at large she makes sarcastic remarks upon the brahmins who hold themselves superior to other castes and plunder the poor and the helpless barbara nimri aziz says her first target was brahmanic system propagated by brahmin priest that gives privileges to few and makes rules that enslave the rest and women of all castes she lodges her protest against brahmins and rana rulers against their graft through the poetic version she details out the hypocrisy and shortcomings of brahmins who make rules and exploit the poor and the marginalized groups in society on the other hand she makes satire upon the brutal reign of rana rulers who exploit the people and get indulged in corruption rampant corruption in rana regime becomes another subject matter of her lyrical poem she further flashes out against the corrupted rulers ctosfndf tof 3 n km6fpnf wff hf fat bellies burst our j8f si6 ldnl hfnf tof 3 lgsl hff bf and those bribes ooze out clxn dfq kr sf 5 e krg 5 g yogmayas lyrical verses have the implications of her call for selfreformation of brahmins who perform immoral unethical and fraudulent activities in the name of hindu culture and traditions her major focus centers upon the selfdiscipline of brahmins and priests her religious idioms are quite appropriate to her time and culture the next consecrated endeavour yogmaya undertakes is to eliminate caste system untouchability racial and gender discrimination despite the fact that she belongs to the clan of brahmins she vehemently denounces caste systems ever persisted in her society she poses her excruciating assault upon the caste system cl3 d f hft lyof before i owned a caste a fdx0f s n df belonging to brahmin clan clxn d f hft 5 g now look i have no caste fv5 r n df ho i chucked it there in the hearth mahatma gandhi demonstrates the way to common people to struggle without violence he breaks the system of indentured indian labor in south africa he fights color and racial discrimination everywhere he lays the foundations for a national language which brings men close together regardless of creed caste or race he supports the sick and the helpless to through kindliness and selfsacrifice against age old prejudice he raises a crusade for the human rights of numerous untouchables opposing the bigotry and dogmatism and the hateful orthodoxy of the caste system gandhi repudiates caste system i have frequently said that i do not believe in caste in the modern sense it is an excrescence and a handicap on progress nor do i believe in inequalities between human being we are all absolutely equal but equality is of souls and not bodies hence it is a mental state we need to think of and to assert equality because we see great inequalities in the physical world we have to realize equalities in the midst of this apparent external to realize equality in the midst of this apparent external inequality assumption of superiority by any person over any other is a sin against god and man thus caste in so far as it connotes distinctions in status is an evil it is because of her strong protest against caste system yogmaya garners the supports of thousands of people especially from dalit communities yogmaya sitting with the people of dalit community shares food and drink unhesitatingly which culminates the wrath of few elitist upper castle who go against her sacred mission since the hearth symbolizes exclusiveness one can find no place more outrageous than the hearth to toss caste into this simple quatrain advocates nothing less than shrugging off ones brahmin caste which implies doing away with all caste her poetic lyrical version shows the caste discrimination she confronts herself c7f k f0f gf jofs0f eighteen puransnine vyakarnas olx r t hljsf j rfs in 1955 a black woman rosa parks was arrested because she did not give up her seat to a white person on a bus this incident made many blacks angry they made a trenchant protest by boycotting the city buses king led the protest of boycott in the 1960s king and his organization started more protest march in washington dc hundreds of thousands of americans black and white took part at the lincoln memorial he held his most famous speech i have a dream more than 200000 blacks and whites gathered before lincoln memorial to hear the speeches and protest against racial injustice king makes a plea for racial justice and freedom against segregation and discrimination i have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character i have a dream that one day on the red hills of georgia the sons of former slaves owners will be able to sit down together at the table of brotherhood i have a dream that one day even the state of mississippi a desert state sweltering with the heat of injustice and oppression will be transformed into an oasis of freedom and justice for a large segment of negro community the social use of protest is viewed as the ultimate device for social change protest at best is an interpretation of the historical struggle going on around us which not only points out the rank inequalities in the distribution of democratic liberties but the reaffirmation of a group to advance then social protest is all too simple a formula for the intricate complex problems of negro community in their struggle for equal citizenship and material wellbeing furthermore in some instances social protest is not only calculated to produce immediate change but is often nothing more than a safety valve for pent up frustration and resentment against institutions and social malpractices yogmaya also points out the fraudulent activities of senior officers and administrators through her lyrical verse wd deml ljrf ul ogfkm u g though right was on our side k f ep ax nfo b08 k g that bully escapes the law s n t xfd f a fdx0f xf 5 gf s n df brahmins we are so unholy hft tf to 5 g xfd f fv r n df ujfgl lets leave our caste in the kitchen yogmayas lyrical verses depict the fraudulent activities of higher officials and politicians who being tempted with money never grant justice to people instead they exploit suppress people and become affluent through unfair means hflubf nf el 5g gofo x b gg holding the universal perspective of mortality and fleeting human life yogmaya reprimands senior officials and politicians for their injustice to common people pleading for truth she surrenders to lord vishnu for the recovery of truth justice harmony and homogeneity it has note of satire against political and social status of contemporary society brahmins and political leaders and the money lenders who lend money to the poor on high interest rate are subject to her criticism money lenders deceive common folk through foul means taking advantage of their illiteracy and ignorance she attempts to figure out the disparity between haves and haves not the feudal class becomes prosperous due to the exploitation of the poor bf nltof x g eof tolx lgwf af6 you became rich plundering the poor cffdln shf ltof td s 5 7f8 this man has paid the debt but the loan bill not torn 5f f lyof afns afa d 5 child was the son father was dead nf le fx dfug uof ltg k 5 ujfgl greedy lender went again to demand the loan yogmaya establishes the cheating on the part of money lenders and higher class she makes severe attacks against cheaters and their accomplices for their trickery and swindling she criticizes the rich for deceiving the laymen on the monetary transaction as it is against divine virtues most of yogmayas poetic versions are replete with religious teachings moral educations and due suggestions to common people even in the darkest period of rana regime in nepal she did not lag behind to castigate rana rules for their tyrannical she daringly puts 26petition demand to juddha smasher for establishing dharma rajya and eliminating social ailments despite the fact that she gets assured to ameliorate the social condition it does not come into action she mocks at the rulers wgo fh ltg sf your excellency you are so great nfld lbg5 afdaf yogmaya boldly rejects the offer made by the queen and advocates her message of truth and harmony she does not surrender before rana prime minister at the cost of truth and realism yagmayas plan to commit immolation is also a trenchant assault upon rana regime being befuddled and dismayed by rulers apathy to social revolution she along with her 68 disciple took jal samadhi in 1941 ad to bring shame to the government her death itself posed a great threat to the existence of rana regime

yogamaya neupane is a progressive poet a spiritual leader a social reformer a nirguna bhakti saint and a feminist revolutionary in nepal she wrote numerous lyrical verses referring to different social evils of her time this article attempts to explore the dynamics of social aberrations inherent in her lyrical verses sarvartha yogavani neupane launches her crusade against different social evils like corruption deception racial injustice caste discrimination fraudulent activities misuse of measurement etc through her sacred verses her verses echo the voices of the voiceless people she is the messiah of contemporary society through her verses she attacks money lenders corrupt bhramins rana rulers sellers of crops and rudrakshya job holders judges etc for their anomalies she adopts the bhakti path to launch her social protest against different social aberrations prevalent at that time the very dynamics of social anomalies of contemporary society are reflected in yogavani through which she attacks the different social agents against their injustice

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or human trafficking 4 although many international and national laws that prohibit child labor exist a tremendous number of children are struggling with child labor according to the united nations in 2020 218 million children were in employment of which 152 million were in child labor and 73 million were in hazardous work worldwide 45 the problem becomes even more apparent in the poorest countries as the number of children between 517 years old engaged in child labor surpasses 22 percent 6 worldwide most children work in agriculture representing 70 percent of all working children between 20122016 7 by gender boys and girls are both found to be almost equally affected by child labor with slightly higher percentages among boys 6 child labor has been strongly associated with various health and social consequences approximately 50 percent of working children are subject to hazardous work that can significantly affect their development 5 in the least developed countries over 25 percent of the children between 517 years old are doing work that is perilous to their health 4 exposing children to such kinds of works was associated with detrimental health issues including lack of growth poor nutrition increased rates of communicable diseases and illness behavioral and mental health disorders and injuries 8 9 10 the ilo had estimated that the worldwide incidence of workrelated injuries among children as 43 percent or 10 million injured children with 22000 deaths every year 1112 in the united states a child dies and 135 get injured every three days because of agriculturerelated work 13 in bangladesh 23 percent of working children had workrelated injuries 14 another study in a brick manufacturing industry in nepal found working children were eight times more likely to have musculoskeletal issues compared to nonworking group 15 egypt has agreed and ratified international regulations besides issuing several national laws that strict child labor 16 however the country still struggles with a high prevalence of child labor according to the ilo central agency for public mobilization and statistics national child labor survey ncls in 2010 18 million children were in child labor of whom 16 million were in hazardous work 17 approximately 63 percent of working children were in the agriculture while 19 percent were engaged in construction and manufacturingrelated work 16 earlier studies showed child labor in egypt was associated with substantial negative social and health consequences a study in 2019 found a positive correlation between physical and psychological abuse and higher rates of child labor in egypt 18 another study conducted in assiut egypt showed that financial hardship was a major driver of child labor the researchers also found that working children of less than 14 years old were more likely to suffer from psychosocial development issues such as anger management and lack of ego strength 19 likewise a study of working children in alexandria showed that 184 percent of working children have had at least one workrelated injury while 74 percent had over one injury 20 there is an ongoing need for evidence on the burden of child labor associated adverse consequences and the impact of policies and interventions this study aimed to estimate the prevalence of workrelated injuries and the associated determinants among working children in egypt a large fastgrowing lower middleincome population that combines the agriculture and industrial communities we hypothesized that this study could contribute significantly to the existing evidence on the health risks of child labor guide policies and interventions and support national and global efforts for combating child labor under the global sustainable strategy and egypt vision 2030 16 methods this study made use of egypts national child labor survey conducted in 2010 by capmas and ilo international program on the elimination of child labor through its statistical information and monitoring program on child labor 21 dataset access and acquisition for secondary analysis was requested from the capmas in the 2010 ncls a national representative sample of about 30000 households containing children aged 517 years was selected from a master sample developed by capmas in early 2010 about 163628 individuals successfully completed the survey of whom 66922 children were 517 years old sampling methods weights and survey estimates were explained in ncls 20l0 report 21 the questionnaire of the ncls comprised three main modules the adult questionnaire the household characteristics questionnaire and the child questionnaire the adult questionnaire was completed by the most knowledgeable individual in the household to get information about demographic and employment characteristics of all household members above 5 years old the household characteristics questionnaire was mainly used to assess the household socioeconomic characteristics the child questionnaire was administered to children 517 years old and comprised questions about their schooling engagement in employment unpaid household services and the health and safety conditions of their work the study sample was restricted to children in employment or working children aged 517 years who reported or reported by their parents at least one hour of paid or unpaid economic activity in the reference week economic activity was defined as any activity that produces a good or services for the purpose of market exchange own consumption ownaccount construction or production of fixed assets for own use the total number of working children aged 517 year as reported by either child or parent in the ncls was 7772 children representing 18 million egyptian children 21 the outcome of interest in this study was workrelated injuries among working children a workrelated injury was defined as an injury experienced by a working child because of hisher work in the past 12 months working children were asked to selfreport on injuries that occurred in the past 12 months because of their work accordingly the final study sample comprised 7485 working children who had responded to the workrelated injuries questions in the ncls child questionnaire based on the international conventions and national legislation in egypt children in child labor include all children in employment under age 12 years children 1214 years who were employed for 14 or more hours per week and children under 18 years who were engaged in hazardous work hazardous exposures in the ncls questionnaires were categorized into ergonomic and safety hazards chemical hazards and physical hazards data manipulation and statistical analysis were performed with spss for windows version 250 primary strata secondary strata and primary sampling units variables were used to create a complex samples plan to account for the complex sampling design in the ncls spss complex samples procedure was used to perform all descriptive bivariate and multivariate analyses using the complex samples plan data are presented in tables as unweighted sample frequency weighted percentages and its standard error and odds ratio and its 95 confidence interval we used a logistic regression procedure to test for bivariate and multivariate associations between workrelated injuries and study explanatory variables in bivariate associations we addressed missing data as a separate category while in multivariate analysis we excluded all missing data in different variables except for the highest school level variable in order not to lose much of the sample wald test of model effect was used to decide on the statistical significance of each the effect of each explanatory variable statistical significance level was set at 5 we followed the purposeful modelbuilding strategy 22 to identify the best fit model for understanding the determinants of workrelated injuries among the egyptian working children aged 1517 years testing for collinearity was first performed and showed no collinearity between any of the explanatory variables the full model included all significant explanatory variables at 010 significance level besides the important variables supported by the literature the decision of removal of an explanatory variable from the model was based on the significance of explanatory variables at 010 significance level and the significance of difference in 2log l between the smaller and larger models at 005 significance level the final model was the most parsimonious model that showed an insignificant difference in 2log l from the full mode we also tested for several interactions based on authors conceptualization of the study variables and literature however they were not statistically significant at 010 significance level and consequently we did not keep them in the final model results in table 1 7485 working children aged 517 years old comprised the study sample of whom children aged 1517 represented 475 approximately 76 of the study sample were boys and 848 were living in rural areas the lowest two quintiles of the wealth index accounted for 655 of all working children more than half of children were of 511 years old when they started work for the first time approximately 56 of children combined work chores and schooling while 115 were only working more than half of the children were engaged in unpaid family work and 641 were engaged in agriculturerelated economic activities twentyone percent of working children were experiencing long working hours while more than half of the children were engaged in hazardous work only 18 had received vocational training outside the schools table 1 also shows that workrelated injuriesin the past 12 monthswere reported by 241 of whom 873 were superficial wounds approximately 58 of the most serious injuries did not make children stop work or schooling while 396 temporarily stopped work or school and only 26 ended up with complete absence from work and school workrelated injuries were more frequent among older children boys children with primary and secondary or older education children living in urban areas lower wealth index starting work before the age of 12 years children who only work engaged in employment or unpaid family work in factories workshops or 1 in table 2 bivariate analyses showed that experiencing workrelated injuries was significantly associated with gender wealth index child activities combinations status in employment type of main economic activity and workplace average work hours per week hazardous exposures and receipt of vocational training however the final most parsimonious model indicated that the only significant determinants of workrelated injuries among the studied sample were the gender age at first time to work main economic activity workplace average work hours per week exposure to ergonomic and safety hazards and exposure to chemical hazards at work the odds of workrelated injuries were significantly 134 times greater for boys relative to girls the odds of workrelated injuries were significantly 161 times greater for children aged 511 years compared to children aged 1517 years the odds of workrelated injuries were significantly 245 and 227 times greater for children engaged in industryand servicesrelated work respectively compared to children engaged in agriculture likewise the odds of workrelated injuries were significantly 193 times greater for work at plantation farms or garden compared to work at dwelling regarding the hazardous exposures the odds of workrelated injuries were significantly 138 and 157 times greater for 2842 work hours and over 42 h per week respectively compared to less than 28 work hours per week likewise the odds of workrelated injuries were significantly 365 and 246 times greater for children exposed to ergonomic and safety and chemical hazards respectively compared to nonexposed children discussion this study has estimated the prevalence of workrelated injuries among working children in egypt as 241 which was largely higher than the ilo global estimate of 43 the study has also identified childrens gender age at first time to work type of economic activity workplace average work hours per week exposure to ergonomic safety and chemical hazards at work as the main determinants of workrelated injuries among working children in egypt these findings contribute significantly to our understanding of the burden of child labor and associated health risks which support the national and global efforts for combating child labor although the egyptian child labor law in 1996 bans the employment of children who are less than 14 years of age the result of the current study revealed that more than half of the working children had started their work early in their life compared by a study in alminia where 732 started work below the age of 10 years 23 in contrast the monthly labor review by bureau of labor statistics 24 showed that by the ages of 14 and 15 years the percentage of children working at some types of job increased to 57 and 64 percent respectively the bureau of labor statistics 2425 reported that hours at work for 16and 17yearolds have declined from a weekly average of 197 h in 2000 to 180 h in 2004 which compared by higher average in the current study where 609 indicated 27 working hours or less and 210 43 h per week which reflects the low socioeconomic status of childs family in an attempt to improve their income most of the working children in the present study were boys which was consistent with other numerous studies in jordan 26 bangladesh 27 and alminia in egypt 23 in the current study superficial or open wounds were the most common injuries and comprised 873 of all injuries followed by eyerelated injuries dislocations strains or sprains fractures and burns a study conducted in usa had showed that sprainsstrains were the most reported problem followed by cutslacerations contusionsabrasions heat burns and fracturesdislocations 28 another study among children working in the streets of four major cities in latin america found that approximately 396 of the children reported an injury sustained while working in the streets scratches cuts lacerations burns car accidents sprains and amputations 29 the difference between the current study results and others might be attributed to the nature of work as most working children in egypt were engaged in agriculturerelated work in agriculture work child laborers under extreme climatic conditions like searing sun and physical hazards for long hours with carrying of heavy loads need more muscular efforts lack of enough nutrition with longlasting awkward body positions with exposure to chemicals like pesticides and accidents due to using sharps like knives and sometimes heavy dangerous tools and machinery besides exposure to insects and wild animals 30 31 32 this similarly corresponds with claims of larsonbright and his colleges who observed increased risks of injury for agricultural working children compared to nonworking children 33 the largest proportions of fatalities among youth engaged in agricultural work are associated with the use of farm equipment or occurred because of drowning 34 high prevalence of child working in agriculture than other occupations as showed by reports of the human rights watch 2006 was estimated that in developing countries at least 90 of economically active children in rural areas are employed in agriculture 35 other studies in different areas in egypt concerned with labor among students aged 1318 years found that 527 of students worked in agricultural duties 233236 this percentage is lower when compared with that found by ilo statistics from 20 developing countries the proportion of children aged 5 to 14 was74 37 this could be attributed to in many rural areas where farm work is the main job many parents believe children will receive more useful training by working on farms than they would in the classroom as well as in egypt economic and social factors have been cited as being responsible for the increasing prevalence of child labor current study results disclosed that the poorest children accounted for most of working population which are consistent with a study in jordan among working children reported that most children work to learn a skill and help their families this makes scarceness and socioeconomic situations as the main reasons for child labor among this study population this also corresponds with claims of ilo that socioeconomic status has a significant role in exacerbating the child labor phenomenon in the world 37 a systematic review conducted upon 25 publications about child labor concluded that the physical and mental wellbeing of working children was adversely affected besides other behavioral disorders 8 studies investigated the prevalence of general symptoms in working children in pakistan egypt lebanon jordan and indonesia had showed that child labor is negatively associated with health 8 watery eyes chronic cough and diarrhea were common findings besides the history of a major injury that lead to work or school absenteeism 2326 38 39 40 child labor was positively associated with body injury and burns and other health problems 27 our results showed that the younger the age for starting work the greater odds for workrelated injuries young children and adolescents bodies and internal systems are still growing and maturating till age of 18 although anatomy physiology and psychology differ from adults these differences may translate into unique risk factors for occupational injuries and illnesses there is a great variation between adults and children in size a lack of fit between machines and the physical dimensions and strength of children and adolescents contributes to increase risk of injury the sleep requirements of children and young youth were different for those in adults and sleep deprivation can attribute to injuries or occupation illnesses multivariate analysis in this study identified childrens gender age at initial work type of economic activity type of main workplace long work hours and exposure to hazardous exposures at workplace as the main determinants of workrelated hazards among working children however a study conducted in brazil showed that age gender smoking school attendance sports activities use of computervideo gamestelevision domestic activities care of other children and care of sickelderly family members work activities and workloads associated with musculoskeletal pains and symptoms 41 other studies concluded that the lack of work experience workrelated training and supervision increase the risk for work injuries and illnesses among children and adolescents 4243 this study had some limitations that need to be acknowledged first identification of workrelatedness of injuries relied only on childrens judgment and ability to recall over a long period particularly most of selfreported injuries in this survey were minor injuries which increases the potential for recall bias second this survey had no data on mechanisms or causes of injuries which limits the ability to make inference on the risk for occupational injury third a difference between reported economic activities in the past week and workrelated injuries in the past 12 months may pose some limitations with the observed association between current work exposures and past injuries finally this national survey is over 10 years old and may pose some limitation for the generalizability of survey findings to the current population however this survey is the latest national child labor survey conducted in egypt which provides a nationally representative data for about 171 million egyptian children aged 517 years conclusions children in employment or working children is a challenging phenomenon in egypt and other lowand middleincome countries the global and national struggles in combating child labor emphasize mainly on its worst forms however workrelated health risks such as injuries are important for all forms of work among children this study highlights the prevalence and determinants of workrelated injuries among children of 517 years who were engaged in employment the study estimated the prevalence of workrelated injuries as high compared to the global estimates the study has identified the gender age at initial work type of economic activity type of main workplace long work hours and exposure to hazardous exposures at workplace as the main determinants of workrelated injuries among working children these findings could guide policies and interventions to combat child labor and the associated health risks including workrelated injuries in egypt and in other lowand middleincome countries the findings from this study could inform policies and employment standards for all forms of child work particularly in terms of new regulations or enforcement of existing regulations related to agespecific works age allowed to work work hours the type of work safety standards and raising the awareness among individuals institutions and society funding all authors did not receive any specific grant for this manuscript from funding agencies in the public commercial or notforprofit sectors open access funding provided by the science technology innovation funding authority in cooperation with the egyptian knowledge bank competing interests all authors declare that they have no competing interests as defined by bmc or other interests that might be perceived to influence the results andor discussion in this paper

background egypt has agreed and ratified international regulations that strict child labor however the country still struggles with high prevalence of child labor and the associated negative social and health effects the objective of this study was to identify the prevalence and determinants of workrelated injuries among working children in egypt

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introduction hiv transmission events cannot be explained solely by individual risktaking behaviors numerous studies in the 1990s and early 2000s have shown that sexual or injecting networks also play a crucial role the rate of transmission and the social and behavioral distribution of who gets infected are determined by the known and knowable structures and dynamics of sexual and drug use networks friedman et al introduced their big events theory during the last decade as a thesis designed to give an insight into the complex pathway and interrelationship of factors at various levels that can result in hiv transmission or in other epidemics of infectious agents they coined the term big events to describe transitions and serious economic crises but also wars and ecological disasters friedman et al exemplified their model through the large hiv epidemic among people who inject drugs in postsoviet russia and discussed how the political transition during the 1980s and 1990s was followed by economic instability deepening poverty changes in the effectiveness or content of normative regulation and by youth alienation creating an hiv risk environment characterized by growing alcohol consumption and injecting drug use sexual hazardous behaviors and female sex work and thus paving the way to a largescale epidemic on the other hand however due to the mixture of causal patterns1 plus random chance big events do not always unleash hiv outbreaks in the philippines in the 1980s and in argentina in the late 1990s to the early 2000s the serious political and economical crisis and the following social unrest did not result in increased hiv spread the big events model provides reasonable pathways to explain hiv transmission in complex situations although many of its components deserve further research and more generalizable evidence wars transitions economic collapse and ecological catastrophes differ in their nature and in many of their effects on peoples and communities but there are some social and economical parameters that are often influenced by them destabilizing events can cause the destruction of housing force population displacement disrupt or harm economic processes produce economic difficulties in many population layers incur changes in law andor public policy promote police violence weaken disrupt or destroy medical and other services and trigger social mobilizations insurrections and intercommunal violence which in turn impact on norms and values the social organization of gender and sexuality youth alienation social and risk networks and of course on behaviors as a consequence even in the short term the riskiness of behaviors may increase or more people can engage in highrisk practices and in denser drug and sexual networks sexual or injection events that result in hiv transmission are embedded in sexual and injection partnership patterns and community networks the big events theory also focuses on the risk event per se and discusses proximate causal factors that affect the probabilistic functions of one partner being infected and the other not and of their involvement together in a risky sexual act or injection that leads to a new hiv infection finally the theory also takes into account the fact that autonomous actions and local struggles of activists and atrisk people to protect themselves2 and others against damages and to keep their welfare might help vulnerable individuals or groups resist sexual or druguserelated risk greece has been experiencing a tremendous economic downturn and this has been accompanied by periods of considerable social movement activity and conflict at around the same time a lowlevel hiv epidemic among drug injectors before 2011 was followed by a tremendous outbreak of almost 1000 new hiv infections in less than 3 years little however is known about how the macrolevel economic changes in greece precipitated hiv spread in pwid we will try to understand how the big events in greeceif they have done soinfluenced sexual and drug injection behaviors and also how they have affected the size turnover and topologies of risky networks since these affect the probability that a susceptible person will engage in sexual or injection behaviors with an infectious partner we will attempt to identify what kind of information is needed to develop a better sense of whether the big events model on the greek paradigm is meaningful and usable in addition further consequences of the current crisis may be yet to come we will thus consider hypotheses about the recent outbreak examine evidence about potential hiv spread to and in other population groups discuss ways in which the crises might create serious socioepidemiological vulnerability in the long term explore opportunities for further research and finally discuss how these thoughts might guide prevention strategies methods this paper reviews the existing literature and used published information to formulate hypotheses and make suggestions for future needed research in addition preliminary data on 128 participants of the transmission reduction intervention project in athens greece are being reported trip is a 5 year multidisciplinary intervention funded by the united states national institutes of health in 2012 and is being implemented in three sites athens odessa and chicago the research protocol has been reviewed by the institutional review board of the national development and research institutes in new york city and by local irbs all participants are asked to sign an informed consent form big events in greece background greece is a southeastern european country of around 11 million people it is a member of the european union and has belonged to the euro zone since the early 2000s greece experienced substantial economic growth in the 1990s and the early 2000s which improved peoples prosperity and reduced to some degree economic inequalities despite being in crisis even in 2013 greece ranked close to the average on many topics measured by the organization for economic cooperation and development better life index as an eu member it also became an attractive destination for migrants from developing areas who were seeking a safer and prosperous working environment and an entry point to the rest of the eu despite these timelimited economic achievements greece has a history of corruption and indebtedness that dates back to the birth of the modern greek state greece was recognized as a sovereign entity in 18291830 following the revolution but the greek people became highly dependent on local elites middlemen speculators and external creditors as a price for gaining political freedom build on the ruins of ottoman empire the greek state was later involved in many local and imperialist wars which along with civil conflicts and periods of authoritarianism corrupted governance and political malpractice had adverse consequences on various economic and social parameters excluding the current financial downturn greece has already experienced five defaultrescheduling episodes spaced some years or decades apart and rather amazingly stood for half of its sovereign existence in default or rescheduling the period following the 19671974 military regime was politically stable and characterized by a bourgeois parliamentary democracy the participation in eu the gradual growth of gross domestic product and the moderate improvement of living conditions nonetheless the economic success was not the result of autonomous and sustainable economic development but rather a domesticdemanddriven explosion based on excessive optimism capital inflowsdriven cheap credit particularly after euro circulation and fiscal profligacy the prominent features of the 1990s and 2000s were the enormous public external borrowing the huge government and private debt and increasing fiscal deficits from year to year the recent crisis after many years of development in 2008 the real gdp growth rate in greece decreased as a consequence of the global financial crisis the financial distress soon turned into economic and political turbulence in 2010 the situation became worse when the greek government imposed harsh austerity policies and made the first cuts to public expenditures even though the government deficit as percent of gdp has been reduced from 157 in 2009 to 89 in 2012 the greek economy shrank for 6 years in a row with a total gdp squeeze of more than 20 in spite of a big restructuring of the greek debt in 2012 government finances still deteriorate the public debt was 304 billion euros in 2012 and reached 319 billion euros or 175 as share of gdp in 2013 the unemployment rate rocketed from 77 in 2008 to 273 in 2013 being the highest in the eu youth unemployment now over 50 is of particular concern and forces talented and highly trained young greeks to seek a professional career abroad early in the crisis era by 2010 almost one quarter of the greek population was at risk for poverty with income below 60 of national median and was experiencing serious material deprivation attacks against labor and social rights by three single party or coalition governments in 4 years resulted in massive demonstrations numerous union and general strikes and many spontaneous gatherings mainly in athens but also in other populous cities that culminated in a huge summer protest at the central syntagma square near the greek parliament the workers response despite being vigorous in absolute terms having its roots in the longstanding traditions of grassroots and leftist movements during the previous decades was disproportionately low compared to the magnitude and the negative consequences of the imposed policies working peoples resistance was attacked rather brutally by the police and was undermined by the efforts of union officialdom and seems now to be subsiding during the crisis years greece also observed the rise of the major nationalistic group who won 18 seats in the greek parliament in the legislative election of june 2012 and finished third in the recent election of the delegation of greece to the european parliament receiving 9 of the popular vote on the other hand massive antifascist protests have also been observed along with the growing popularity of one of the leftist parties who won the 2014 european parliament election and its platform supports human rights and prioritizes the needs of vulnerable and marginalized sections of the greek society nonhiv health consequences as part of greeces austerity cuts public spending on health should not exceed 6 of gdp these cuts included reductions in public spending on drugs decreases in workforce cuts in salaries of health care staff changes to purchasing of health services closure of facilities and restructuring of the public hospitals sector compared to previous years public health spending declined by 1239 in 2010 and by 1238 in 2011 in a country with a household netadjusted disposable income per capita of around 19000 us dollars that is even lower in poorer groups and almost 5000 usd less than the oecd average costs have been gradually shifted to patients by instituting user charges for public health services general public hospitals that were performing better than notforprofit competitors now need to face elevated demand and service utilization with dwindling resources which created increased workloads and long waiting lists especially in emergency rooms the linkage between health coverage and employment status in greece has been a critical issue given the tremendous unemployment especially among youth the inability of the selfemployed population to cover social insurance costs and a limited period of entitlement to unemployment benefits a large pool of uninsured people has gradually been created whose access to and receipt of essential treatment and care is endangered various scientists and organizations described the early effects of the economic crisis in greece and other european countries early reports from greece provide estimates of annual or biannual increases in suicides between 19 and 40 homicide rates also increased by 25 between 2007 and 2009 research based on telephone surveys in 2008 2009 and 2011 reported an increase in the prevalence of suicide attempts from 06 in 2008 to 15 in 2011 the 1 month prevalence of major depression also escalated from 33 in 2008 to 68 in 2009 and to 82 in 2011 following a steady decreasing trend from 2001 to 2008 infant mortality in greece increased in 2009 and in 2010 and remained higher in 2011 and in 2012 compared to 2008 a recent letter reported also a 32 rise in the number of stillbirths during the last years in greece surveillance data indicated substantial increases in some infectious diseases in 2010 the first clinical cases of westnile virus infection were documented in humans in central macedonia and the virus has since spread southward affecting the metropolitan area of athens which may herald a longterm establishment in greece following decades of zero reports between 2009 and 2012 62 locally acquired malaria cases were identified particularly in a welldefined agricultural area although there is no clear evidence to connect the appearance of wnv infection and the reemergence of malaria with the economic instability in greece the increased epidemiological numbers of these two mosquitoborne diseases during the crisis epoch are very important and given the unique regional conditions in some areas constraining resources and vectorcontrol measures could facilitate their transmission with unpredictable consequences hiv epidemic the hiv epidemic in greece was traditionally concentrated in men who have sex with men before 2011 sporadic hiv cases reported among drug injectors ranged between 10 and 20 per year early in 2011 the hellenic centre for disease control and prevention received hiv reports in excess of expectancy and finally by the end of that year 266 drug injectors had been diagnosed with hiva 16fold increase compared to 2010 at the beginning of the outbreak the hcdcp tested 62 samples of drug injectors diagnosed in 2011 using avidity assays which documented that the majority of infectees had acquired the virus quite recently most of the newly diagnosed pwid in 2011 were residents of athens suggesting that the outbreak was localized there in treatment facilities the picture also indicated a large outbreak the percentage of hiv positives among drug users contacting treatment services in athens increased to 8 in 2011 from less than 2 in 2010 in 2012 hiv continued to spread in drug injectors547 new infections were diagnosed among them during the same year the total number of hiv reports reached a historical peak and injecting drug use became the most frequently reported probable route of transmission in august 2012 a respondentdriven sampling program named aristotle began in athens consisting of five successive rounds of hiv screening during the first round 1404 drug injectors were tested and around 20 were hiv positive in collaboration with the new multidisciplinary trip project most first round positive samples were further tested by limitingantigen avidity assay which showed that approximately one fourth of positives had acquired hiv recently perhaps within 46 months from their diagnosis molecular analyses on pwids samples in 2011 and in 2012 revealed transmission networking in more than 90 of them in high contrast to extremely lowlevel clustering before 2010 in addition new hiv strains have been circulating in the infected drugusing population during the outbreak years taken together these data further support the newness of the epidemic and the large hiv spread in drug injectors in 2012 surveillance data for 2013 suggest that hiv transmission in drug injectors may have started to decrease a total number of 262 hiv infections was reported in 2013 in pwid which is lower than the 547 reported in 2012 although surveillance numbers are influenced by testing and reporting patterns it is likely that despite cuts in health spending largescale responses of health agencies universities and nongovernmental organizations may have reduced hiv transmission prevention coverage before the start of the outbreak fell far short of internationally recommended standards big events and the hiv epidemic in greece hypothesized partial model of pathways from the economic crisis to hiv transmission in pwid has the economic crisis as a big event contributed to the hiv outbreak in pwid it may well be true but it is difficult to describe the pathways through which that occurred given the lack of studies to collect necessary information we can nevertheless formulate reasonable hypotheses based on the evidence we now have we have already conducted ecologic analyses that connect the economic crisis with the recent hiv outbreak among drug injectors in greece by using regression models we found that the diagnosis rate of hiv in drug injectors was increasing while gdp was declining in addition we observed significant associations between gdp growth rate and a couple of other variables including hiv prevalence in pwid in athens hepatitis c virus prevalence in new injectors and the homelessness and unemployment rates in pwid in athens furthermore in the first round of the aristotle program in athens lack of stable accommodation was the most important predictor of hiv seropositivity it seems thus reasonable to assume that the general economic instability quickly affected vulnerable parts of the greek population like drug injectors and their families in athens many injectors who lost jobs or whose families became unable to support them had decreased income they likely became unable to pay rents or mortgages and thus became homeless and began to gather and live in the traditional central drug user settings of athens where as shown before the epidemic is confined unstable housing or the lack of accommodation has previously been connected with behaviors and network characteristics that result in hiv transmission it is likely that previously small networks of injectors both of greeks and of migrants started to mix in these localities the high hcv prevalence and the reportedly frequent sharing of injecting equipment among drug injectors who were contacting treatment services in the preepidemic period indicate the longterm presence of risky practices in the drugusing community we can argue that the limited hiv spread before 2011 could thus be either due to pure chance or more likely the result of selective sharing in small size networks the new conditions in the centre of athens brought together previously separate clusters of people thus increasing the size of risk networks as a matter of fact in the aristotle program unstably housed people did report larger network sizes it is also very important that the new environment allowed groups with different hiv prevalence to interact data from the first round of the aristotle project showed that hiv prevalence in athenian drug injectors from iranafghanistan was around 31 but was 19 among greeknational injectors furthermore molecular analyses identified four major transmission clusters in infected pwid who were diagnosed in 20112012 circulating recombinant form 14bg crf35ad subtype b and subtype a in one of these networks the most similar sequences could be found in iranafghanistan generally the geographic origin of most hiv isolates was consistent with the migratory waves in greece police operations in central athens against drug sellers and users that can result in relocation of pwid may have also facilitated the mixing of different networks to the best of our knowledge there are no studies that have measured injecting norms in greece which are very likely to be affected by economic turbulence however sharing injecting equipment was common before the epidemic boom and we can hypothesize that new and rapidly established normative rules in the street probably allowed sharing between otherwise distant ethnic groups with different levels of hiv the nsp coverage and control measures were at that time completely inadequate and could not stop transmission chains or contain the outbreak will there be further spread of hiv in greece among groups other than pwid mediumterm hiv risk associated with big events hiv outbreaks among nonpwid could happen due to spread from the pwid epidemic andor from greek big events shaping transmission within and among other subpopulations as of this writing there are more than 1000 pwid who have recently become hiv infected some of whom still have high viral loads as a result there is thus a high shortterm probability for hiv transmission from pwid to nondrug using heterosexuals and also to msm the extent to which this occurs will primarily be determined by efforts to reduce hiv infection among pwid and to get infected pwid into antiretroviral treatment the characteristics and magnitude of sexual networks and group sex events that connect pwid to heterosexuals lesbians and msm and the social network locations of those pwid who have high viral loads in addition rates of unprotected sex in these sexual networks will also help determine the magnitude of hiv transmission within them beyond that sexual networks group sex participation and sexual behaviors within each key population will shape the extent to which hiv continues to transmit within each of them it is likely that people who use drugs but do not inject them may be an important bridge population with high rates of sexual risk behaviors increased contact with pwid as a result of drug use and perhaps high rates of involvement in sex work we have a limited amount of data about sexual networks group sex participation and behaviors of pwid and about epidemic trends among msm and heterosexuals in aristotle information was collected on the sexual behaviors and partners of respondents including those who were infected with hiv at the time of their interviewand thus were potential transmitters of infection to others from the analysis of the first round when asked about the person with whom they last had sex 48 of men and 22 of women said their most recent partner had not injected any drugs this is very importantit documents sexual links between pwid and noninjecting population groups condoms were not often used by infected drug users in the first wave of the aristotle project around 40 of positive males and one third of positive females reported that they usually do not or never use condoms during vaginal or anal intercourse female drug injectors also engage in sex work with 37 of aristotle round 1 hivpositive women reporting sex in exchange for money or drugs the multidisciplinary trip project collects data about group sex events which can be considered as hiv risk and potential bridge environments that in nongreek studies have been found to involve widespread participation of people who take drugs by noninjection routes of msm lesbians and sex workers by midnovember 2013 128 individuals mostly drug injectors had participated in trip the sample included 20 recently infected pwid and their firstsecond degree contacts 4 longterm hiv infectees and their 2 first degree network members and 18 hiv negatives only 6 male participants reported that during the last 6 months they had been present when group sex was taking place among these six subjects four were hiv positive including three recently infected cases half of them said that they also had sex once in the group sex event place without using condoms therefore at the moment it seems that group sex is either not very popular in the druginjecting population perhaps because of the type of drugs used or is being underreported by respondents trip of course will continue to enroll subjects including their network members who may not inject or use drugs along with followup interviews we will soon be able to analyze a substantial volume of longitudinal data on group sex events that will help us draw firmer conclusions routine surveillance data offer little support of large increases having yet occurred in transmission rates in other population groups such as msm and heterosexuals although these patterns are somewhat uneven as shown in table 1 fewer hiv infections were reported in 2013 in pwid than in 2012 sexually acquired infections seem to predominate but the number of reports in 2013 both in msm and in heterosexuals still remain lower than the corresponding figures in 2012 if however we compare the 20122013 years with the preoutbreak period we observe that the heterosexually acquired hiv transmissions in the last 2 years are slightly more than those occurred in 20092010 none of these variables should be considered to be stable in a big events situation like that of greece in which both economic and political instability are high and in which many people face lives of increasing poverty the extent and social distribution of sex in exchange for money goods or a place to spend the night is likely to change so are popular norms toward what forms of sexual relationship are acceptable little is known about what the political economic and social future of greece is likely to be little is known about if and how changes in these will affect sexual mixing patterns norms or behaviors in the country nor about how such changes will affect the amount and social locations of hiv transmission and care research is needed on these issuesboth for the sake of the greek people and for that of other countries that face similar situations now and in the future will big events increase the size of the atrisk populations what is happening among youth and newly marginalized populations longterm hiv risk associated with big events the economic and political big events have now lasted for several years and may well continue for many years more they are likely to lead to many deep transformations in the lives of the people and to their forms of social organization and culture as we discussed in two earlier papers the consequences of these transformations for the future of the hiv epidemic after big events may be heavily mediated by the extent of youth experiencing despair over their future prospects and the related degree to which intergenerational normative regulation breaks down such that a large number of youth gravitate toward drug use sexual hedonism and perhaps toward trading sex andor drugs for money goods or services this mediation can be better understood in terms of cultural historical activity theory aspects of which appear in the chat processes box in the third column of figure 5 this points to complex and nondeterministic interactions among the activities in which they engage the intersubjective communication they engage in with their friends neighbors employers and other people including the ways in which this leads them to define their own and others life situations and the creative and routinized ways in which they respond to changes in their environment and activities in the current greek situation little is known about these pathways variables we have been collecting a small amount of pilot data on selected variables in the context of the aristotle and trip projects trip will soon start to also gather followup data and it will then be able to study whether some of these parameters changed over time nonetheless these pilot data will not suffice to make strong inferences and it is thus important to expand the measurement and include many other variables that will help us better understand the causal pathways to hiv transmission in the long term in the greek situation as discussed above there is a large hiv outbreak among pwid little is known about the extent to which greek pwid are parts of sexual networks with other drug users but based on data from the united states and other countries it seems likely that such network connections are fairly extensive in new york city for instance the stabilization of hiv incidence in injecting drug users was followed by a sexual transmission phase and equal prevalence rates between injecting and noninjecting groups to the extent network ties do exist between injectors and noninjecting people who use drugs in greece changes in the size of the nidu population may be one important determinant of the future of the hiv epidemic in greece discussion based on what we have learned from the greek hiv epidemic among people who inject drugs we can suggest some improvements in the theory of big events and their epidemiological implications we can also present ideas about what we do not know and about research that would be useful for us to better understand how big events can and do affect drug use patterns hiv epidemics and public health more generally we can conceptualize how big events affect hiv epidemics in terms of the potential for shortterm mediumterm and longterm effects in the short term these events may affect those key populations such as pwid sex workers other highrisk heterosexuals or msm among whom hiv is already present if this leads to higher rates of risk behaviors denser mixing patterns andor decreases in intervention programs that help reduce risk behaviors or help the infected to keep their viral loads low an epidemic outbreak may occur in one or more key populations in athens such an outbreak occurred among pwid once such an outbreak occurs it may remain concentrated in the given key population on the other hand depending on mixing patterns and risk behaviors in risk networks between members of the group in which the outbreak occurs and other population groups and on the extent and nature of interventions to prevent further hiv transmission hiv can spread to other key populations or perhaps become generalized it is not yet clear what will happen in athens figure 5 provides an overview of conditions that might affect this it is important to note that the network and behavioral patterns in this figure are not constant and may change as a result of the big events and their sequelae or in response to the hiv outbreak and programs to combat it big events may be able to spark hiv epidemics through a longer term path as well this can occur if the big events lead to changes in the social economic and cultural situation in a city or other region if such changes occur and lead to the formation or enlargement of subpopulations of pwid sex workers or people who engage in highrisk sex with multiple partners then conditions can be ripe for an hiv epidemic this is maybe what happened in the former soviet union and in south africa figure 5 provides an overview of how this can happen these same dynamics can of course occur in the same places where shortterm and perhaps mediumterm outbreaks have occurred in which case some or all of the key populations that may have epidemics within them may grow considerably in size andor epidemics that have been contained within one or more key populations may become generalized epidemics as is clear from our review of the hiv outbreak in athens very little is known about most of the pathways variables that are described in figure 1 or in later figures little was known before the epidemicand much remains unknownabout the normative pressures that influence the behaviors of key populations like people who inject drugs little is known about sexual network connections between key populations friedman and his colleagues have conducted one network study that presents an overview of such networks in one section of brooklyn new york but far more research of this kind is needed in general and particularly where big events occur the authors of this paper are currently conducting intervention research in athens that may provide more information about the sexual networks of pwid who have recently become infected with hiv for longerterm pathways little or no research exists for greece or other countries on most of the variables mentioned in the figures in this paper this is because measures have not been developed to accurately assess many of these variables ongoing research is attempting to develop and validate measures on many of the chat variables in figure 5 the questionnaires of the aristotle and trip projects also contain some of these scales on a pilot basis but certainly more research of this kind is needed in order to understand big events and their sequelae better it would be useful to have annual or biannual sociobehavioral surveillance surveys in a number of countries that would measure these pathways variables in key populations and among youth and others who might become recruited to highrisk behaviors if a big event occurs these would provide baseline data that might be useful in planning how to mitigate big events effects in those countries and that would also be useful in studies of what changed and how after the big events interventions to mitigate the effects of big events are likely to interact with the interests understandings and values of powerful economic and political stakeholders as well as with those of urban planners police agencies drug user treatment agencies and other institutions research is needed on how to mitigate big events effects successfully intervention failures as opportunities for learning and posited processes such as failure blindness have not been adequately considered in substance use intervention generally or within big events theory more specifically finally we need research on how to respond to big events both in short run terms and in the middle and long term to minimize their effects on hiv transmission and other health issues in immediate terms it is important to maintain or increase programs like syringe distributionexchange and drug user treatmenteven though the neoliberal response in times of economic crisis might be to reduce them in greece in spite of budget cutbacks nsp and ost programs were remarkably reinforced but it is crucial to improve them further to meet current and future needs it is also important to establish effective surveillance systems to monitor for hiv and other infectious outbreaks so as to enable early and ongoing interventions if they occur in greece the presence of phylogenetic surveillance procedures allowed much faster detection and description of the outbreak among pwid than might otherwise have occurred interventions to prevent transmission sexually from one key population to other people should be developed and implemented in addition as we learn more about what pathways lead to the growth of highrisk populations after big events interventions should be developed to minimize adverse consequences some of these might be politically controversial or difficult such as efforts to reduce police violence or to reduce stigmatization or social subordination of women foreign immigrants drug users or gays nonetheless as the examples of south africa and russia make clear the consequences of not acting in these ways can be public health catastrophes glossary big events transitions serious economic crises wars and ecological disasters the term refers to major events natural as well as manmade which effect adaptation functioning and qualityoflife of individuals as well as social relationships and systems existential threat instability and chaos are major dimensions and loss of control over ones life is experienced 2009 theorizing big events as a potential risk environment for drug use drugrelated harm and hiv epidemic outbreaks the international journal on drug policy 20 283291 in some cases such as with normative regulation and the organization of gender and sexuality and as with corruption and insecurity variables that fit together in homologous places in the system of arrows have been grouped together so the model remains readable note pwid people who inject drugs hypothesized partial model of pathways from the economic crisis in greece to hiv transmission among people who inject drugs arrows that are in bold represent associations for which there are supporting data once an hiv epidemic breaks out among people who inject drugs there are factors that may affect mediumterm spread of the epidemic to people who do not inject drugs these factors are not fixed but may change either due to the big events or in response to the hiv epidemic itself the oval represents people who use but do not inject drugs some evidence suggests that they are more likely than other nonpwid members of the population to have sex with pwid and also to engage in highrisk behaviors interacting pathways that may affect longerterm developments of drug use and of the hiv and related epidemics in greece pwid people who inject drugs chat cultural historical activity theory biographies georgios k nikolopoulos phd has received a postdoctoral research fellowship from the international aids society and the national institute on drug abuse and is now leading the transmission reduction intervention project in athens greece he earned a phd in the epidemiology of infectious diseases at the school of medicine of the athens university in greece and has served at the greek public health agency for almost one decade focusing on hiv surveillance dr nikolopoulos also has expertise in the conduct of systematic reviews and metaanalyses with useful contributions to the evolving domain of genetic epidemiology

big events are processes like macroeconomic transitions that have lowered social wellbeing in various settings in the past greece has been hit by the global crisis and experienced an hiv outbreak among people who inject drugs since the crisis began 2008 greece has seen population displacement intercommunal violence cuts in governmental expenditures and social movements these may have affected normative regulation networks and behaviors however most pathways to risk remain unknown or unmeasured we use what is known and unknown about the greek hiv outbreak to suggest modifications in big events models and the need for additional research

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introduction the hivaids pandemic underscores sexual health as a critical area of practice and research more than 35 million people live with hivaids and approximately 15 million aidsrelated deaths occurred in 2013 in the united states alone an estimated 11 million persons live with hivaids and one in six are undiagnosed and unaware of their hiv infection people who do not know their hiv status account for more than 50 of all new hiv infections and 88 of all hiv cases in 2010 were due to sexual contact including maletomale sexual contact and highrisk heterosexual contact and sex with a partner known to have or to be at high risk for hiv infection the world health organization notes that accessible acceptable affordable and highquality sexual health services are fundamental for achieving a sexually healthy society although effective hiv risk assessments and interventions are needed sexual health professionals including nurses lack a shared conceptual understanding of risky sexual behavior especially as it relates to increased risk of hiv transmission for the purposes of this paper we broadly view rsb as sexual behavior that increases ones risk for unintended sexual health outcomes but that definition is unhelpful insofar as the terminology surrounding sexual practices remains vague the lack of a clear shared concept of risk in relation to sexual behaviors may hamper effective sexual health assessment and the development of intervention initiatives and indeed there are no nationally established competencies for the definition and assessment of rsb as clinical competencies drive education and practice the absence of such standards has substantial public health implications considering that sexual behaviors account for the majority of all hiv cases adequately defining rsbs will provide an important contribution to hiv prevention in clinical practice during assessment and education with clients about reduction of rsbs screening errors may occur due to provider andor client stereotypes and providerclient misunderstandings for example while current clinical guidelines call for routine hiv screening of all clients aged 13 to 64 a dearth of open discussion the presence of provider assumptions or biases and discomfort discussing sexual topics by either or both parties can impede realization of these standards especially with youth and older adults and in age or gender discordant clinical encounters in a systematic review examining nurses preparedness to discuss sexual health issues many nurses were found to lack preparation and willingness to engage clients in conversations regarding the clients sexual health needs with respect to providerclient misunderstandings adolescents have been found to associate abstinence with refraining from heterosexual vaginal intercourse while failing to perceive that anal and oral sex are real sex in the context of health care and disease prevention in sexual health behavioral research the limited operationalization of hiv risk hampers the evidence base for applied hiv prevention science that is most behavioral hivaids researchers continue to focus solely on male condom use as an effective prevention tool even while the menu of available prevention options has expanded with emergent technologies such as treatmentasprevention preexposure prophylaxis microbicides and female condoms in response to technological advances clinicians and researchers who develop risk assessment and counseling tools should also consider strategies beyond the traditional but to develop effective new strategies health behavioral scientists must more clearly define how they understand and represent to their clients what sexual risk is and what behaviors contribute to it to elicit accurate information during sexual health assessments one needs to know which questions to ask clients andor research participants a working definition of rsb that encompasses a broad range of sexual practices that increase hiv risk as well as social mechanisms that amplify that risk would offer a starting point we begin this commentary by providing the evidence base and rationale for reconceptualizing rsb second we present themes from our critical review of the literature on social mechanisms highly correlated with increased rates of hiv transmission third we propose a definition of rsb that is appropriate across a diversity of behavioral contexts and sexual health disciplines lastly we discuss the relevance of this work to clinical practice our aim is to improve sexual health assessment and intervention through clear unambiguous communication between health professionals and the public we believe that sexual health professionals including nurses physicians community health workers health educators and other social service providers are wellpositioned to lead this paradigm shift we hope to strengthen practice and research initiatives by illuminating discrepancies among definitions that may influence clinical and scientific understanding of rsb the evidence base and rationale for change despite the frequent use of the term across various practice disciplines health behavior theory and research rsb has not been conceptually analyzed in scientific circles instead rsb is used nearly as loosely in scientific discourse as in everyday language carrying with it myriad implied cultural social and scientific meanings the ambiguous language becomes problematic when attempting to assess an individuals risk and promote protective behaviors because precision in the language of scientific inquiry enables both theory building and practice application a more exact definition of rsb would be an advantageous starting point for sexual risk health assessment and education a concise working definition of rsb and standardized assessment questions that align with current practice guidelines would facilitate the role of sexual health professionals in preventing sexually transmitted infections including hiv upon critical review of multidisciplinary hivaids literature however we noted that a specific shared definition is virtually nonexistent the absence of a standard definition for rsb poses two potential threats to public health and the promotion of a sexually healthy society 1 health care professionals are limited in their ability to conduct comprehensive sexual health histories and develop individualized risk reduction plans and 2 the general public may inaccurately identify the risk of sexual practices thereby increasing their susceptibility to hiv infection the cdc sexually transmitted diseases treatment guidelines states that effective delivery of prevention messages requires that providers communicate general riskreduction messages relevant to the client and that providers educate the client about specific actions that can reduce the risk for stdhiv transmission what constitutes safe sex and unsafe sex however has historically been categorized in different ways with emphases falling divergently on condom use or multiple sexual partners clarity in terminology is key to meeting clients needs during clinical exchanges yet misunderstandings and a breakdown in communication often occur in the clientprovider relationship clear definitions could reduce those break downs with the negative connotations surrounding risk and in the absence of a clear authoritative definition rsb may come to imply deviance and immorality to many recall for example the terminology formerly used to describe hivaids risk groups as the 4 hshemophiliacs heroin addicts homosexuals and haitians we posit that the metalanguage of rsbs may serve similarly to reinforce and perpetuate stereotypes and prejudices debates about the origin and subsequent trends in hivaids infection persist with hiv theories ranging from government conspiracy to witchcraft these beliefs and the stigmatizing ways in which aids has historically been defined result in distrust and misguided understandings about rsb given extensive documented evidence that hiv is transmitted sexually we argue that definitions and messages need to be clear and encompassing highlighting behaviors rather than identities and emphasizing that anyone engaging in sexual behavior is at risk although measures can be taken to reduce this risk indeed even in committed mutually monogamous relationships evidence suggests that exposure may occur if one or both partners break the commitment normalizing risk through a carefully articulated definition of rsb means clarifying that sexual activity quite simply always carries some threat not the stigmatized deviant threat of past stereotypes but a serious widely distributed risk that requires everyones attention three decades into the hivaids pandemic hiv risk perception remains loweven among individuals whose behaviors put them at increased risk as a health care community if we continue to define rsb within contexts of highrisk groups those outside the defined risk groups may fail to accurately recognize their risk of acquiring hiv and those who identify with the highrisk groups may mistake the source of their risk defining behaviors that place an individual at risk for hiv may be the better approach for example men who have sex with men are not at risk for hiv because of their sexual orientation but because of increased patterns of sexual behaviors that hold greater potential for hiv transmission more specifically rectal tissue is prone to abrasion during penetration and the protective humoral immune barrier in cervicovaginal secretions is absent in rectal mucosa anal sexual behavior places individuals at increased risk for contracting hiv regardless of gender or sexual orientation thus it is unprotected anal sexnot being a man who has sex with other menthat increases ones risk of hiv sexual behaviors rather than culturally delineated sexual identifications influence risk equally important because the typical prevention message is that msm are at increased risk for the virus women and heterosexual men engaging in anal sex may be misled to believe that their behaviors are free from risk while msm may not perceive that a range of other physical interactions available to them represent much less risky optionsthat in other words it is not sexual orientation but specific types of unprotected activity that defines their risk similarly africanamerican and latina women are not inherently more sexually at risk nor are euroamerican white women inherently less at risk because of their ethnic origins in fact there is no physiological association between ethnicity and heightened hiv risk increased rates of stis among individuals with membership in culturally defined groups and a public health focus on these specific populations give the impression that there are inherent connections between sexual health risk and ethnic andor racial identification and further contribute to objectification of these groups as hivaids has disproportionately affected racial and ethnic minority women and adolescents many resources have been devoted to identifying and managing rsb in these populations this is good in that it targets resources to a real need but without careful articulation the message such efforts send could lead men and women who do not identify ethnically with these groups to underestimate the risks associated with their behaviors and again may cause men and women who do identify with the risky groups to misidentify the source of their risk the conundrum of risk attributed to certain groups and not others and the weighting of rsbs differently by gender sexual orientation age and socioeconomic status has the potential to impede prevention efforts against the spread of hiv semantic and conceptual clarity are necessary to improve sexual health assessment and intervention we posit that the current categorization of risk unhelpfully and perhaps dangerously implies groupbased biases and reinforces historically stigmatizing associations sexual risk behaviors risky behavior problem behaviors risky sex and unsafe sexual practices are common often interchangeably used terms the national institutes of health defined rsb in relation to hiv transmission as sexual contact including oral with an infected person without using a condom and sexual contact with someone whose hiv status is unknown though most agree that unprotected sex is risky debate continues to arise elsewhere especially over the perceived risks of penetrating versus nonpenetrating sex and the risk of transmission in bonded partnerships where condom use diminishes as trust develops over time social mechanisms of risky sexual behavior an rsb definition with wide behavioral applicability may prove beneficial particularly to sexual health professionals who are developing strategies to reduce other undesired outcomes from sexual behavior such as unwanted teenage pregnancy and the proliferation of other stis effective interventions require an indepth understanding of what constitutes rsb and how these behaviors increase the risk of contracting and transmitting disease in addition to sexual practices that increase hiv risk some social mechanisms compound risk it is equally important to acknowledge multilevel mechanisms associated with rsbs although there are several wellknown contributors to rsb such as limited comprehensive sexual health education our critical review of the literature indicated that three factors in particular are frequently linked with increased rates of hiv transmission gender inequity socioeconomic status and depression these factors can influence actions taken by clients to avoid or reduce identified risks and should be included in sexual health assessments during clinical encounters and research gender inequity power differentials influence interpersonal dynamics in sexual relationships and have the potential to affect communication about and negotiation of sexual activity across the lifespan the pervasive social construction of sexuality as a maledominated arena creates a standard in which men may dictate when and where sexual encounters occur and whether or not condoms are used heterosexuality is structured in such a way that a mans societal power is often carried into intimate relationships which may encourage a womans sexual and emotional subservience risky sexual behavior occurs within the context of differing degrees of power within relationships and genderdifferentiated norms for sexual behavior to understand rsb it is essential to investigate how gender inequalities in power are played out in sexual relationships and how this power differential may influence sexual risk one of the ways power differentials are enacted in sexual relationships is through intimate partner violence researchers in social science and public health have documented heightened risk for hiv transmission among people experiencing intimate partner violence more specifically women who report a history of intimate partner abuse may be at increased risk for hiv power differentials within relationships affect risk when a more passive member in a relationship feels unable to object to his or her partners having multiple sex partners unable to ask about past or current history of stis and unable to request changes to unsupportive unhealthy patterns of interaction theorists posit that intimate partner violence negatively affects a womans ability to control sexual activities with a known hivpositive partner women experiencing intimate partner violence have also reported inconsistent condom use with partners with known hiv risk factors and coercion by their abusive partners to practice other sexual risk behaviors lastly structural factors such as inequitable gender norms deter hiv prevention strategies among women even in the absence of violence by serving as a barrier to condom negotiation and effective sexual communication for example condom coercion a form of selfsilencing occurs when women are pressured to agree to have anal or vaginal sex without a condom when they wanted their sexual partners to use one while we focus on women because the traditional patriarchal structure of western society often still results in their occupying a disempowered social position men are not exempt from the deleterious effects of power imbalances in intimate partnerships violence and coercion put women and men at risk for hiv transmission and men who are socially positioned to behave with passivity in a relationship can experience similar outcomes with women or with other men our intent again is not to point toward genderbased risk groups but rather to highlight the relationship between traditional structures of gendered inequality and the socially normative behaviors linked to them that increase risk for hiv socioeconomic status in the united states in 2012 465 million individuals were living in poverty a 25 increase from the previous five years low ses is believed to increase hiv risk through its association with reduced access to quality medical care and education several researchers have demonstrated associations between ses and high hiv prevalence in geographic mapping studies researchers have also discovered increased rates of hiv prevalence and highrisk behaviors in lowincome neighborhoods community stressors associated with living in poverty are associated with hiv risk behaviors marginalization including poverty perpetuates a cycle of disempowerment and subjects the individual to additional risk behaviors in the absence of appropriate interventions just as gender race and ethnicity are not causal agents of hiv transmission ses alone is not a definitive risk factor however factors associated with low ses such as poorer quality of health care and lack of access to resources need to be taken into account when attempting to understand rsb depression depressive symptoms are associated with intimate partner violence victimization and aggression with established links between intimate partner violence and hiv risk it is essential to assess the relationship between depression and the decisionmaking power that sexual partners have in relationships a growing body of knowledge suggests a strong positive correlation between depressive symptoms and rsb including but not limited to having sex with multiple partners having a greater number of lifetime partners having unprotected sex having sex while under the influence of drugs andor alcohol and having sex with injection drug and cocaine users adolescents with mental health diagnoses are at even greater risk of hiv exposure because they practice the same risky behaviors as their schoolage peers and at greater rates depression may affect an individuals likelihood of engaging in rsbs when sex is used as a means of mitigating distress the disorder may also compromise motivation to change adverse behaviors if psychological andor emotional needs are being met by the behaviors it is important to be cognizant of the role of depression and other psychiatric disorders in rsb as they may alter an individuals ability to advocate for and follow through with measures to decrease sexual risk proposed definition given the widespread use of the term rsb it is important that the concept encompass the behaviors that it purports to represent building on the extant literature the national institutes of health definition of risky sexual behavior and drawing insights from cooper shapiro powerss definition of risky behavior we propose the following definition of rsb related to hiv transmission any sexual behavior that increases the probability of exposure to hiv including but not limited to unprotected genital contact with or without penetration orgasm or ejaculation concurrent sexual partners or multiple sequential sexual partners sexual activity under the influence of drugs andor alcohol sexual activity in exchange for emotional support or material goods andor sexual activity with a partner of unknown hiv status by shifting the focus from groups to specific behaviors the message is clear that all individuals who are sexually activeregardless of raceethnicity gender sexual orientation marital status etcare at risk for acquiring hiv just as universal precautions are automatically and uniformly performed for infection control providers should automatically and uniformly conduct sexual health assessments for all clients while the proposed definition assists to clearly identify behaviors that increase hiv risk in attempting to understand rsb and adequately describe levels of risk health care professionals and educators should also attend to the role that social mechanisms play in the sexual decisionmaking process of clients broader social and structural concerns including the role of social norms and networks should be considered in communications with clients and in the development of programs and interventions the proposed definition moves toward a more precise and coherent understanding of rsb one that we hope will a encourage providers to engage all clients in sexual health dialogues without defaulting to group biases b prompt clinicians and researchers to include nontraditional risk factors in their sexual health assessments and c clarify for the general public that all forms of sexual activity bear some degree of hiv riskalthough actions can be taken to reduce that risk the flexibility offered by this new definition allows for broader discussion and operationalization of rsb and has the potential to reduce the subjective assignment of risk based on biases against groups additionally this definition is widely applicable across a diversity of behavioral contexts for example traditional classifications do not include exposure risks associated with nonpenetrating genital contact or account for the importance of knowing a sexual partners hiv status further to reduce the threat of further stigmatizing individuals and their behaviors we suggest using the terminology sexual risk behaviors or hiv riskrelated sexual behavior in lieu of rsb relevance to clinical practice the relevance of this work to clinical practice is threefold 1 transdisciplinary sexual health professionals have an opportunity to be at the forefront of clarifying rsb by modeling consistent behaviorbased definitions and messaging for other health professionals and the general public 2 educators are in a position to improve training programs and curricula so that clinicians are better able to address clients sexual health needs and 3 providers are urged to uphold their responsibility to engage all clients in sexual health discussions while remaining cognizant of their own unconscious biases although there is room for improvement we would be remiss not to commend the providers who are already leading the charge to promote sexual health for all clients everyone deserves the opportunity to be engaged in dialogue with providers about their sexual health providers however hold stereotypes typically outside of conscious awareness and these shape clinical decisions interpretations of behaviors and symptoms and interactions with clients it is time to move past individual biases cultural taboos and stereotypes and repudiate preconceived notions about particular groups a shared understanding of rsb and a concise working definition can strengthen research and practice initiatives by providing an objective starting point we propose a paradigm shift to focus on behaviors and the social context of those behaviors as they relate to hiv risk focusing on a broader range of sexual practices that increase hiv risk and the social mechanisms such as gender inequities socioeconomic status and depression that amplify risk will improve sexual health assessments and intervention strategies without a clear definition of rsb the effectiveness of riskreduction and abstinence promotion education intended to reduce hiv transmission is hampered using a shared definition with broad applicability in a variety of behavioral contexts may improve outcomes in clinical practice research policy and public education the promotion of comprehensive sexual health assessments for everyone normalizes health promotion behaviors such as routine hiv testing by bracketing or eliminating individual biases and historically stigmatizing norms clinicians will be better able to offer individualized plans of care that meet the needs of clients with particular attention to relationship context and emerging options for prevention information about newer technologies such as the female condom and tasp could be added to clinical and research protocols for sexual health management based on our review of the literature and our experiences as sexual health professionals we created a list of sample questions for clinical and research assessments to explore contextual factors associated with sexual transmission of hiv these questions are not exhaustive by any means but rather are intended to highlight the contextual nuances necessary to comprehensive sexual health assessment we acknowledge that some of the items are very direct and may make providers or clients uncomfortable however we contend that such information must be elicited to fully understand a clients sexual health promotion and risk reduction needs in support of a forthright approach the literature consistently demonstrates that once providerclient rapport is established clients are receptive to indepth conversations about their sexual health with providers sexual health professionals can also play a pivotal role in ensuring that adequate sexual health education is grounded in empirical knowledge of hiv transmission given the significant impact of hivaids ensuring that hiv prevention education is offered in a variety of settings including clinical will be crucial in turning back the epidemic diversification of delivery can be accomplished through curricula development for degree programs as well as through the development of training programs for community health workers school teachers health educators victim advocates and social workers can all be trained to deliver sexual health information and nurses in particular are uniquely suited to teach healthtechnical and interpersonal skills conclusion significant public health challenges such as hivaids require clear clientprovider communication to distinguish between risk and protective behaviors to successfully implement sexual health assessments and interventions it is critical that language is unambiguous and fully understood despite relevance to clinical practice and research the conceptual development of rsb is limited and a widely shared understanding of risky sexual practices does not exist in this commentary we explored clinical and scientific thought regarding risky sexual behavior and proposed a new definition that has wide applicability across a diversity of behavioral contexts as there is no cure for hivaids prevention remains a pivotal tool to decrease the rampant spread of this devastating virus during the past three decades we have seen the stereotyped face of hivaids change from that of the homosexual white male to racial and ethnic minority msm and women we believe that between migration of people a global economy and a lack of behavioral change we will see a fading away of populationbased assumptions about hiv in order to reduce risk behaviors among all people regardless of group or identity we submit that clarifying definitions creating uniform public messaging and encouraging provider adherence to established guidelines is a necessary first step from there sexual health professionals including nurses physicians community health workers health educators and social service providers can better lead the way in supporting behavioral change while all may not agree with the proposed definition or the conceptual understanding we have advanced and while some may have additional questions they deem necessary to consider in screening clients we hope we have made a strong case for the need to establish a clearer more encompassing more uniformly shared and less biased conceptual basis for rsb future research should consider the following questions how does an individual come to determine whether or not a particular sexual behavior or action is risky what interandor intrapersonal factors cause providers to differ in their perceptions of clients sexual risk behaviors should we eliminate the term at risk group from our descriptive epidemiology of hiv how can sexual health professionals affect an individuals sexual decisionmaking process these questions will hopefully incite collective and scholarly debate about the merit of how the term rsb is articulated in the literature prevention messages and other educational activities ultimately such questions advance our clinical practice and the state of the science by clarifying the meaning of risk for given populations additionally those working to decrease rates of unintended sexual health outcomes such as unwanted teenage pregnancies may find that a shared definition has wider applicability to their respective areas of focus this question helps to probe for sexual partner coercion given the links between sexual relationship power dynamics and increased risk for hiv it is important to have an understanding of clients autonomy in sexual decision making with their partners what do you know about your partners sexual history some people do not have conversations with their sexual partners about that persons past therefore it is important to assess risk factors among sexual partners as these risks directly affect the clients risk do you feel safecomfortable talking to the people you have sex with about what you like and dont like sexually this question allows the provider to elicit information about perceived control over sexual decisionmaking and sexual partner coercion probing for specific behaviors will also help individualize risk reduction plans when you are feeling sad or angry about your relationship are you more or less likely to use protection with your partner this question allows the provider to probe whether the mentalemotional status of the client influences hisher engagement in certain behaviors at this time or in the near future do you want to get pregnanthave a baby desires and intentions to have children often hinder consistent condom use thus increasing hiv risk talking with clients about their conception plans helps personalize risk reduction strategies in a manner that suits their current lived experience further it serves as a reminder for them about hivsti risks associated with unprotected sex this question allows providers to assess if clients engage in sexual activity with their partners with exchange motivations this is important to assess given that this can possibly influence engagement in unwanted sexual behaviors have you ever had sex with someone who was incarceratedlocked up for more than 24 hours inmates in jails and prisons across the united states are disproportionately affected by multiple health problems including hiv and other stis this question will allow the provider to assess whether the client has knowledge of the hivsti status of any previously incarcerated partners question rationale do you talk to any of your partners about your other partners do you talk to any of your partners about their partners this question allows providers to probe about whether the client has any awareness that their sexual partners may have other partners this also provides an opportunity to communicate about the risk of engagement in concurrent partnerships what types of things do you and your partner do to turn each other on asking about behaviors used to promote sexual arousal provides a comprehensive picture of sexual acts engaged in with partners while mutual masturbation does not have inherent hiv risk it may advance to vaginal anal or oral sex note questions marked with an asterisk represent the items we recommend asking at every client encounter public health nurs author manuscript available in pmc 2017 march 01

risky sexual behavior accounts for the majority of new hiv infections regardless of gender age geographic location or ethnicity the phrase however refers to a relatively nebulous concept that hampers development of effective sexual health communication strategies the purpose of this paper is to propose development of a shared conceptual understanding of risky sexual behavior we reviewed multidisciplinary hivaids literature to identify definitions of risky sexual behavior both the linguistic components and the social mechanisms that contribute to the concept of risky sexual behaviors were noted risky sexual behavior was often defined in a subjective manner in the literature even in the scientific research we urge a paradigm shift to focus on explicit behaviors and the social context of those behaviors in determining hiv risk we also propose a new definition that reduces individual biases and promotes a broader discussion of the degree of sexual risk across a diversity of behavioral contexts sexual health professionals can

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background open defecation is one of the causes of health problems globally using latrines as a means of elimination is still not optimal one in three people does not have access to proper sanitation and one in seven people still practice open defecation it impacts health especially in children such as diarrhea and contributes to an increased risk of premature death in 2018 over 340000 children under five died due to unhygienic sanitation and water unicef and who study results also stated that more than 370 indonesian toddlers died from bad behavior in open defecating situbondo regency is the second highest district in east java province with the number of open defecation rates based on data collected by the east java provincial health service regarding the achievements of open defecationfree districts better known as open defecationfree east java province in december 2021 there were 18 districtscities where open defecation it is a big challenge for east java province and regenciescities in east java with open defecation status to achieve the east java province target of 100 odf in 2024 based on lb1 data the february 2022 situbondo district health service progress report on latrine access stated that there were 83 villages out of 136 villagesdistricts that were odf while the remaining 53 villages still open defecation some households have latrines but defecate in the open area despite the efforts made by the situbondo regency government to achieve 100 odf status by 2024 this is undoubtedly a challenge the high level of this problem is due to the need for more individual awareness of the importance of implementing clean and healthy living behavior including defecation in appropriate infrastructure previous studies showed that access to latrine facilities does not guarantee avoiding open defecation practices the problem of families still practicing open defecation is not limited to the lack of infrastructure namely toilets and the provision of clean water but more to the behavioral aspect namely community behavior that does not compromise on clean and healthy living behavior healthy latrines are benchmarks in the clean and healthy living behavior indicators a healthy toilet is also an indicator of a persons clean environment reflecting how they are used to having a clean environment previous studies state that good sanitation in latrines will affect a persons health previous studies state that good sanitation in latrines will affect a persons health appropriate use of latrines can reduce the risk of contracting diarrheal disease and maximum utilization is achieved when improved sanitation and clean water supplies are combined and hygienic practices health behavior is influenced by predisposing factors that facilitate or arise automatically from within the individual regarding age education knowledge gender economic status values and perceptions and family size age educational level and family size are sociodemographic factors that influence a persons behavior in using toilets a previous study showed that many respondents who used latrines were over 48 years old the last study stated a significant relationship between gender and their participation in environmental sanitation with men having a nine times greater chance of participating than women previous studies also stated that the better the communitys education attitudes and culture the better their behavior in using existing latrines there was a relationship between economic status and family behavior in using latrines a family size of more than five had a greater chance of practicing open defecation than respondents with a family size of less than five it is in line with the results of previous study which states that the number of family members more than or equal to five is a factor related to latrine use however several previous studies stated no significant relationship between sociodemographics and family latrine utilization the gender difference did not affect latrine use behavior the level of education also did not affect family latrine utilization and there was no significant relationship between income based on the results of previous studies which showed differences between the results of one study and another researchers hypothesize that sociodemographic factors can influence the behavior of using toilets for defecation therefore this study aims to analyze the influence of sociodemographic factors on family latrine utilization behavior in situbondo regency methods the study design is descriptiveanalytic with a crosssectional approach the study was conducted in situbondo regency in march december 2022 the population was families who received social assistance from the family latrine program through the 2019 situbondo regency apbd funds namely 500 families from 5 villages namely klatakan dawuhan patokan patemon and kertosari the sample size was 135 respondents calculated using g power software version 31 g power was used to calculate the sample size precisely where the test used is multiple regression and to avoid type i and type ii errors the sample inclusion criteria were families receiving social assistance from the family latrine program through 2019 situbondo regency apbd funds acting as head of the family able to communicate well not currently sick requiring hospitalization do not have physical or mental limitations that could interfere with the conduct of study willing to be a respondent the sampling technique used was cluster random sampling namely klatakan dawuhan patokan patemon kertosari this study has two variables the independent variable and the dependent variable the independent variables are sociodemographic factors consisting of age education level of knowledge income level gender and number of family members the dependent variable is the familys latrine utilization behavior the measuring instrument used in the study was a questionnaire a sociodemographic questionnaire was used to determine age gender education income and number of family members the family latrine utilization behavior was measured using a questionnaire adapted from the concept of family health tasks consisting of 14 question items which include the domains of recognizing diseases caused by od making decisions about using a latrine maintaining latrine cleanliness for health modifying the environment and using latrine facilities with a likert scale of 1 5 so the score range is 14 70 the higher the score the better the familys behavior in using the family latrine the validity and reliability test of the questionnaire was carried out by researchers in situbondo regency on people who were not respondents to this study using a sample of 60 respondents the validity and reliability test results were r 0353 0685 with cronbach alpha 0811 family latrine utilization behavior was categorized into poor moderate and good data was collected by interviewing respondents directly at the respondents home before data collection the researcher explained the aims benefits procedures and possible risks to prospective respondents after the prospective respondents understood and were willing to become respondents the researcher asked them to sign a consent form data were analyzed using descriptive and inferential analysis using spss version 27 descriptive analysis used central tendency and dispersion the inferential analysis used the multiple logistic regression and difference test the ethical committee of health research of the faculty of dentistry jember university approved the study with protocol number 1665un258 kepkdl2022 results the study results showed that the average age of respondents in this study was 4779 years and the most were in the age range 41 60 years in addition most respondents were women had a middlelevel education had an income of less than the regency minimum wage and had less than four family members most of the respondents had family latrine usage behavior in the high category with the highest subvariable being the indicator of deciding to use latrines respondents who had a high average family latrine utilization behavior were in the 18 40 years age group male middle education income level less than the minimum wage and number of family members 4 people the result of the normality test for the family latrine utilization behavior showed that the data was not normally distributed based on table 3 the mannwhitney u test showed that male respondents had a higher average rating of family latrine utilization behavior than female respondents likewise respondents with income below the minimum wage had a higher average rating of family latrine utilization behavior than those above the minimum wage however there was an insignificant influence between family latrine utilization behavior based on income level and gender based on the kruskalwallis test the results showed that respondents in the 1840 year category had a higher in addition respondents with secondary education levels had a higher average rating of family latrine utilization behavior than different education levels respondents with family members of 56 people had a higher average rating of family latrine utilization behavior compared to those with other family members however there is an insignificant influence between family latrine utilization behavior based on the number of family members there is a significant influence between family latrine utilization behavior based on age and education level based on the multiple ordinal logistic regression test the results showed that only the education level indicator had a significant influence on family latrine utilization behavior with a predominance in the secondary education age range discussion the study results showed that most respondents are 4160 years old with an average age of 4779 years female with a middle education level apart from that most respondents had low socioeconomic status with incomes below the minimum wage and had family members of less than four people in one residence the results of this study follow a previous study which stated that age educational status and family size influence behavior in using toilets in fact from this study it was also found that the respondents who used the latrine the most were over 48 years old age 40 to 60 years is the stage of generativity where a person forms a family and career is the longest of all stages so in that age period a person begins to mature in deciding the best behavior for his family the study results showed that most respondents are female this studys results could be because females use latrines more often than men so females have a greater opportunity to use the available toilets than males however the results do not agree with a previous study which states a significant relationship exists between gender and their participation in environmental sanitation with men having a nine times greater chance of participating than women the study results show that most respondents have a secondary education level the results of this study follow previous studies namely that the better the education attitudes and culture of the community together the better their behavior in using existing latrines the results of this study also agree with another study which states that there is a relationship between household latrine use and the education level of the head of the household other similar studies on the impact of sanitation interventions on latrine coverage suggest that education level influences community latrine use education from an early age must be applied to every individual so that humans are of good quality and do not harm themselves or others especially when using toilets so it is assumed that the higher a persons level of education the more they can know understand or analyze clean and healthy living on the other hand a higher level of education means a higher understanding of excretion information especially when using the family latrine however the results of this study do not agree with the results of the previous study which stated that education level had an insignificant relationship with family latrine use another study also noted that the educational status of the respondent has little connection with latrine use the study results showed that all respondents were of low socioeconomic status this studys results follow a previous study that stated family income level influences latrine use the better the income level the better the behavior in using the toilet the study showed that all respondents were of low socioeconomic status this studys results follow a previous study that found that family income influences latrine use the better the income level the better the behavior income level also shows how the family maintains the available toilet facilities if latrine facilities are well maintained latrine utilization will also improve the study results showed that the level of latrine utilization was dominated by families with less than four people this study follows the results of a previous study that stated respondents with a family size of more than five have a greater chance of defecating than respondents with a family size of less than five another study noted that households whose family size is more than or equal to five aor 051 95 ci 032 082 were 49 less likely to use a latrine than households with fewer than five families the study results showed that most respondents have family latrine utilization behavior in the high category this study does not follow the results of the previous study that having latrine facilities does not guarantee to eliminate the practice of open defecation and even existing latrines still need to be consistently used 100 percent by the community because families are said to consistently use the available latrine facilities when they have used the latrine continuously for one week the study results showed that younger males those with higher education levels and fewer family members than four had higher scores of family latrine utilization behavior based on the kruskallwallis test with a confidence level of 95 it was concluded that those aged 1840 with secondary education levels and more than four family members had a higher average level than others in family latrine utilization behavior meanwhile based on the ordinal regression test only the education level variable has a value of p0001 005 meaning that the education level significantly affects family latrine utilization behavior based on the mannwhitney u test with a confidence level of 95 it was concluded that male gender and an income level of less than the minimum wage had a higher average level than others in the behavior of using family toilets meanwhile based on the ordinal regression test no variables significantly affect family latrine utilization behavior younger ages have a higher average value of latrine utilization behavior than older ones this study follows previous studies that there is a strong reason that people learn through their experiences besides that there is another factor namely that young people have better access to information so that it is possible to get adequate information about the dangers of open defecation behavior on their health this study follows a previous study that stated men have a nine times greater chance of participating than women regarding their participation in environmental sanitation respondents from secondary education levels have a high average value of latrine utilization behavior compared to lower education levels this study follows a previous study that stated the better the communitys education attitudes and culture the better their behavior in using existing latrines the results of this study also agree with another study which states that there is a relationship between household latrine use and the education level of the head of the household the study results show that family members with less than four people have a higher average value of latrine utilization behavior than other family members following the results of a previous study this study found that households with more than five family members are less likely to use a latrine than households with less than five this study had limitations namely that it only tested the influence of sociodemographic factors on family latrine utilization behavior meanwhile other factors such as psychosocial factors were not studied future studies can test the effect of these factors which may influence because based on the analysis results the contribution of sociodemographic factors is only 162 so 838 of other factors still influence family latrine utilization behavior modeling studies involving many variables can also be carried out in further studies to comprehensively identify factors that influence family latrine utilization behavior conclusion the study results showed that most respondents had latrine utilization behavior in the good category respondents with a high latrine utilization behavior score were in the 1840 year age group male with secondary education income level less than the minimum wage and number of family members under 4 the results of the study showed that there was a significant influence on latrine utilization behavior based on level of education meanwhile based on gender age income level and number of family members the effect is not significant in health promotion efforts to increase family latrine utilization behavior health workers should consider educational level factors to achieve goals and reduce open defecation behavior

providing healthy latrines for each family is an effort to reduce open defecation od however there are still many people who do not use family latrines for defecation which can increase the risk of fecaloral transmission of disease many factors influence od behavior one of which is sociodemographic to analyze sociodemographic factors influence on family latrine utilization behavior observational analytic with a crosssectional design the sample size was 138 respondents using the cluster random sampling technique data were collected using a questionnaire family latrine utilization behavior and sociodemographic and analyzed using multiple logistic regression and difference tests most respondents were 41 60 years old 732 women 573 moderate education 558 with family members less than four people 8188 and all respondents had income level less than regency minimum wage 100 most respondents had family latrine utilization behavior flub in the high category 667 the modeling test showed the model fit p0034 r20162 it showed that age gender education income and number of family members simultaneously significantly affect flub by 162 however partially only the educational factor had a significant effect p0001 in addition the mean difference test shows significant differences in flub based on education level p0001 the sociodemographic factor that significantly influences flub is the education level health workers should consider peoples education level in health promotion efforts to increase flub and reduce od behavior further study can be carried out by analyzing other factors such as psychosocial which may also influence flub

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review of literature although limited some literature has investigated factors associated with persistence among rural youth who attend college yan found that ses high school program number of science courses taken and various college experiences were predictors of college persistence among rural youth in pennsylvania drawing on a sample of about 300 iowa rural youth schonert and colleagues also found that family background high school achievement and college involvement predicted college persistence however given that these studies focused on small samples in specific geographic regions it remains to be seen whether their findings are generalizable to a more diverse and broad rural student population in college other studies have indicated that rural youth tend to face a unique set of challenges when transitioning to college specifically studies conducted in the 1970s documented that college students from rural areas showed higher levels of stress alienation and attrition than students from urban areas in a more recent ethnographic study of students in a small rural town in northeast ohio maltzan also found that rural youth who attend college experienced more difficulty than their urban counterparts in adjusting to college largely due to pronounced differences between their experiences in rural communities and those in the new urban settings however previous research on the college adjustment of rural youth was limited to one or two institutions of higher education given that pathways to college completion are becoming increasingly complex data that follow students attending multiple institutions may provide more robust attrition rates among rural youth indeed empirical studies using such data do not fully support rural disadvantages in college persistence and degree completion for example using data from students across iowa schonert and colleagues found that rural students who attended college persisted at rates even higher than the national average in the study of college graduation rates using the national longitudinal survey of youth gibbs found that although rural students were slightly less than urban students to attend college rural students who did attend college tended to graduate at the same rates as urban students although not explicitly testing the ruralmetro gap adelman also found few rural and urban or suburban differences in bachelors degree attainment some researchers have pointed to unique college attendance patterns among rural youth for the relative success of students from rural areas in the college setting despite lower ses and a lack of rigorous precollege preparation for example gibbs found that rural youth were more likely than urban youth to attend public and nonselective colleges the author attributed this result to the following public colleges in rural areas are more numerous and have larger enrollments than private colleges rural students are less able to afford higher tuition private colleges public colleges are less likely to require advanced course work which is often lacking in rural schools and selective colleges are mostly located in metro areas 1 however few studies have examined the extent to which these unique college attendance patterns among rural youth contribute to their bachelors degree completion in addition little is known about which precollege and college experiences shape bachelors degree completion among rural students attending a fouryear institution in this study drawing on nels we seek to extend previous research by empirically investigating how background characteristics precollege preparation and college experiences of rural youth at fouryear institutions differ from those for metro youth which factors may be related to bachelors degree completion for rural youth and how predictors of bachelors degree completion for rural youth may differ from those for metro youth data and methods sample to address these research questions we drew on data from the nels of 19882000 and the postsecondary education transcript study collected as part of nels 2 in 1988 the national center for education statistics drew random samples of approximately 25 eighth graders in about 1000 randomly selected schools nels followed these students through high school in 1990 and 1992 and beyond in 1994 and 2000 the nels panel of 19882000 consisted of approximately 12100 students 3 of these students who reported enrollment in postsecondary institutions in one of the last two followups were included in the pets sample and their postsecondary transcripts were requested from institutions they attended all of our measures came from the pets data the exceptions were some family background variables and college involvement variables which we extracted from the 1992 and 1994 waves respectively and merged with the postsecondary transcript data file we selected students who participated in the second through fourth followups ever attended at least one fouryear institution as of 2000 and had a complete transcript record due to small sample sizes we excluded american indianalaska native and multiracial students missing rurality identifiers and postsecondary information resulted in the final analytic sample of approximately 4880 with 1 according the gibbs of the 335 schools classified as most highly or very competitive in the 1990 of barrons profiles of american colleges only 61 were located in rural counties 2 the nelss education longitudinal study of 2002 has followed a more recent cohort of high school students but its second follow up does not yet provide data that can be used to examine postsecondary degree completion 3 sample sizes throughout the article are rounded to the nearest 10 in compliance with nces regulations for using restricted data rural suburban and urban youth being approximately 28 42 and 30 respectively measures dependent variablethe dependent variable is bachelors degree completion status and indicates two states noncompletion and completion noncompletion refers to students who enrolled in a fouryear college at any time after high school graduation but had not earned a bachelors degree by 2000 completion refers to students who enrolled in a fouryear college at any time after high school graduation and earned a bachelors degree or higher by 2000 explanatory variablesnumerous studies have investigated factors associated with college completion including individual background characteristics precollege preparation and college experiences guided by prior literature we included a variety of explanatory variables that measure individual background characteristics high school preparation and college experiences for individual background characteristics we included gender raceethnicity parental education family income family structure number of siblings and parental educational expectations all individual background variables were measured at grade 12 gender was measured by the students selfreported sex raceethnicity was measured by students selfreported raceethnicity parental education was the highest level of education that parents reported family income was based on parents report of family income at grade 12 and measured by the trichotomous categories less than 25000 25000 49999 and 50000 or more family structure was measured by whether students lived in traditional families vs nontraditional families parents reported the number of siblings that a student had at grade 12 parental educational expectations were based on parents reports of how far in school they wanted their teenager to go and was measured with the dichotomous categories some college or less and bachelors degree or higher high school preparation was indicated by standardized test scores and curriculum intensity standardized test scores were from the mathreading composite test score provided by nels 4 curriculum intensity was the rigor of students high school curriculum on a fivequintile scale 5 college experiences were indicated by the location of institution first attended the sector of institution first attended the level of the first institution attended the selectivity of the first institution attended delay of entry enrollment intensity participation in intramural athletics student governmentpolitics and social clubs fraternitiessororities and firstyear cumulative gpa the location of institution was whether the college or university first attended was located in the same state as high school or in a different state the sector of institution was measured by whether the college or university first attended was private or public the level of institution was whether students first attended a twoyear college vs fouryear college selectivity was the selectivity of institution first attended and provided by the nels its original measures were 1 highly selective 2 selective 3 nonselective 4 opendoor 5 unrated but we collapsed those into the dichotomous categories highly selective or selective vs otherwise delay of entry was whether students entered a college within seven months vs within 820 months vs after more than 20 months after high school graduation we collapsed these into the dichotomous categories within seven months vs within 820 months or more enrollment intensity was a dichotomous indicator of whether student ever enrolled in college parttime vs fulltime participation in intramural athletics student governmentpolitics and social clubs fraternitiessororities were measured by whether the student participated in each of these three activities while attending college finally the firstyear cumulative gpa was the quintile version of the first calendar year gpa analytic strategies the first research question focused on observed differences in individual background characteristics high school preparation and college experiences among students from rural suburban and urban schools to address this question we performed descriptive statistics and conducted analysis of variance or chisquare test for each covariate depending on their scale for the continuous measures we then conducted appropriate posthoc tests to identify differences between specific subgroups with main focus on differences among students from rural suburban and urban schools we next examined which background traits precollege experiences and college experiences mattered for bachelor degree completion among rural youth using logistic regression logistic regression is the appropriate method of analysis for dichotomous dependent variables such as bachelors degree completion we entered the explanatory variables simultaneously rather than in a stepwise fashion because the aim was not to test a theory or model but to examine the explanatory significance of the variables in the model predicting the likelihood of completing a bachelors degree among rural high school graduates attending a fouryear institution we examined nagelkerkes r 2 to assess the overall fit of the logistic regression equation to the data nagelkerkes r 2 is known as a pseudor 2 as it approximates the amount of variance accounted by the model results of the logistic regression analyses allowed us to determine which factors mattered in bachelors degree completion among rural students at fouryear institutions after other variables were held constant the third and final analyses compared and contrasted the predictors of bachelors degree completion among students from different types of communities specifically we tested the differences in the logistic regression coefficients for statistical significance between rural and metro students using a ztest the aim was to investigate how predictors of bachelors degree completion differed by rurality for the multivariate models we applied the longitudinal weight which applied to the 12 th grade freshened panel respondents with high school transcripts who have completed postsecondary transcript records we employed the ice option in stata to impute missing data for family background and college activities we generated five imputed datasets and then averaged the coefficients and standard errors using the mim option in stata to address the nested nature of the nels data we used the cluster option in stata which adjusts for the inflated standard errors resulting from the violation of the independent errors results the following sections summarize the results for each of the research questions each section corresponds with one of the guiding research questions of this study characteristics of rural college students we first examine selected background characteristics precollege preparation and college experiences of rural students at fouryear institutions and how they differed from those of their metro counterparts table 1 provides weighted descriptive statistics for the sample by rurality the first row of table 1 showed few unadjusted differences in bachelors degree completion rates between rural and metro students about seven out of ten rural students who ever attended a fouryear institution after high school graduation earned a bachelors degree as of 2000 which was similar to suburban and urban students rural students who attended a fouryear institution were more often white compared to urban students rural students who attended a fouryear institution less often had parents who had a bachelors degree or more compared to suburban and urban students rural youth were less often from families whose annual income was 50000 or more than suburban and urban students rural students were less likely from singleparent families or other nontraditional families compared to urban students no observable differences between rural and metro students were found in gender number of siblings and parental educational expectations results of table 1 also clearly showed differences in high school preparation between rural and metro students although rural students performed as well as their suburban and urban counterparts on standardized tests rural students had significantly lower curriculum intensity compared to suburban and urban students significant ruralmetro differences were also detected in several college experiences specifically rural students more often first attended a public college than suburban students and urban students in contrast rural students less often first enrolled in a selective college than suburban and urban students of interest rural students less often enrolled in college parttime than suburban and urban students rural students also more often participated in intramural athletics than suburban and urban students the firstyear cumulative gpa of rural students was as high as that of urban students but significantly higher than that of suburban students no significant ruralmetro differences were found in other college experiences including the location and the level of the institutions first attended delay of entry and participation in student government and greek social clubs predictors of bachelors degree completion of rural students we now turn to the second research question which background traits precollege experiences and college experiences matter for bachelor degree completion among rural youth at fouryear institutions the first column of table 2 presents results from the logistic regression predicting bachelors degree completion for rural students when other factors were taken into account gender was not a significant predictor of bachelors degree completion for rural students hispanic students enrolled in a fouryear institution were less likely than white students to earn a bachelors degree while asian and black students were as likely as white students to obtain a bachelors degree family income was significantly related to bachelors degree completion among rural students students whose family income was 50000 or more were more likely than students whose family income was 25000 or less to earn a bachelors degree however parental education was not significantly related to bachelors degree completion among rural students neither family structure nor number of siblings was a significant predictor of bachelors degree completion for rural students attending a fouryear institution amongst the college experience variables timing and intensity of college enrollment were significantly associated with the odds of bachelors college completion of rural youth rural students who delayed college entry after high school graduation were less likely than students who attended college right after high school graduation rural students who ever attended college parttime were less likely than students who attended college fulltime to earn a bachelors degree rural students who participated in social club fraternities sororities while attending college were more likely than students who never participated in such social clubs the firstyear cumulative gpa was associated with the higher likelihood of obtaining a bachelors degree among rural students however none of the institutional features of college first attended predicted bachelors degree completion among rural youth participation in intramural athletics and student governmentpolitics was not a significant predictor either how do the predictors of bachelors degree completion differ by rurality we now examine the third research question how do the predictors of bachelors degree completion among rural youth differ from metro youth the second and third columns of table 2 present logistic regression results for suburban and urban students results showed similarities and differences among rural suburban and urban students specifically hispanic origin parental educational expectations and participation in greek social clubs were significant predictors of bachelors degree completion for rural students but not for suburban or urban students in contrast parental education family structure and selectivity of institution first attended were not significant predictors for rural students but they were significant predictors among suburban and urban students gender was a significant predictor of bachelors degree attainment among urban students only we further tested whether differences in the magnitude of the coefficients between rural and metro students were statistically significant the results showed that hispanic students from rural communities were significantly more disadvantageous in bachelors degree completion than their suburban and urban counterparts of the same ethnicity rural students from nontraditional families were significantly less disadvantageous in fouryear college completion than their urban counterparts from nontraditional families no significant differences in the impact of family structure were found between rural and suburban students finally the relation of curriculum intensity and fouryear college completion was significantly stronger for rural students than suburban students no significant differences in the impact of curriculum intensity were found between rural and urban students discussion and conclusions a recent national report indicates that a growing number of students from rural communities are increasingly becoming a part of the american higher education yet this group of college students has received little research attention over the last decades as a result there is little descriptive information on the background characteristics high school preparation postsecondary education experiences of rural adolescents in higher education and the relation of these various factors to their college success compared to their metro counterparts in this study we addressed this limitation by broadly investigating characteristics of rural students attending fouryear institutions predictors of college completion among these rural students and the differential role of key factors in predicting college completion of rural and metro youth given the lack of scholarship on rural students attending college the current study has important implications for higher education research and programs we began by examining similarities and differences in precollege characteristics and college experiences between rural and metro adolescents who attended a fouryear institution as prior studies documented results showed several unique challenges that rural college students faced rural adolescents who attended a fouryear institution were disproportionally more likely to be firstgeneration college students and to come from lowerincome families compared to their metro counterparts in addition rural students were more likely to enter college with a less rigorous academic curricular background compared to their metro counterparts despite these challenges rural students were more likely than their metro counterparts to attend college fulltime furthermore rural students performed as well as their urban counterparts and even outperformed their suburban counterparts during their early years in college most importantly there were few differences in bachelors degree completion rates and between rural and metro adolescents while consistent with prior research this finding suggests that rural adolescents enrolled in a fouryear institution do not suffer disadvantage in their degree completion simply as the result of their attendance at rural schools gibbs argued that the college success of students from rural areas could be attributed to their disproportionate enrollment in public nonselective colleges which are less demanding consistent with gibbs findings our results indicated that rural students were disproportionally more likely to be enrolled in a public less selective college compared to their metro counterparts at the same time however our results showed that attending public selective colleges was not significantly related to the likelihood of earning a bachelors degree among rural students not fully supporting gibbss argument in contrast attending selective colleges mattered in college completion for both suburban and urban students an alternative explanation for the relative success of rural college students may be that impoverished but academically talented rural youth may especially value college education as a pathway toward economic prosperity due to declining employment opportunities in rural communities while this view of higher education as an instrument of upper economic mobility for socioeconomically disadvantaged students has long been discussed in the history of american higher education it is also associated with substantially greater geographical mobility for rural youth who must leave their home communities to attend fouryear institutions elsewhere in this context rural students who may be turning toward college education as a pathway to a different future from their parents may be more dedicated to college education another possible explanation may be favoring institutional features of rural schools and communities that offer additional social resources for rural adolescents especially socioeconomically disadvantaged students to persist to achieve their postsecondary education goals rural schools are diverse but share several characteristics including small size strong communityschool connections and supportive teacherstudent relations all of which have positive benefits for youth unique rural high school experiences may enable students to develop greater feelings of school belonging and stronger commitment to education beyond high school which may lead to persistence and ultimately improve the likelihood of completing a college program for these students indeed our results showed that rural students whose parents did not attend college or who came from nontraditional families were as likely as their counterparts whose parents did attend college or who came from traditional families to persist to achieve their postsecondary education goals by contrast lower parental education and nontraditional family arrangements significantly decreased the likelihood of earning a bachelors degree for both suburban and urban metro students nevertheless the results showed that rural hispanic students who enrolled in a fourinstitution were more disadvantageous in bachelors degree completion than their suburban and urban students who had the same racialethnic background one possible explanation for this finding may be that hispanic students tend to have the most difficulty managing college enrollment and completion unless additional college guidance and counseling is provided a recent study of chicago students showed that while hispanic students were the least likely to plan to enroll in a fouryear college after graduation and the least likely to apply to a fouryear college their college plans and behaviors were more dependent on the expectations of their teachers and counselors and connections with teachers given the lack of provision of college guidance and counseling in rural schools hispanic students in rural areas may be particularly disadvantaged in college enrollment and completion in that regard this study has several important implications for secondary education policy as well as for higher education policy first our findings suggest that the provision of rigorous high school curriculum for students preparing for college is important for all students but especially beneficial for rural youth adelman highlighted the importance of academic preparation during high school but the current study disaggregates his general conclusion by offering more nuanced insights into the potential differential impact of the academic rigor of the high school curriculum on rural students who tend to have the least opportunity to take ap courses second the current study suggests that greek organizations social clubs and fraternities sororities may be particularly important in improving the college completion rates of rural students prior research highlights the important role of participation in various collegiate activities in college success but again our findings offer more nuanced insights into the potential differential impact of a particular form of collegiate activities among rural students who tend to feel lost and out of place at large colleges finally our findings of the positive relation of parental educational expectations to college completion for rural students suggest that psychological encouragement from parents may have an especially important impact on rural students achieving their postsecondary education goals when they experience economic hardship in this vein encouragement from high school teachers and counselors and faculties may offer additional social support for rural students to persist through college to degree attainment there are several limitations of this study that need to be considered in future research perhaps the most important limitation is that some students whose postsecondary attainment was identified as incomplete within the data collection timeframe of nels may eventually earn a college degree a longitudinal study with a longer time span may increase our understanding of the complex patterns of college persistence and completion among rural students as well as among metro students secondly the present study examined the relationship between selected family precollege and college factors and bachelors degree completion among rural youth previous research suggests that various other factors including parental interaction styles high school experiences and expectations as well as college costs and financial aid availability are related to the likelihood of bachelors degree completion an investigation of how these factors may shape college completion among rural students who attend college compared to their metro counterparts will further inform secondary and postsecondary education policy for developing intervention programs that better reflect the unique and similar needs of rural and metro students

using the national education longitudinal study this study explored various factors that predicted bachelors degree attainment among rural youth attending a fouryear institution results showed that hispanic origin family income parental educational expectations the rigor of the high school curriculum timing and intensity of college enrollment and participation in greek social clubs were significant predictors gender parental education family structure number of siblings institutional features of college first attended and participation in intramural athletics and student government were insignificant predictors we discussed similarities and differences between rural and metro students in factors predicting bachelors degree completion approximately nine million students attend public schools in rural areas representing 19 of the public school population in the united states johnson strange 2009 in recent years these rural students are increasingly attending college in 2003 35 of rural high school graduates attended a fouryear college while 42 did so in 2007 showing a 7 point increase snyder dillow 2010 during the same period between 2003 and 2007 fouryear college attendance rates of high school graduates increased by approximately 4 from 325 to 361 in city areas and by approximately 1 from 403 to 412 in suburban areas snyder dillow 2010 despite the growing number of rural high school students enrolling in college little is known about background characteristics precollege preparation and college experiences of these rural students and how these factors may shape their college completion prior research has mainly focused on samples of college students in general without considering potential differences in background characteristics and predictors of college completion among students from different types of communities eg

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introduction family literacy programs are defined for the purposes of this paper as interventions often with an emphasis on adults reading and talking about books with young children 1 the main focus is on those family literacy programs sometimes called bookgifting programs that involve the distribution of free books to children and their families particularly those that distribute books directly to babies and young children alongside guidance for parents we begin by examining the research evidence that underpins the rationale for family literacy programs that focus on sharing books with young children research suggests that the quality of experiences and interactions from birth have a major influence on the way the brain develops recently hutton horowitzkraus mendelsohn dewitt and holland using functional magnetic resonance imaging found that for preschool children greater exposure to listening to stories being read aloud was positively associated with the activation of brain areas that support mental imagery and narrative comprehension additionally the vocabulary of books read aloud has been shown to be an important source of linguistic input for young children particularly as picture books have been found to contain more unique word types than are found in parents regular childdirected conversations strong positive connections between shared book reading and early literacy learning have been demonstrated involvement in shared book reading has been found to increase young childrens motivation to participate in literacy activities to support positive childparent relationships and lead to positive educational and cognitive outcomes that last over time at least up to an age of 10 to 11 there is further strong evidence from a large study by the organisation for economic cooperation and development that the benefits of early book sharing are cumulative and longlasting from analyses of the pisa reading data of students from thirteen countries it was shown that regardless of family income certain literacy practices in the home during childrens early years were related to student performance on reading tests when they were age 15 these home practices included using words within context telling stories singing rhymes and songs and reading books to children by the time they were starting primary school the most highly significant of these practices was reading books to children at age 15 students whose parents had read to them read at least as well as their peers one grade above them additionally 15yearold students whose parents had read books and sung songs with them during their early years reported significantly higher levels of reading enjoyment these findings suggest that promoting higher levels of parental involvement may increase students cognitive and affective outcomes and may help reduce schoolbased performance differences across socioeconomic groups the results of a series of metaanalyses on ninetynine studies by mol and bus suggest that the effects of exposure to reading may be even longer lasting these researchers examined print exposure across three age groups of students preschoolers and kindergartners students in grades 112 and college and university students moderatetostrong correlations were found with print exposure on all measures of reading comprehension and technical reading and spelling exposure to print explained 12 percent of the variance in oral language in preschool and kindergarten with the amount of explained variance rising for each educational level to 19 percent in high school and 34 percent at the college university level mol and bus suggest that the outcomes support an upward spiral of causality in that shared book reading with young children may be part of a continuum of outofschool reading experiences that facilitate childrens language reading and spelling achievement throughout their development while such research has shown reading with young children to be associated with cognitive and affective outcomes over time there is also some research to suggest that the type of interaction that takes place around the reading of books with young children is highly important in the shared book experience the dialogic reading model has been shown to help develop childrens emergent literacy language and metalinguistic skills dialogic reading is a method of reading picture books with young children in which parentscaregivers are shown how to encourage the child to actively participate in the reading of a book with the aim of the child eventually taking over the role of narrator adults support the childs learning of story vocabulary and discussion of the plot through various questioning and explanatory techniques joint attention to text through shared sustained thinking as parentscaregivers and the child jointly explore and extend concepts is a powerful means of supporting early language and literacy this model highlights the importance of dialogue during the reading as parents scaffold elicit and respond to comments from the child about the pictures or text and hence adapt the discussion to the childs level of understanding although research has established the power of book sharing it is also acknowledged that there are many different ways in which families from socially linguistically and culturally diverse communities engage children library trendssummer 2016 in highly effective language and literacy learning however research suggests that because of the emphasis on a bookbased education system some children may be disadvantaged at school due to a mismatch between home and school literacy practices thus a number of family literacy programs emerged around the world as a means of introducing families to strategies that support young childrens literacy in ways that potentially help bridge the gap between home and school these include programs in the united kingdom europe north america andaustralia they are informed by research suggesting that parents who are not used to sharing books may need ongoing support in selecting appropriate texts and scaffolding interactions through meaningful talk evaluating family literacy programs owen sees evaluation of an intervention as the process of making a judgment about the value of an objectthat is an intervention policy andor program and its purpose as enhancing the quality of the intervention in order to solve or ameliorate a problem within a social setting he also views the process as worthwhile if the knowledge produced is reliable responsive to the needs of policy and stakeholders and can be applied by these stakeholders in recent years there has been much interest in trying to quantify the magnitude of the impact of particular educational interventions through the use of metaanalysis which provides an effect size for an intervention hattie has explained the effect size as a useful method for comparing results on different measures or over time or between groups on a scale that allows multiple comparisons across content and over time and he identifies an effect size of 04 as the hinge point for identifying the effectiveness of an educational intervention he does however point out that a smaller effect size for an intervention that requires few resources may be more critical than a larger effect size for a program that requires more resources this may be particularly important for those family literacy programs that involve parents or other family members as the agents of intervention interacting around books with their young children in his review of more than 900 metaanalyses of interventions that targeted student learning hattie included one metaanalysis classified as a family literacy intervention which with an effect size of 018 is well below the 04 hinge point this review also included three metaanalyses of exposure to reading with effect sizes well above the 04 mark ranging from 059 to 078 carpentieri et al who conducted a review of six metaanalyses of family literacy interventions study found this to be the only study with an effect size below 03 while four of the studies had effect sizes greater than 04 the highest being 068 they concluded from these findings that family literacy interventions have a relatively large impact on child literacy acquisition nevertheless carpentieri et al raise a number of issues concerning the reasons for such conflicting results of metaanalyses the inclusion of different primary studies the number of studies the breadth of program type and measured outcomes the intervention and different interpretations of data they discuss in detail the intervention characteristics that may impact on results which include the duration and site of intervention the nature intensity and quality of parent training the quality of the implementation of the program and participant characteristics in terms of family disadvantage and the childs gender and age carpentieri et al also point out that these factors can combine to limit confidence in the interpretation of metaanalyses that often must synthesise the effects of interventions which are different enough to be considered apples and oranges they emphasize the importance of complementing metaanalytic assessments with highquality quantitative primary research and also highquality qualitative research family literacy bookgifting programs having examined the evaluation of family literacy programs in general we now focus specifically on the nature and evaluation of bookgifting family literacy programs two of the most widely disseminated and researched programs that involve the provision of free books for babies and young children are the bookstart and reach out and read programs from respectively the united kingdom and the united states which have served as models for other programs reach out and read is a healthcarebased intervention run by a nonprofit organization that has been operating in the country since 1989 with the mission of giving young children a foundation for success by incorporating books into pediatric care and encouraging families to read aloud together the program has a special emphasis on serving those in lowincome communities and is presented at a number of regular health checks when the child is between 6 months and 5 years of age at each checkup a pediatrician or nurse explains to parents the importance of reading aloud from infancy onward and the child is presented with a new book in many program sites books are provided in the waiting room and volunteers are available to model techniques for reading aloud to the child the program library trendssummer 2016 is implemented in 5500 sites throughout the united states and each year 65 million books are distributed to children a total of ten pediatric checks may be conducted between the ages of 6 months and 5 years the uks bookstart program was initiated in 1992 by the reading charity book trust working with library services health authorities and the university of birmingham as a pilot project involving threehundred babies it is now funded by the government and the book industry and coordinated nationally by book trust and locally by the library service in cooperation with early years settings and health professionals bookstart aims to inspire a love of reading that will give children a flying start in life it provides a baby pack to encourage parents to engage in bookrelated activities with children from the earliest years by providing books and guidance on reading for every child this pack distributed by health visitors in babies first year consists of books and guidance for parents on sharing books a treasure pack containing books crayons and paper is distributed to children ages 34 in early years settings parents and young children can also attend rhymetime and story sessions that take place in libraries and various early years contexts during 20132014 almost 15 million packs and 3 million books were provided to young children throughout england wales and northern ireland including almost 5000 to children with additional needs two of the most widely disseminated family literacy programs in australia lets read and better beginnings may be considered as broadly based on the bookstart model lets read is a shared reading intervention for children from birth to age 4 and was developed by the centre for community child health at the murdoch childrens research institute and the royal childrens hospital the mcri and the smith family charity have partnered to implement lets read within communities across australia this multipoint intervention provided by a trusted community professional has been extensively researched it is designed to be delivered at four points during a childs preschool years early literacy resources and materials including tip sheets for parents book suggestion lists ageappropriate books and key messages are delivered at each of the intervention points the reach out and read and lets read programs described above were created as preventative health initiatives public libraries have been highly involved in the implementation of bookstart since its inception the oecds 2012 report lets read them a story the parent factor in education shows the importance of parents reading to their children it also points out the importance of parents taking their young children to the library and talking with them about the books they are reading over recent years australian libraries have been highly proactive in developing and implementing family literacy programs further libraries are increasingly partnering with family literacy programs and becoming part of the lets read distribution and support network the better beginnings family literacy program that is explored further in this paper was launched in 2005 as an initiative of the state library of western australia and designed to provide positive language and literacy influences for young children through supporting parents as their childrens first teachers a reading pack is given to parents of young babies usually by the community childhealth nurse at the scheduled sixtoeightweek clinic health check the pack contains a board book and other associated materials including information on reading to babies and invitations to join the library and to librarybased activities for babies and young children that feature rhymetime and story sessions at the health check the contents of the pack and the importance of reading with babies and young children are discussed with parents caregivers the program is funded by both state and local governments and by industry evaluating bookgifting programs it will be seen that there are a number of differences between the four programs described above recent reviews of the nature and outcomes of bookgifting programs have been undertaken as part of the evaluation strategies for bookstart in the uk and lets read in australia while recognizing the importance of sharing books with young children these reviews have identified some methodological issues that are potentially problematic in researching these programs and drawing conclusions about their impact the following classification of issues which has many similarities to that of carpentieri et al for family literacy programs in general is based on findings from both reviews about key elements that need to be considered in the design and interpretation of intervention studies both reviews found the methodology of the study to be particularly important for planning and interpreting results shortterm studies may not be long enough to establish new practices whereas in longterm studies it is possible that the impact of established programs may appear less although this can be a direct result of a programs success in that ceiling levels leave little room for improvement another issue is the size of the study largescale longitudinal studies which often rely upon selfreporting questionnaires may include variations in the implementation of the respective programs such as the training of practitioners timing of book distribution to participants and level of intensity or guidance on the other hand smaller randomized control trials in which subjects are allocated to an experimental or control group according to a strictly random procedure require a high degree of standardization of implementation and assessment of children over time both of which are difficult to monitor in largescale bookgifting programs nevertheless cara and brookes have claimed that there is a lack of systematic evaluations in family literacy programs including rcts that are frequently used to investigate cause and effect in medical interventions and as hattie points out are part of a move toward more evidencebased decision making in education evaluating bookgifting programs through rcts there appear to be few published rcts of bookgifting programs and the results of those that have been reported are not consistent the us reach out and read program has been wellresearched using various methodologies including rcts mendelsohn et al document the results of an rct of this clinicbased literacy intervention in order to examine its effects on the language development of preschool children the participants were 112 impoverished innercity spanishor englishspeaking latino and black families who attended one of two wellchild clinics with their under age 6 child who did not attend kindergarten the intervention group from one clinic had been exposed to a reach out and read program for three years the control group from the other clinic had been exposed to the program for only three months all assessments were conducted in the childs primary language the results showed that the intervention families reported reading with their children significantly more often and that their children had significantly higher receptivelanguage scores further the intensity of exposure to the intervention as measured by the total number of contacts with the program was associated with increased parentchild reading activities the uk bookstart program has also been extensively researched through various methodologies an rct of the bookstart treasure pack which is given to all children between ages 34 was conducted in order to measure the impact of the pack by comparing change over time among 138 parents in intervention and control groups on five key outcomes these outcomes were • the perceptions of parents about books rhymes and songs • the perceptions of parents about their childs engagement with books stories rhymes and songs • parental practices and the frequency of reading with their child • the use and membership of a public library and • the childs book ownership the results showed a statistically significant difference in change over time on only one of these indicators which was for fathers reading with their children this difference was not noted for mothers and the researchers identified a number of confounding factors that may have accounted for this result they also identified some important factors that may well have accounted for the overall lack of positive results that include but are not limited to the low intensity of the program that was conducted over a short period of time and the presence of baseline ceiling effects for example nearly threequarters of parents in both the intervention and control groups indicated in a preprogram questionnaire that someone read to their child every day thus leaving limited room for improvement for many families the addition of this questionnaire which asked parents to report on their family literacy practices and perceptions of the program allowed for data that complemented results of the rct study and indicated that key stakeholders regarded the treasure pack as a highly regarded and significant intervention in australia goldfeld et al reported no measurable differences between intervention and control groups in their fouryear multipoint rct study of the lets read program this was delivered by nurses at child health centers in five relatively disadvantaged areas at four points in time to mothers and their babies who attended the usual wellchild care visits at 48 weeks and 12 18 and 42 months of age at each visit the nurses who had received training by the research team were asked to spend about five minutes delivering modeling and discussing the lets read promotion messages with the mother the nurses also gave the family a takehome pack of an ageappropriate picture book book list and guidance on shared interactive reading activities and appropriate book selections however results indicated that there were no significant differences among the experimental and control groups on the outcome measure of a childs emergent literacy skills at age 4 the researchers suggest that the study may have been limited by the facts that the parent participants living in the targeted disadvantaged area were among the more advantaged in their region that there were no translating resources for families who spoke english as an additional language and that for some families the library trendssummer 2016 intervention was delivered via telephone rather than face to face they also suggest that a more intensive program might have produced more positive effects no rcts have been reported for better beginnings as can be seen the results of rcts for bookgifting programs presented above are inconsistent there are many possible reasons for these results including the intensity of the program families involved in reach out and read could experience up to ten clinicbased intervention sessions including advice and modeling provided by specifically trained pediatricians and nurses on the other hand lets read with its four points of program delivery and bookstart with two widely spaced points of intervention are much less intensive recently burden has presented a highly detailed critique of the use of rcts with a particular emphasis on their use in measuring the effectiveness of literacy interventions he outlines a number of important issues that need to be considered in order to meet the minimal criteria of acceptability when using this methodology for evaluating an intervention the first two of which are randomization and control in terms of randomization the issue is the creation of intervention and control groups that are truly representative of the target population as a whole given the multiplicity of possible biases within samples control issues that may affect results include the integrity of the program and the teaching provided to each group burden concludes that the process of learning is extremely complex in terms of context teachers and learners whereas rct methodology is underpinned by a simplistic view of the learning process he proposes a more inclusive approach to program evaluation that features a cyclical review of context plans actions and reflections that in combination can lead to a realistic evaluation of the effectiveness of a program and to decisions about its future directions in general it seems that randomized control trials may not be able to capture the many complex factors and their interactions involved in most universal bookgifting programs in particular it seems that results depend on the ability to control for a range of variables including randomization of the sample the intensity of the program and the social cultural and linguistic backgrounds of families there have been some positive results for the highintensity reach out and read program when sociolinguistic variables are tightly controlled showing that under these particular conditions strong evidence for the effectiveness of bookgifting programs can be obtained nevertheless in view of the lower intensity and much more fluid nature of other universal bookgifting programs which make randomization and control exceedingly difficult if not impossible it seems that a more inclusive approach is needed as discussed by demack and stevens in the rct of bookstarts treasure pack questionnaires that address family perceptions and practices can provide highly valuable data that help explain results this accords with the conclusions of carpentieri et al that highquality quantitative and qualitative research methods are indicated when evaluating family literacy programs a mixedmethods approach to the evaluation of bookgifting programs the need to take an inclusive mixedmethods approach that incorporates both quantitative and qualitative methodologies in the evaluation of bookgifting programs is indicated in order to capture the complexities of literacy learning this approach is especially important in the current political climate that seeks to legitimize hard evidence as the most compelling means of demonstrating the effectiveness of interventions many program providers are under pressure from funding bodies to demonstrate program effectiveness in relation to specific academic outcomes in australia there are mandated literacy and numeracy assessments that begin at school entry since they have to manage limited resources policymakers and funding bodies are increasingly driven by scientific evidence and accountability based on shortterm results this approach however may limit our understanding of bookgifting programs as it does not take into account program implementation and contextual variables within communities that help determine the significance and impact of programs for children and their families carpentieri et al have argued that insufficient evidence is available from primary studies to understand why when where and for whom they are effective thus potentially misleading policymakers and funding bodies in their decisions about supporting particular programs an inclusive approach to the evaluation of bookgifting programs that involves the collection and use of both quantitative and qualitative data provides the opportunity to explore the complexity of program implementation and impact quantitative methods like surveys provide breadth of evidence and qualitative methods like case studies interviews videos and observations provide depth combining these methods has the potential to produce broad evidence from a wide range of participants and communities while also capturing the lived experience of participants within a particular time and place carpentieri et al argue that impact should be identified through a wide range of measures including recognition of the broader effect of programs such as changes in attitudes confidence and selfefficacy in addition program implementation should take account of the context in which it is delivered because the ways in which programs are enacted are related to personal social economic and cultural factors in order to illustrate the process and outcomes of an inclusive mixedlibrary trendssummer 2016 methods approach to the evaluation of bookgifting programs the following sections draw on the longitudinal evaluation of the better beginnings bookgifting program initiated by the state library of western australia this state covers an area of more than 25 million square kilometers and has a population of 25 million people most of the local governments are in regional and remote western australia the largest of which covers almost 4 million square kilometers and has a population of only 8000 it can be seen that geographical constraints create enormous challenges to statewide accessibility to this program the better beginnings evaluation process the pilot study in 2004 the better beginnings pilot was set up as an intervention program in six very diverse communities in western australia evaluation was built into this exploratory program from the start through the use of a formative experimental design that allows for the investigation of factors that contribute to or detract from the effectiveness of an intervention the evaluation took place in two of the six communities a mining town with a significant aboriginal and torres strait islander population 600 kilometers distant from the nearest major city and an outer metropolitan suburb containing a range of residential settings and a small aboriginal and torres strait islander population in carrying out this evaluation we were mindful of owens proposition that it should be a process that investigates the value of an intervention in order to enhance its quality and produce knowledge that is reliable responsive to the needs of policy and stakeholders and can be applied by these stakeholders the quantitative data for this pilot study consisted of 107 preprogram surveys completed by mothers before they received the reading pack and a postprogram telephone survey completed by sixtyfive of these mothers some qualitative data were also included in the surveys as the mothers were encouraged to provide openended comments at the end of each section qualitative data were also provided by eleven mothers who represented a crosssection of socioeconomic and educational backgrounds and were interviewed in their homes and observed reading with their children in addition five community health nurses who delivered the program the central coordinators and a librarian from each community were interviewed in this way the voices of a diverse range of participantsmothers and professional library and health personnelwere heard the results identified reported changes in the mothers perceptions and practices some strengths of the program design and implementation and issues that indicated key areas for modification and development family literacy programsbarrattpugh rohl 31 extending the program and evaluation cycle based on the results of the pilot study some modifications were made to the program and it has been gradually extended to include every family with a new baby in western australia and thus may be considered a universal program because the methodology used in the pilot evaluation had provided depth and breadth of information it was decided to employ similar instruments in the following evaluations but with some additions and minor modifications to reflect the development of the children from infancy to kindergarten two underlying questions have been addressed how effective is the better beginnings program from the perspectives of the participants how has the program including its implementation been developed and sustained in order to address these questions annual evaluations were undertaken in four diverse communities as in the pilot project these evaluations included a survey of parentscaregivers from varying socioeconomic backgrounds and educational levels the research instruments were somewhat modified each year to capture the ongoing impact and sustainability of better beginnings but were similar enough to allow for comparisons over time a longitudinal study of data from the first four evaluations was made in order to examine the implementation of the program from a longitudinal perspective in addition to the surveys each year we undertook interviews with forty casestudy mothers drawn from the sample of parents individual interviews with ten local librarians across the four communities focusgroup interviews with thirteen childhealth workers who delivered the resource packs in the four communities and interviews with the state library coordinator in the following year based on recommendations of the fouryear evaluation additions were made to the study methodology these included videos of the casestudy mothers sharing books with their children and interviews about books and reading with them 2 the following section summarizes major findings and how important issues identified by both the quantitative and qualitative data were addressed in order to modify and extend the program in addition to some impacts on policy these are discussed in relation to key elements identified earlier in this paper that need to be considered in the design and interpretation of intervention studies and include not only the program methodology and participants but also the role of the state library and librarians the program evidence from the evaluation demonstrated that the state library in collaboration with local librarians and childhealth nurses had the capacity library trendssummer 2016 to deliver sustain and extend the better beginnings program feedback from the annual parent evaluations and the collection of data from childhealth and library participants and stakeholders resulted in a number of strategies being implemented to strengthen the infrastructure of the program and increase its reach some of these strategies related to the central coordination of the program and the training and roles of library staff central coordination of the program data from ongoing interviews with library staff informed the development of the role of the central coordinator as it evolved to encompass responsibility for maintaining partnerships with public libraries organizing professionalstaff development delivering the program reinforcing links with other agencies and strengthening the networks within the program accordingly the coordinator supported and nurtured the partnerships among the childhealth nurses librarians and other professionals which have impacted on policy in terms of a memorandum of understanding that has been developed between the state library of western australia and various state health agencies to facilitate statewide provision of the program further funding for better beginnings has become part of the state librarys standing budget thus ensuring ongoing support that allows for longerterm planning central coordination also facilitated a major media campaign to publicize better beginnings as a recognized brand in and across communities this has reinforced and sustained the better beginnings message of sharing books with babies from birth and provided links across western australia to other early literacy family programs such as lets read central coordination has also allowed better beginnings activities to be included in the childrens section of the annual perth writers festival training feedback from interviews with childhealth nurses and librarians has informed the professional development of librarians based on identified needs during the course of the evaluation several librarians requested more information about practical aspects of the program and examples of practice they also identified a need for information about networking with other librarians and ways of working with aboriginal and torres strait islander peoples and other culturally and linguistically diverse families accordingly professional training was developed that addressed these needs in view of diverse geographical challenges in western australia delivery has moved from a printbased handbook to an integrated approach that includes where possible facetoface handson modeling and experiences and also webbased information and sharing of practice most recently four online modules for librarians are being developed that have the potential to engage a wider audience family literacy programsbarrattpugh rohl 33 role of the librarian based on feedback about the responsibility for and management of the better beginnings program several initiatives have been implemented in local libraries first where possible a librarian has become the designated better beginnings coordinator who welcomes informs and encourages families to join the program and obtain library membership second space permitting familyfriendly areas have been identified with coded books for easy access and choice third rhymetime and story sessions have been timetabled on a regular basis and integrated into library services for families thus providing librarians the opportunity to model booksharing strategies for families and introduce them to library resources and other programs that target literacy for infants an innovation to encourage and engage nontraditional library users has involved librarians taking better beginnings into the community including mothers groups play groups and parks involvement of the families the surveys and interviews with the mothers provided longitudinal evidence that for the majority of them the program helped to introduce or reinforce beliefs about the importance of sharing books they reported an increase in the frequency of book sharing the number of books in the home selfconfidence and selfefficacy there also appeared to be a ripple effect in that other family members became involved in book sharing with the target child and other children in the family including any additional newborns additionally the mothers reported increased access to resources and booksharing practices through library membership and attendance at library activities in some remote aboriginal and torres strait islander communities it appeared that the better beginnings gift book was the only source of childrens literature changes in child literacy practices were also reported such as asking for books to be read developing a love and understanding of books and developing a positive selfconcept as a reader other important outcomes reported by a small number of mothers included motherchild bonding increased literacy skills for adults in the family who had low literacy levels and a number of fathers or male partners becoming involved in sharing books and singing nursery rhymes in each year of the evaluation the mothers were asked to identify the ways in which delivery content and activities could be improved or developed and were also invited to add further comments about their experience with better beginnings accordingly suggestions were made about ways of improving the program and where possible these were incorporated into the development of the resources delivery of the program and library activities from the openended survey questions and interviews with mothers librarians and childhealth nurses two key issues emerged the first was a strong interest by mothers about how to continue to facilitate their childrens literacy as they matured and how to prepare them for formal school the second was a concern by librarians and nurses about how to engage culturally and linguistically diverse families including those living in remote aboriginal and torres strait islander communities in the better beginnings program extending the program given the evolving evidence base for the effectiveness of better beginnings and in response to feedback about the program from the ongoing evaluation it was decided in consultation with the major funding bodies to extend the program as a result a number of new programs have been developed piloted and evaluatedtwo of which on the basis of the evaluative findings have been continued better beginnings four to five this program is delivered by local librarians through kindergartens in western australia it consists of a reading pack given to the child and two sets of resources that may be borrowed a discovery backpack containing a variety of picture books and electronic resources puzzles and reading tips and a readaloud book set for shared reading along with suggestions read to mei love it this program has been developed to support the specific early literacy requirements of children living in remote aboriginal and torres strait islander communities the program is delivered to a hundred such communities in western australia twice a year by local distributors who are recognized as being part of the community the reading packs include a range of specifically designed culturally appropriate books and activities that have been developed to support the early literacy requirements of children living in remote communities help library services become more relevant to the lives of aboriginal and torres strait islander australians and provide resources for communities who have limited access to books and library services these programs show how evaluation identified the need for and informed the nature of new programs and as a result has finetuned program content delivery and activities in a number of important ways the content in the better beginnings four to the study methodology the inclusion of qualitative and quantitative methodology in all the better beginnings evaluations posed some challenges in relation to both data collection and analysis but is discussed here in relation to the better beginnings birth to three fouryear longitudinal study the first issue relates to the decline in the number of mothers participating in the survey there was a decrease in the number who responded to the surveys over the four years year 1 300 mothers year 2 177 year 3 102 year 4 84 although perhaps not unexpected given the nature of family demands and the transient nature of some communities in the study this could also be a reflection of different levels of importance placed on literacy by mothers who remained in the study and those who withdrew we were not able to recruit fathers and other male primary caregivers who might have provided a different perspective on the better beginnings program the second issue concerns the validity and reliability of the selfreport surveys and casestudy interviews with a selection of mothers the same research assistants contacted the mothers each year to conduct the telephone survey and as they had knowledge of the mother and child in some cases they had built up a strong rapport with the mothers a desire to please and or give perceived right answers as well as being prompted by a telephone call about literacy practices might have colored the mothers responses on the other hand this approach had the potential to build trust and to collect reliable data as researchers sought clarification illustrations of practice further information and checked for misinterpretation in the fifth year of the study video observation of motherchild book sharing and child interviews were also undertaken adding further layers to the picture emerging from the evaluation in a subsequent evaluation of the read to mei love it program in remote aboriginal and torres strait islander communities where appropriate and possible the interview data collection was modified to include conversations around the program rather than direct questioning we chatted with participants within contexts that were part of their everyday experiences such as around the shop in the playground and in the play group thus the datacollection methods were designed to help capture the ways in which better beginnings was experienced and enacted by families in different communities our analysis of the data collection revealed some of the complexities contradictions and ambiguity of the effectiveness of better beginnings the relationship between better beginnings and the myriad of family literacy practices embedded in cultural social and linguistic contexts was multifaceted as well as the broad endorsement of the value and impact of better beginnings a number of additional realities began to emerge from both the surveys and interviews with the mothers which included the following • shared book reading as a means of forming relationships mothers reported bonding with their baby • shared book reading as a means of supporting adult literacy mothers reported fatherspartners learning to read with the new baby • shared book reading as creating conflict in one family being literate was viewed as shameful and thus the program posed a number of conflicts • shared book reading as a means of creating inclusivity one mother talked about how she and her specialneeds child felt included for the first time in a mainstream initiative • using the gift book as a means of recognizing and endorsing cultural diversity several mothers reported the importance of the themes and illustrations in the resources that reflected their cultural experiences • using the gift book as a way of marking and celebrating a milestone in the babys life some mothers reported this was their babys first book and thus worthy of celebrating and keeping • using the gift book as filling a void within a family a small number of mothers reported that the gift book was their only book and one talked about how she used it to fill a silent house • using the library as a safe place within the community two mothers reported that the program had introduced them to the library and this was the only place they felt safe with their children this brief discussion of the studys methodology and analysis has shown some limitations of the data collection nevertheless the contextual adaptation of the datacollection methodology which was informed by previous evaluations and the qualitative data analysis have allowed some insights to emerge that illustrate the diversity of families and their contexts it also allowed for additional interpretations of the meaning of the program to different families above and beyond its original aims in terms of equity it is important that universal family literacy programs are able to take into account such diversity in program design implementation development and analysis conclusion our review of the evaluation of family literacy programs with a focus on those that provide free books and resources to mothers babies and young children illustrates a need to move beyond simple causeeffect relationships and to identify the multiplicity of ways in which these programs are experienced within and across families specifically our overview of the evaluation of the better beginnings program has attempted to show how the program is taken up differently by different families suggesting that there is no absolute reality in terms of implementation engagement or outcomes we have identified the complex interplay among the mothers and babies the providers and the librarians that is mediated through the reading pack and the library activities by offering a broad view of how bookgifting programs are experienced and uncovering the assumptions that underlie the design implementation and evaluation of such programs we hope to provide new insights about early literacy programs that honor diversity and ultimately make a difference to the future of our children this approach demands a methodological framework that incorporates both quantitative and qualitative data quantitative studies offer greater breadth of coverage while qualitative studies have the potential to illuminate the complexity of literacy practices within the social cultural educational and political contexts in which literacy programs are situated in relation to the better beginnings program our research suggests that libraries have an important role to play in continuing to support family literacy as key service providers of free resources and activities the role of better beginnings is multifaceted and its ongoing evaluation process has informed the ways in which it has grown to meet the needs identified by the participants differentiating the program according to the community context and making a difference to children and families in those communities notes 1 the term parent is used to encompass mother father and primary caregiver 2 detailed results of the evaluation can be found in barrattpugh and allen barrattpugh androhl and barrattpugh anderson north library trendssummer 2016 australia her research interests include language and literacy in families communities and formal educational settings and the evaluation of early literacy programs she has been a codirector and director of several state and national literacy research projects and is currently director of the evaluation of the better beginnings family literacy program in wa numerous publications and engagement with professionals parents and other key stakeholders through her research has resulted in evidencebased recommendations for policy and practice across the early childhood sector mary rohl is a literacy specialist whose research has concentrated on literacy learning and teaching with an emphasis on the early years literacy learning difficulties and prevention of literacy difficulties over a number of years she has been a member or codirector of various national and state childrens literacyproject research teams which have focused on a wide range of literacy issues including effective teaching practices in the early years of school and home and school literacy practices she also has extensive teaching experience within a range of early childhood settings in the uk and australia and in teacher education in western australia

this paper examines the nature of family literacy programs with a particular focus on those that are based around the provision of free books to babies and young children sometimes called bookgifting programs first the paper explores the rationale for family literacy programs in general and identifies some issues in their evaluation it then focuses specifically on bookgifting programs using examples from several wellestablished programs it reviews the research on which they are based with particular reference to evaluation procedures next the paper identifies some important issues that need to be addressed when planning and evaluating these programs and notes some fundamental differences between particular programs that may have impacted on the results it argues that this area of research needs stronger definition and a more inclusive approach to evaluation that includes both quantitative and qualitative methodologies in order to illustrate the potential of a mixedmethod approach the paper examines the evaluation of the better beginnings bookgifting program for babies that has been initiated developed and extended by the state library of western australia for over a decade the paper concludes by suggesting that effective program evaluation is complex and multifaceted and must consider changes in behavior confidence and attitudes as well as the ways in which such programs are experienced and integrated into family literacy practices this approach provides insight into the contextual variables that determine the effectiveness of programs within and across families and therefore inform further program development

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background as a result of conflict persecution and wars in other countries each year australia receives many requests for asylum and humanitarian resettlement according to the australian department of immigration and citizenship in 20112012 almost 43000 applications were lodged for protection visas 1 of which 7038 were granted 2 half of the applications were from irregular maritime arrivals those who arrive by boat and the remainder were lodged through the united nations high commissioner for refugees 34 globally 46 of the refugee population is aged under 18 years 3 and in australia for the 20122013 program year the largest proportion of the humanitarian visa applications were in the age group of 1519 years 1 children and young people seeking asylum are particularly vulnerable to the longterm impact of human rights violations discrimination and trauma experienced in their home country transition and resettlement country 5 given the importance of adolescence and early adulthood as a critical time of significant physical mental and emotional development support programmes for the successful resettlement of refugee youth should be a priority for host countries commissioner for refugees most of these refugees are resettled in the usa canada australia some european nordic and latin american countries 6 australia is a signatory to geneva convention and has granted 75000 humanitarian visas since world war ii in its humanitarian entry program 7 australia continually reviews its resettlement programmes settling in payments reflecting its commitment to helping humanitarian entrants into australia 5 8 9 10 after resettlement the first 36 months are funded by diac through the international humanitarian support scheme 11 those arriving through the overseas resettlement route receive continued support through medicare and centrelink 11 in recent times diacs emphasis on selfreliance has led to a reduction in support especially of social services and sponsored housing policy changes often create confusion a lack of clarity regarding available services and increase pressure on community and volunteer organisations 12 factors affecting resettlement an australian study reported on psychological factors that facilitates refugees resettlement experience 13 overall wellbeing was linked to indicators of belonging specifically social status support lack of discrimination and a peaceful environment the study documented that if these indicators are addressed then refugee youth felt included in society and would thrive 13 asylum seekers and refugees arrive in australia with a background of human rights violations often presenting complex health issues such as torture exposure to prolonged trauma and mental health issues 51415 in addition separation from family often led to feelings of loneliness guilt and ostracism 1415 community based organisations provide limited services but the absence of essential ongoing mental healthcare impacts the overall wellbeing of refugees 1112 refugees are often stigmatised and discriminated against and this discrimination often increase with their inability to understand the language and culture 5 in a study of afghan female youth in melbourne resettlement was improved through relationships with others from the same cultural background the same study found that those attending english classes for over 6 months felt more optimistic and competent in their ability to communicate 5 refugee youth also recognise and value the freedom that they have in australia but are often confronted with cultural conflict 5 resilience there is a direct link between resilience and coping strategies in the context of the vulnerable populations 16 luthar and cicchetti refer to resilience as positive adaptation despite adversity programs which focus on integrated and comprehensive interventions by working with the individual family unit and community have been successful in increasing resilience within marginalised societies and have shown that emotional distress in the absence of strong social structures impacts negatively on resilience 16 17 18 another study documented that an individuals resilience was enhanced if there was a sense of hope strong structures and leaders social support and a feeling of personal security 1920 research to ascertain the resettlement experiences of refugee youth is needed particularly studies which focus on the development of intervention models that address the complex needs of this population and build resilience 18 this crosssectional study undertaken in western australia hoped to address this gap and was framed in the context of australian humanitarian policies methods due to the sensitive nature of the issues being exploredresettlement issues faced by refugee youth a qualitative approach was considered appropriate as it allows for an indepth exploration of issues the study comprised of focus group discussions key informant interview and a systematic review of literature this study was conducted between july and november 2013 as part of a larger project and examined the resettlement and coping strategies amongst refugee youth from afghanistan the democratic republic of congo ethiopia sudan south sudan iraq pakistan and burma at an intensive english centre and centacare employment and training in western australia purposive sampling was used to recruit participants the institutions were approached to take part in the study as they were known among wa migrant networks and had made a difference to the community and also played a role in empowering refugee youth the study examined resettlement experiences and social and community support available to the refugee youth in regards to health education social support and employment in wa it also explored the participants coping strategies as they established a new life in wa conceptual framework used for the study the study was underpinned by the psychosocial conceptual framework which rests on the assumption that the psychosocial wellbeing of an individual is defined by three core domains human capacity social ecology and culture and values these domains map the human social and cultural capital available to people responding to challenges of prevailing events 21 broad themes raised for discussion and drawn from the analysis explored factors that enhance resilience the sociocultural contexts of the adolescents lives their sense of belonging and community cohesion experienced as they resettled in australia and their perceptions regarding future aspirations figure 1 illustrates the interlocking of these domains human capacity social ecology and culture and values these domains also map the human social and cultural capital available to people responding to the challenges of prevailing events and conditions these domains have utility and validity as discrete lenses through which the impact on resources at the community level is considered 21 participant recruitment and data collection participants were selected using opportunistic and purposive methods to ensure selection of informants who were uniquely positioned to share their experiences of the process of resettlement refugee youth were recruited at the intensive english centre cyril jackson senior college and centacare employment and training in wa three fgds were conducted one with one male and two female participants from the drc the second with four male participants from afghanistan and the third group consisted of four females and four males two from burma two from iraq two from south sudan one ethiopian and one pakistani almost all the participants were adequately proficient in english to be able to converse and share their thoughts except for two male youth in the third group who had a lower level of participation in the fgd in the fgds participants shared demographic information their mode of migration languages spoken their experiences of health and education services social support acculturation and aspirations for the future the fgds were conducted such that refugee youth from the same cultural background were interviewed in the same group so that they felt at ease except for one of the fgds which was organised such that participants with the same level of english participated in the interview there were no gender based questions so males and females participants were interviewed at the same time the first two fgds were conducted at the cyril jackson school campus and the third one at the centacare in mid2013 two research assistants from ethnic minority backgrounds and the second author conducted the focus groups the fgd was concluded when data saturation was achieved and no new information was forthcoming from the groups every effort was made by the research team to avoid bias after the fgds two key informants were purposively recruited from amongst refugee advocates with knowledge of the diverse experiences of asylum seeker and refugee youth and the complex issues surrounding resettlement in australia the first ki was a migration support officer with a social work background working with the west australian red cross the second ki worked as a human rights lawyer with refugee support centres for more than 5 years both kis were passionate about refugee and asylum seeker resettlement issues semistructured indepth interviews were conducted with kis and the issues discussed were coping and resilience during resettlement humanitarian resettlement quotas and the process of onshore and offshore asylum applications their responses supported the responses of the fgd participants ethics approval ethics approval was obtained from curtin universitys human research ethics committee written informed consent was obtained from all participants under aged participants obtained consent from their parents or legal guardians and also signed the consent forms information sheets were distributed prior to the study and participants were informed that they could withdraw from the study at any time research rigour this research used dependability credibility confirmability and transferability 22 important components of this qualitative research 23 trustworthiness was established through reflexivity and clearly defining the roles of the researchers and refugee youth in every stage figure 1 the domains of the psychosocial framework 21 of data collection and findings 24 member checks with key informants clarified issues that emerged during data analysis to enhance validity 22 an audit trail 24 ensured that methods were documented so that data analysis and results were confirmed and transferable and the study replicated by other researchers data analysis the psychosocial framework allowed for recurring and significant themes to be identified under the themes of human capacity culture and values 2125 the fgd and ki interviews were taperecorded and transcribed verbatim for analysis a two fold process to data management and analysis using a modified framework approach was adopted through the reading and rereading of the transcriptions to identify themes this allowed the researchers to review the data to generate themes identify quotes to enhance rigour 2627 member checking was undertaken through interpretation of themes between members of the research team themes were shared informally with some participants and key informants to corroborate themes and validate conclusions the second stage refined the existing themes 2829 through a process of reviewing grouping and identifying overlapping themes and identifying key issues that were recurring the key emerging themes were discussed amongst the researchers and the responses of youth participants triangulated with findings from the two key informant interviews themes drawn from the analysis and underpinned by the psychosocial framework are presented in table 1 the theme aspirations for the future overlapped all domains and has thus been included in all the domains in table 1 participant quotes relevant to each themes were incorporated into the analysis to validate the themes and were selected by a member of the research team who had undertaken the interviews and then were considered by other members of the research team finally the third author went reviewed the themes and quotes results study participants the participants from the drc were all aged 19 years and had been in australia from 3 months to 15 years on humanitarian resettlement visas two had lived in tanzania and one in zimbabwe they had come with their families and spoke swahili french shona and english three had high school education and were attending intensive english classes over 16 weeks before moving to mainstream classrooms four participants from afghanistan were male one was aged 17 two were 18 and one was 20 years old three participants had arrived in australia alone by boat and sought asylum 1218 months previously they spoke hazaragi dari persian and english participants in the third group were aged 1928 years and entered australia on humanitarian resettlement visas except one ima four were with families upon arrival while the rest of the group entered australia alone the time being resettled in australia ranged from 1 year to 8 years with most of the participants being here 2 years human capacity themes language fluency in english language especially spoken was either a barrier or facilitator to successful resettlement only one congolese participant had spoken english prior to coming to australia although she was not proficient in the language the youth reported that if they felt confident with the language they had less problems overall and settled in faster yes it is the most difficult the language you cant talk to anyone everywhere you go even at home when someone is calling from company centrelink or hospital you cannot communicate with them i just tell them sorry i cant speak english but after that i feel very sad congolese female when i came here i didnt want to do english because honestly i was ok with english but the school principle told me i dont have any papers showing that sometimes i feel like i have lost so much time doing english when i was supposed to go to mainstream classes congolese female education all the youth had some formal education in their countries of origin however none of them were taught health and wellbeing all the participants reported that in wa they have better access to healthcare with access to medical treatment if needed language is a barrier to this access especially on arrival when english language proficiency is minimal two afghani youth who were unaccompanied arrivals relied on guardians or friends for translation assistance interpreters were used by almost all the refugee youth at medical facilities while those that used an interpreter reported a better experience with the health care system interestingly the only emotional health issue mentioned was that of being torn between newfound freedom in australia and the sadness that came from leaving behind friends and family this was rather unusual as higher levels of mental health issues such as posttraumatic stress disorder and depression were possible given their history of trauma and dislocation and current circumstances of enforced separation from loved ones however these young refugees were also very resilient participants all commented on the unpleasant situation they had experienced in transient countries and reported that they felt emotionally better in australia i like it because its good for me to see the doctor because in africa we were sick like 2 years 3 years without seeing the doctor so i dont know if im sick or not but here when i visit the doctor i can know all what is going so for me yes i like it congolese female the positive thing is that the service here is better than my country the negative thing is you miss your parents and sister and brothers iraqi female a medical appointment is important so it is important to make sure they bring the paper work they need and if they need somebody to be there for them because the majority of our clients are single adult males in their 20 or 30s and they are completely by themselveskey informant 1 employment the congolese females stated that they were focusing on education rather than employment the males were all looking for jobs and reported finding it difficult to find employment the three afghan participants had vocational skills that were not recognized in australia resulting in considerable disappointment participants reported having limited access to computers and the internet and not being familiar with these technologies as their main difficulty given that most job opportunities in australia are posted online i want to study business management my second plan is community services congolese female social ecology themes social activities refugee youth participants reported limited social activities outside of structured support and their community most of their social interaction took place at the college the congolese males played soccer in a league and the afghani men played sport at least once a week with other men from afghanistan the congolese womens social activities revolved around church events the main social activity with their own community was through church or special functions with afghan and congolese ethnic communities providing limited support to youth for everyday social life theres a place that everyone can play afghani guys and if you like you can play soccer and if you like you can play basketball or volleyball afghani male religion all of the youth from the drc mentioned that they went to church at least three times a week the afghani youth also attended religious islamic celebrations for me its three times a week we have a church service in wednesday night saturday night and sunday morning congolese male we always go to mosque to pray i meet many muslim sisters there and feel happyiraqi female provision of free transport facilitated refugee youth attending church regularly almost all boys took part in sports which had helped them to find friends and socialize while the girls didnt play sports so lacked opportunities to meet others outside of school religion played an important part in the lives of the youth support structures all participants expressed that they received minimal assistance from caseworkers the unaccompanied minors relied mostly on guardians for support or friends that were resettled in wa guardians were usually community members from the same ethnic group and for unaccompanied refugee youth aged 1618 years the state specifically the department of child protection is their guardian and they are normally provided with a group home only one of the participants had an australian friend and the rest had friends from school or other refugee background those with family in australia relied upon family members to discuss and solve problems and two female participants mentioned receiving a small level of support from their neighbours those entering australia on their own mostly received support from friends of the same ethnicity one of the key informants mentioned a successful community volunteer program that community members could register and diac would supply them with the necessary services available to refugees actually they should help us for 67 months but they didnt they helped us just for 1 month or 2 months and after that they didnt care about us and it was very hard afghani male i have one friend she has been here 10 years she is my best friend when i have any problem i go to her and she says to me do this and that congolese female the good thing i found here that was never in sudan is that neighbours help a lot every time i want to go out my neighbour asks me do you know when the bus comes my neighbour is australian and she is too nice sudanese female community volunteer program was discontinued and despite pushes for that to be reinstated because it was a really successful programnothing happened key informant 2 cultural capacity themes connection to family refugee youth felt they shouldered responsibility to provide financial and emotional support to the family remaining behind in their home country and it was a big concern for both youth and their families they constantly felt upset that their family members siblings or parents were left behind in the country of conflict or transit country they are able to contact and talk to family and do so often sometimes unwittingly incurring high telephones bills when they first arrive in australia yes absolutely because my family in afghanistan they live there in danger and i cant do anythingafghani male its very difficult here i came here alone i had a big family there i havent seen them in a long time now i have to send money back home…they think i have lots of money here but they dont know the expenses here are very high pakistani male i talked to mum and said i miss you mum i want to come back and live with you sudanese female parental language and skills all participants who arrived with family found that their parents had more difficulties learning english and this increased their own responsibility as they had to provide communication support some participants also stated that their parents had lost the status they had in their home country due to their lack of proficiency in language many refugee youth had to help their parents with their everyday activities in australia english is the number one need so getting our clients to set on english programs whether it is to bringing clients to english classes or doing oneonone assistance at home or doing it here is really important key informant 1 my dad my mum they werent able to speak so i was the only one who can understand so we went out together and i showed them…congolese female the youth were required to help whenever an interpreter was needed sharing their experience of attending hospital maybe i think we should just have some interpreter for other languages that cant speak english its very hard to go to the hospital afghani male aspirations for the future all participants had plans for the future they indicated a greater feeling of freedom and opportunity compared to their home country for example the congolese girls shared plans to go into business management the male participants planned to finish technical and further education and to find a job as police officers army officers mechanics and others most indicated they felt like they had many more options for study and work in australia in future i want to finish school go to another school or uni i want to do my course then i can plan future to be nice to find a good job congolese female actually i am very happy because here i have peace and lot of opportunity for the future and i have freedom i am free to do anything i want i think australian government is good because if someone wants to become everything they can really afghani male overall the participants shared that they had a better life peace and freedom in australia despite unemployment and were grateful they had been resettled in this country some recommendations shared by refugee youth at the end of the fgd the refugee youth were asked if there had any recommendations for improving resettlement experiences the afghan youth expressed the desire to be able to sponsor family members to resettle in australia the timeframe of 713 years before family members can be resettled was described as disheartening overall participants said that although support received through centrelink was appreciated it did not cover all expenses and they often had financial difficulties one participant recommended more help in finding housing many participant mentioned learning english prior coming to australia and ongoing english language support as the key to be successful discussion this qualitative study drew on the experiences of a small number of refugee youth from afghanistan and the drc who have arrived on humanitarian visas in comparison to those who arrive by boat seeking asylum and examined factors that help or hinder successful resettlement the analysis of both fgd and the key informant interviews revealed that resettlement experiences were strongly connected to language education social activities support structures and health the refugee youth experienced both positive and negative resettlement experiences during resettlement the strategies adopted by the refugee youth that enhance their coping and resettlement are learning the english language and developing new skills engaging in sports furthering their education to increase their employment opportunities and seeking support from family and through religious activities many of these findings were consistent with the experiences of refugee youth identified in previous research internationally 458913 a relevant and recurring theme found was the issue of language proficiency either when accessing health employment and commercial services or as a barrier to study and work in the new country previous studies have documented that higher english language proficiency increases confidence in accessing services 528 despite the fact that refugee youth appreciated the free medical treatment available in australia lack of english proficiency and interpreters in the health system was a frustrating barrier to our knowledge this is one of few studies that documents the impact of the lack of recognition of prior education and learning on refugee youth resettlement some of the older youth who had some skills in their home or transient countries could not have these recognised in australia all of our participants reported a positive education experience with teachers willing to help refugee students from a refugee background 14 social activities and support networks in this group revolved around family friends and religious groups with similar background 91013 highlighting the importance of culture and religion but also how these aspects influence the social ecology limited support from caseworkers was an important finding and is an area that warrants further exploration it is possible that his may be a reflection of the large proportion of humanitarian entrants who are imas and the punitive approach taken by the australian government which has meant community support workers to assist with resettlement are under resourced and there is a greater dependence on volunteers a suggestion shared by the key informants in this study was that community volunteer programmes could greatly assist the resettlement of unaccompanied minors and imas despite continuing change in government policy actions can be taken by migration support organisations to facilitate successful resettlement 11129 emphasis on engaging community members providing more assistance in the first year of resettlement education on available language and health resources will aid the process of successful resettlement community volunteer programs provide access to government services interpreters legal advice localised help sources and also help with integration previous studies also support the recommendations shared by the participants and key informants of enhancing english language skills implementing strategies to improve educational outcomes and providing greater community support 143031 thus recommendations proposed by refugee youth and key informants need to be taken into consideration to build resilient communities of refugee youth with a strong capacity to cope and thrive there are severe long term impacts on refugees who are unable to gain english proficiency in terms of their ability to work and social connections which highlight the critical importance of early support to assist refugees with adapting and integrating in their new country 32 the problems with resettlement that were identified in older refugee youth many of whom had been in australia for many years reflect that their aspirations for resettlement had not been realized 33 the study provided rich data from a small group of participants however there are a few limitations to the study the sample was small and thus whilst not possible to generalise the findings the recommendations proposed are transferable and add to the growing body of research on refugee youth the funding constraints meant that the study could not be expanded to include more participants this capacity to cope and be resilient may be adversely affected with more restrictive government policies that were implemented in july 2013 the australian government implemented new policies pertaining to those arriving by boat stipulating detention and processing in centres in nauru or papua new guinea and no resettlement in australia 34 in september 2013 there was further policy change and imas were referred to as illegal maritime arrivals and a media embargo on reporting was implemented changes which are considered a violation of international human rights law 35 there is already evidence of the adverse impact of these punitive approaches on the mental health of refugees but what is often not recognised is the adverse impact for those who are trying to resettle in australia when their families remain in danger elsewhere in 2014 there was a name change from the diac to department of immigration and boarder protection although these changes did not directly impact the study participants these changes had impacts for family members remaining behind and meant that they possibly could not be resettled in australia these changes also impact wider public perception and how refugees are viewed by society 36 conclusion the results of this study highlight that refugee youth participants are resilient want to succeed and have aspirations for the future this study drew on the psychosocial framework and considered the culture values and human capacity of the youth our findings support previous australian and international literature which highlight that programmes promoting a sense of belonging and those that promote coping and adaptation are vital and much needed for the wellbeing of refugee youth the hostility portrayed by the current government towards asylum seekers allows a humanitarian issue such as refugee resettlement and asylum seeking to be translated into a security and border protection issue resulting in refugees and asylum seekers being perceived as a threat refugee youth already in australia need to be provided with the opportunity to thrive to be included and to belong their efforts to forge a new identity in their resettled country is often shaped by prevailing social and government policies there is an urgent need for a more humane approach that ensures sustained opportunities for education skill enhancement and inclusive policies that allow refugee youth to become resilient and independent future citizens in multicultural australia abbreviations competing interests the authors declare that they have no competing interests

background in australia the two major pathways of refugee entry are the united nations high commissioner for refugees resettlement programme and irregular maritime arrivals imas seeking asylum the australian governments policies towards imas since july 2013 are controversial uncompromising and consistently harsh with asylum seekers held in detention centres for prolonged periods refugees and asylum seekers have distinct and unique stressors that make resettlement difficult methods this exploratory study examines resettlement experiences for refugee youth in western australia using the psychosocial conceptual framework and qualitative methods focus group discussions and key informant interviews were undertaken with verbatim transcripts analysed using thematic analysis to identify themes results themes documented that language and its impact and experience with education health and social activities support structures provided to youth and supporting future aspirations as critical to successful resettlement this exploratory study contributes to developing a broader understanding of the resettlement experiences of refugee youth drawing on their current and past experiences cultural differences and mechanisms for copingfluency in english language especially spoken was a facilitator of successful resettlement our results align with previous studies documenting that support programs are vital for successful resettlement although faced with immense difficulties refugee youth are resilient want to succeed and have aspirations for the future strategies and recommendations suggested by refugee youth themselves could be used for developing interventions to assist successful resettlement

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background to the study migration cannot be inevitable from the history of the story of man families villages and nationstate therefore migration can be traced as far back as the existence of man most especially when man desired to go in search of food during various famine seasons also another reason for migrating in those days was the desire of separating from the crowd as well as the seeking for independence as earlier revealed virtually all individuals and nation states have one or two traces of migration history mostly influenced by two factors these are the pull and push factors migration can be internal or international internal migration explains the movement of individuals within same geographical territory which in this case can be from rural to urban or from lagos to abuja while international migration has to do with the crossing of borders or international boundaries such as cameroon to nigeria described as southsouth migration nigeria to united states of america described also as southnorth migration for the sake of this study international migration as regard southsouth migration also known as regional integration and southnorth migration are focused on for international migration to take place the sending state the receiving state and the migrant is involved in the migration process this is where the nigerian immigration service and various migration policies play a part which is to regulate the migration activities in nigeria as a destination nation state and a sending nation state international migration is a global culture in which a reasonable amount of individuals practice developed countries about 1billion migrants are around the world presently not residing in their nation state of origin as these migrants around the globe can make up a 6 th nation state after the order of china indian united states of america indonesia and brazil as people tend to move from a particular place to another for various reasons best known to them also being an essential part of mans nature international migration is said to be at its increase due to the wide spread taught benefits and awareness of opportunities in various countries through various platforms such as the television internet among other mediums international migration is a sensitive issue in discussions and debates in the international system however this foundation and trend as well as various rising phases of globalization have contributed in influencing the tradition and culture of international migration in our immediate world this globalization which has unfolded itself in different phases has raised alarm of great benefits and opportunities around the globe this benefit ranges from job opportunities international education certifications inter connectedness international relations between countries creating avenue for interdependence most especially in the aspect of manpower other great benefits among them are the pleasure of being a citizen of the nation state individuals so well desire due to this perceived opportunities international migration became a popular culture and trend in our present world the rate and speed at which international migration is increasing is alarming as it cannot be completely stopped but can be managed properly to the nation states advantage bringing socioeconomic development international migration as a major and popular economic factor can revive a nation state it has the capacity to develop a nation state through other means such as filling the nation states labour force with quality skills and expertise for maximum productivity as earned results however international migration is needed and highly embraced since the combination of individual experts from various cultures and nationality can make a nation state flourish the present 21st centurys experience on international migration matters is revealed to be the tip of the ice berg as international migration will keep unfolding and remain on its increase due to the exposure and experiences of migrants with the help of different unfolding phases of globalization the high increase in demand for labour makes international migration inevitable so are the pull and the push factors of international migration these factors make individuals to desperately desire migrating out of their nation state of origin this describes international migration as an activity and also a reaction that makes the migrant unstoppable however due to the high increase and desires of migrants to be part of a nation state at all cost or become a resident in their favorite destinations the international system is consciously concerned about this high rate of movements of migrants across borders this answers the reasons and questions on why nation states guide their boundaries and entrance gate jealously because without proper control and conduct of these migrants as regard international migration activities there will be more unskilled workers and unwanted persons in the nationstate which in turn can cause nuisance resulting to unwanted outcomes skilled migrants are always assets to the receiving nation state statement of the problem the 1970s and 1980s fortunes derived from nigerias oil sector increased the number of immigrants from the west african neighboring countries into the nigerian state the nigerian state shares borders with cameroon located at the eastern part of nigeria chad to the northern part of nigeria while the southwest nigeria region is bordered by benin republic the porous borders which are mostly economical to her fellow west african neighbors keeps nigeria at disadvantage as they are majorly unprotected thereby threatening the socioeconomic development and security of the nation state though the movement is perceived to bring peace and unity to west africans as well as to promote trade which would lead to economic growth of the west african states ecowas in all these the nigerian immigration service plays an important role more so due to the lack of socioeconomic development among other reasons in the nigerian state the issue of emigration has been a trend in nigeria for graduates experts and hustlers the hustlers most especially who are in search for a greener pasture most times walk through the porous borders out of the nation state nigeria as a nation state through the nigerian immigration service has a responsibility if truly she wants to enjoy the positive aspect of international migration as the developed world presently enjoys as earlier revealed the agency plays a peculiar role in the management of international migration activities as linked to the socio economic development and security of the nigerian state effective duties carried out by this agency can generate a reasonable level of socio economic development it can initiate better quality of life and security since the agency is regarded as the gate keeper of the nationstate the agency was created out of the nigerian police force in 1958 then it was known as the immigration department headed by the chief federal immigration officer during this period the department had a narrow law as well as a narrow scope profile and a simple strategy in achieving its objectives the department was basically responsible for visa and business sections nigerian immigration service department became independent in august 1 st 1963 becoming a department under the supervision and control of the federal ministry of internal affairs while the federal ministry of internal affairs which is now officially known to be the ministry of interior has the responsibility of maintaining nigerias internal security and nigerias integrity to trigger good governance this ministry also manages some agencies which are seen as tools for their effectiveness among these agencies we have the following civil defense corps federal fire service nigerian immigration service and the nigerian prison service for this study the nigerian immigration service is practically the subject matter relating to nigerias socioeconomic development and security relating to international migration activities in the state still examining the nigerian immigration service the head of this department was known as the director of immigration but now known as the comptroller general of the nigerian immigration service in that same year an immigration act was made but literature reveals that the act was not strictly enforced or properly implemented as it was supposed to take care of the law relating to admission residence or employment of aliens this agency was officially established by the act of parliament the first officials were from the nigerian police force nigerian immigration service is legally responsible for the regulation of movement of persons coming in and going out of the nation state this involves two categories of people the emigrants and the immigrants among various achievements of the nigerian immigration service is the introduction and implementation of ict for effective operations the introduction of combined expatriate residence permit and alien card in 2002 as it made the institution improve from paper work type residence permit which admitted some errors there was also an introduction of the online payment this paved way for erevenue collections and also made the agency effective in her duties and responsibilities this was also later emulated by the federal government there was also an introduction of forensic laboratory to examine travel documents of holders nigerian immigration service officers in charge of this laboratory have been highly skilled as they have been exposed to a lot of trainings locally and internationally on document fraud detection techniques in 2013 the agency formed a border patrol corps in that same year an additional 30 control post and 27 patrol bases for backups were established which made the control post a total of 114 and the total of 372 patrol bases in nigeria the agency has also embarked on various reforms to strengthen the epassport system against possible manipulations from various criminals and also various reforms to avoid frauds of travel documents the service also commissioned a data centre to address various epayment platform challenges in the year 2014 the sector reintroduced a new cerpac which improved on the shortcomings of the former cerpac this new cerpac came with an enhanced machine readable features that helps the nigerian immigration service to solve and detect a reasonable amount of security challenges as well as frauds there was also an introduction of the readable electronic passport also known as electronic passenger automated registration system to replace the old machine readable passport which was more of manual procedures this is also counted as an achievement as this made the nigerian state recognized as the first nation state in africa and among the first 40 countries to have adopted this system in the world this has been helpful in tackling transborder crimes and illegalundocumented international migration most especially identity theft fraud among other illegal acts and intentions since the epassport contains biometric details of the individuals the nigerian immigration service succeeded in establishing a passport office at warri delta state there was also an opening of more residence permit production center there was also a construction of automatic rising bollards at nigerian immigration service head quarters the agency succeeded in installing security scanning equipment at the main entrance of the alhaji shehu shagari complex nigerian immigration service head quarters also according to the federal republic of nigeria official gazette the nigerian immigration service introduced a new immigration regulation that compliments the 2015 immigration act which was introduced to meet up the standard of the new international migration activities in the globe the act replaces the outdated 1963 immigration act this new act lay emphasis on regulating border crimes especially terrorism activities this immigration regulation was established to meet up with the demands and trends that come with the present day international migration activities the regulation also was drafted to empower the nigerian immigration service in addition to her achievement the nigerian immigration service has also taken some steps in the battling of border mismanagement by creating a border management information system at the ilela border with niger a border post at relating this study to international relations the study explains the benefits of citizens relations in the globe and how the nigerian immigration service plays a role in this interconnectedness and communication of these nationals as it has the legal authority and responsibility to secure the nation state as well as initiate socio economic development within its own quota and as well protect the image of the nigerian state through the thorough checking of immigrants and emigrants research questions nigerian immigration service out of many other sectors is also held responsible for the security of the nationstate as they are the gate keepers of the nigerian state scope of the study this study centers on the nigerian immigration service in maigatari and babura borders in jigawa state as an agency that have legal responsibilities to influence nigeria immigration service in providing internal security mechanism through observing the nature of international migrants who are either coming or moving out of the country research method the researcher has uses both primary data through use of questionnaire to the 110 respondents both staffs of the immigration service local border communities and the resident migrants from niger and chad who are residing in the study area of kanojigawa state of nigeria purposive sampling has been used to select respondents which have knowledge of the subject matter secondary data was also used from relevant publications to support the primary data in finding out security implication of illegal migrants from other countries the concept of international migration according to iheanacho international migration pathways international migration has various pathways which are described as origin and destination which is also known as sending and receiving states these path ways are the southsouth routes the southnorth routes the northsouth routes and the northnorth routes which involves the movement of individuals from a developed country to also a developed country of the same ranking status the nigerian state borders and international migration nigeria is popularly known as a nation state that has engaged in transit and destination international migration over the years due to the influx of migrants most especially from her neighboring west african countries likewise also nigerian migrants to the neighboring west african nationstates and other nationstates in the region and in the international system in search for better opportunities among other reasons the influx of west african neighboring migrants has been one of the major concerns in raising security questions in the nation state the porosity of her borders has made it possible for this unwanted influx of migrants from her neighboring west african states into the nation state nigeria has about 1500 routes into the nation state at present only 100 is been manned by the nigerian immigration service due to the challenge of shortage of manpower leading to ineffective physical presence while the remaining 1400 is unmanned and ignored creating a way for illegalirregular migrants into the nation state and also exposing the nation state to security threats according to iom one of the legal responsibilities of the nigerian immigration service is the management of the nigerian borders this means that the agency have the responsibility of securing her entry and exit gate thereby in her own quota securing the nigerian state but the illegal activities and other various factors responsible for undocumented and irregular migrants into the nation state questions the competency of the nigerian immigration service as a weak border presence can threaten the security of a nation state and when a nation states security is threatened as well as carries the status of a nation state at risk then there might be little or no development because the right investors will disengage their minds from taking the step of investing in the nationstate in concerned this is why security at the borders is one out of several priorities of every nation state among other challenges facing the nigerian immigration service is the inadequate information on the exact number of individuals leaving and coming into the nationstate in many cases data available are outdated this means that there is an uneven report on international migration activities in the nation state the main responsibility of the nigerian immigration service is to monitor the movement of individuals taking the exit door and those coming into the nation state for example it is generally known that emigration of skilled workers makes the labour force scarce and due to its scarcity makes the skill price high and the productivity of the nation state low more so affecting its aggregate income there is a connection between international migration and development there are millions of highly skilled nigerians in the diasporas such as the united states of america united kingdom italy canada spain france germany to mention a few that are well established in skills and ideas for a nation states development as stated previously there is an alarming increase of nigerians migrating to europe north america middle east and south africa to mention a few anofi also affirms that efficient and able nigerian professionals in various fields engage in emigration due to the dissatisfaction in the home nation state which is majorly due to lack of opportunities this has led to shortage of highly skilled professionals leading to brain and skill drain in the nation state and in another way led to the tarnishing of the nation states image due to the desperation of nigerian migrants engaging in illegal activities to get out of nigeria at all cost according to lawal it is revealed that in the northern part of nigeria illegal aliens are often recruited to vote by unethical political parties taking advantage of the weak nigerian borders from niger and chad often undocumented immigrants are used by unethical politicians as machineries to carry out crimes posing threats of insecurity in the nation state according to the literature 40 beniniose were found with the nation states permanent voters card this place a question on how these beniniose entered the nation state unnoticed reasonable amount of migrants from niger republic mali and chad have taken to begging in virtually all parts of the nation state as they have little or no skill to be employed also due to their inability to secure a good residential accommodation these large numbers of illegalundocumented migrants resides in slums and shanty residential areas more so the impact on the influx of undocumented immigrants in nigeria can be an additional pressure on the social amenities provided by the nation state to her citizens the nation state who is still suffering from lack of proper economic planning herself may find it as a burden and can also render the government efforts ineffective the nigerian borders according to blum borderlands are meeting points between two nation states these are security hot spots of nationstates due to the movements of migrants in and out of the nation state while naziru et al says that borders are an invisible line that demarcates one nation state from another nation states are now conscious and alert of every move around their borders according to literatures the nigerian borders is not efficiently controlled due to the porosity of the borders as it has a land mass combining land and water also coupled with the nigerian immigration service deficiencies such as manpower challenges resulting few border presence of the officers lack of resources infrastructures and various needed equipments to effectively carry out their duties among others is the lack of leadership and sincerity of those in authorities a nation state who desires to benefit positively from international migration must be conscious of the effectiveness of her borders nigerias porous borders are one of the major reasons behind her security issues and also one of the factors responsible for illegal international migration there are various unknown path ways mostly in damaturu and maduguri in the northern part of nigeria that links other neighboring countries like cameroon chad and niger still linking to other countries like libya mali and sudan these unknown pathways are unprotected and majorly used for illegal exchange or purchase of arms and other businesses that are considered illegal this explains the porosity of the nigerian borders ekpemede cited in evans reveals that there are various unprotected and unknown routes that are used by irregular migrants in nigeria there are about four thousand and eighty routes in nigeria out of which only ninety one is legally authorized and protected this situation puts nigeria in an unsecured situation the porosity of the nigerian borders can threaten a nationstates national security international migration in west african region has experienced undocumented flows of migrants due to the fairly existence of the nigerian immigration service presence and the porous nature of the nation states borders securing nigerias porous borders is not going to be any easier because as the nation state begins to develop and the international system begins to engage in international migration there will be increased movement of goods and people through land air and sea this will add even more pressure to an already stretched border security ministry of interior according to lt general abdulreham dambazau confirmed the statement that nigerias borders are mass and porous according to blum the ineffective security measures on entry and exit gates of a nationstate can easily be penetrated if that specific nation state refuses to effectively monitor and focus consciously on every individual going out and coming into the nation state as well as effectively monitor every international migration activities carried out in relation to the nation state in particular in nigeria one of the most vital and sensitive borders in west africa is the nigerianbenin border according to this literature there is said to be an increasing rate of criminal activities from the two countries blum reports that the nigerian benin border is weak in governance and control as it gives easy passage of all sorts of crimes and trafficking activities in and out of the nation state this literature also reveals that the same challenge is also observed in other nigerian borders respectively the question remains what is the nigerian immigration service doing to effectively make sure the nigerianborders are free or drastically reduced from criminal activities how effective have they carried their duties to ensure that the border are orderly organized and security free to some extent or totally according to naziru et al the nigerian immigration service with her responsibility to border management can be a positive outcome for nigeria if the borders can be focused on dedicatedly as border management can bring political development and socio economic development effective management of the nigerian borders by the service can enhance productive economic activities that are legally and profitable as well as befitting to the nigerian image portraying assured security as well seen as organized and respected nation state by other west africans and other foreigners international migration in nigeria has been associated with various crimes and trafficking such as smuggling of arms other dangerous weapons as well as various prohibited goods the porosity of the nigerian borders and its mismanagement results to the just mentioned illegal activities socioeconomic development factor the socioeconomic status of nigeria is faulty with many issues which can be related to the push factors the deficiencies of various institutions in the nigerian state are responsible for her unworthy socioeconomic status this study tends to focus on the nigerian immigration service as part of the institutions that can bring about proper socioeconomic development if managed effectively the human capital level in the nigerian state is low due to the lack of the necessary skilled individuals this is responsible for the low productivity in the state literatures reveals that about 150000 skilled nigerians in various important fields which can bring proper innovation such as nurse midwives doctors engineers left the country obviously their decisions were traced to the pull factors from their various destinations and push factors in nigeria how has the nigerian immigration service raised alarm to the present administration on the importance of skilled individuals and the reasonable amount of skilled individuals leaving the nigerian state socioeconomic development in any nation state refers to meaningful improvement in the states economy and most especially the comfortable standard of living of her citizens every administration in a nation state holds a duty of bringing socioeconomic development in a nation state citizens expect to see progress as an administration transfer to another every developed countrys government speaks 95 of the mind of her citizens this is evidenced through the socioeconomic development strategies of the country for a nation state to be respected in the international system there must be a high level of socio economic development in the state this development involves the effectiveness of all sectors that makes up the government security security is a state of peace freedom and highly safe environment according to okechukwu et al security connotes safety its a place of safety security is the state of being free from any form of danger or any form of crisis security is the absence of violence and other form of terrorist activities in a particular geographical area it is the absence of insecurity security is also a condition or a state of being protected from all forms of threats which might appear in various ways emotionally psychologically and for this study physically literatures assert that security is one of the main challenges facing the nigerian state according to hussien nationstate with a security challenge is a big threat that can be exposed to danger anytime security in a nation state is very much needed and very important blum reveals that security is very crucial to a nation states socioeconomic development or economic growth relating to this study on international migration and the nigerian immigration service security is one of the essential pull factors nigeria must have if she wants to benefit effectively from international migration this links us to nigerias border and its porosity according to onwuka security is a very sensitive commodity in nationstates as it affects the international system making the system conscious and dedicatedly watchful of various enemies and threats that might destroy the nationstate in question one of the enemies of a nationstate is the terrorist group this is one reason why a nationstate through the nigerian immigration service and other security agencies in the nationstate are conscious of her security where there is no peace and where there is perceived insecurity development might not be positive as investors would not risk their lives and resources in fact various warnings from the home countries of migrants and the various media platforms would definitely make the world know how insecure the nation state is and also how dangerous it can be for anyone to venture into either for business purposes or for any other reason nigeria is not excluded as in recent times the nationstate has been tagged as not secured and risky for various citizens to come in this is why the effectiveness of the nigerian immigration service is very important through the support of the nigerian federal government the nigerian immigration service has the responsibility to strengthen the nigerian borders the level of security consciousness at the gate of entry and exit of an organization or society determines the level of security in that society and in this case the nationstate the nigerian immigration service automatically reduces the pressures for the other security agencies as they maintain the security inside the nationstate by cleaning up the remaining security threats that slipped away from the hands of the nigerian immigration service and those threats experienced in the service this means that the nigerian immigration service has the first responsibility to secure the nationstate before the other security agencies gets involved they are the first to be confronted before any form of enemies or threat can penetrate into the nation state in other words the nigerian immigration service has the responsibilities of not allowing criminals into the nationstate and individuals who pose as threats to nigerias development and security among many reasons un reveals that nigeria has been rated a high risk rating out of eight of the identified major associated crime areas such as trafficking smuggling drugs among others and one of the ways to strengthen the nations security is through the effective performance of the nigerian immigration service to support this statement haas also revealed that the status of nigeria as to been risky also is a push factor that also drive potential skilled individuals from nigeria and also cause the emigration of skilled nigerians out of the nation state in the light of these challenges how has the nigerian immigration service helped in communicating this information to the nigerian government nature of international migration types and kinds of international migration changes over time reason is that researchers reveals new and various categories of international migration as they get interested on the subject matter this reveals that international migration is a subject that keeps on emerging in various ways as the world and various nation states in the international system changes socio economically and geopolitically according to jennissen these are various types and kinds of international migration these are  labour international migration  return of international migration chain international migration assylum international migration labor international migration is majorly explained to be migration for the purpose of job opportunities exchange of skill and expertise from one nation state to the other this kind of international migration can also be influenced by nation state bilateral relations it can also be a decision of the individual all kinds of migrants with the intention of migrating for jobs of any sort is venturing into labor migration also labor migration are engaged by individuals seeking job opportunities in their various however destination and locations has been cited by jennissen labor international migration can also be engaged by voluntary migrants for the sole purpose of working or getting a comfortable job this is mostly more of a personal gain and indirectly profitable to the receiving states simply put labour international migration is the transfer of skill from one nation state to another return international migration occurs when a particular individual retires back home to his her nation state of origin after leaving the home nation state to another for quiet sometime or a long period of time sometimes migrants go to their various destination nation states to make some amount of money after that retires back home to start a business or permanently back to live after studies abroad it can also be explained as the relocating of migrants back to their respective countries chain international migration is described as movements in which various individuals migrate out of their home countries with the sole aim of joining their family members abroad this type of international migration can also be referred to as reunification this involves invitations from family members and friends in the destinations individuals wish to arrive at asylum international migration are practiced by asylum seekers that seek refuge in a destination nation state due to frustration and push factors surrounding them in their home countries they describe themselves as been in need of help and refuge this is also described as forced international migration this type of international migration is mostly engaged by refugees internally displaced persons and others who claim refugee status according to wickramasinghe international migration is grouped into three types these are environmental international migration political international migration with intention of improving hisher living standard through better job opportunities in their destination countries environmental international migration is influenced by push and pull factors such as desert nature in home nation state rise in sea levels and drought among other factors while the pull factor is perceived as multiple found opportunities in that region such as serene environment in the destination state among other factors political international migration is also influenced by political push factors in the home nation state such factors may be civil wars corruption of leaders political discrimination and tribalism to mention a few effects of illegalundocumented international migration activities on the nigeria state illegalundocumented international migration can affect the following areas of a nation state resulting to but not limited to economic and security threat negative social impact and health risk this effect of international migration affects both the sending state and the receiving state socioeconomic development and security threat illegalundocumented migrants pose threats to the economy of the receiving nation state economically illegal migrants have both positive and negative impacts on the two countries illegal immigrants reduce the number of unemployment in the state of origin while increasing the rate in the receiving state known as the host nation state though it is true that illegal migrants take up jobs that the citizens reject but in the process jobs belonging to the citizens are also taken by these migrants the uncontrollable influx of illegalundocumented migration can cause destabilization in a nationstate the influx of illegal immigrants also triggers unemployment in the receiving state they also create a high rate of inflation in the nation states essential commodities due to their hiding underground leading to undocumented statistics as their needs cannot be budgeted for due to the incorrect calculated figure as such there can be scarcity of essential food items or have inflationary effect as undocumented migrant cannot transfer money legally through commercial banks so they indulge in smuggling trafficking of currency while some of them patronize the black market where various countries currencies are sold as commodities international migration activities has brought about insecurity in various nation states this alone has affected international relations and shaped foreign policies of these nationstates on diplomatic and security matters one experience relating to the security issue that made countries alert is the 911 attack this has created a sense of consciousness on border national security in nation state a nation states border is very important to her survival this is one of the main reasons why there is migration agency presence in every nationstates border not just to prevent smuggling but to prevent illegal entry of migrants through the nation states gate for security reasons as well as for development of the nation state international migration has become a principal pattern for international economic relations as it links individuals generates interactions and melts down artificially imposed barriers due to the status of a globalized world however movement must be regulated in other not to bring dangers and make the nation state in question at a disadvantage this means nigeria must take cognizance of movement in and out of the nation state illegalundocumented migrants pose security threats to the receiving states mostly due to porous borders where there is security threats investors will be discouraged to invest in that nation state because it is assumed not to be safe for business and lives most especially popularly terrorism threats majority of the immigrants in nigeria are from the west african neighboring states and are mostly not the desired immigrants because of the low or no skill status they possess which cannot improve nigerias productivity to its maximum when there are low skilled and a weak labour force in the receiving state there is bound to be a decline in the aggregate gdp of that specific nation state social impact of illegal migration illegal undocumented migrants mostly engage in illegal activities due to their undocumented status as a result when various acts is perpetrated the perpetrators are usually nowhere to be found where there is a greater population of undocumented immigrants crime rate increases such as armed robbery thefts to mention a few it is also on the record that undocumented migrant contributed a lot to the maitasine religious riots which took place in kano and claimed lives the event also led to the huge destruction of public and private properties in that vicinity according to the borno state comptroller of immigration babayo alkali the influx of illegalundocumented migrants into a nation state poses security threats to the nation state in question also deportees are more likely to constitute great social and environmental risk not only to themselves but also to the already nigerian society on the receiving states most of the undocumented immigrants are unemployed or unemployable as well without means of livelihood this means they have no good houses to live in the majority of undocumented immigrants live under the bridges flyovers or uncompleted buildings while some of them have built shanks in recreational places they live in unhygienic poor conditions and polluted environment the inappropriate housing facility without basic amenities can spread diseases to other persons health impact illegal migration puts both states in potential health risk it is obviously known that the nigerian immigration service has the legal responsibility of not admitting anyone who has any form of mental or physical condition that can be contagious and dangerous to the health of her citizens through undocumented migration these group of persons can find their way into the nation state and settle in the local communities this can pose health risk in these local communities and spread to other areas of the nation state if not properly handled such diseases could be ebola tuberculosis among other deadly diseases factors responsible for international migration in nigeria international migration has grown to a reasonable amount due to the demands and emergence of new phases of globalization from literatures these are various factors responsible for irregular illegal international migration in nigeria pull factors international migration can be influenced through the pull factors operating in the receiving states these factors are but not limited to the sincere presence of democratic government and the rule of law socioeconomic development vast employment opportunities with higher incomes quality education favorable policies better access to medical facilities better working and living conditions as well as respect for human rights nigeria has always been one of the poles of attraction for the citizens of the west african neighboring countries due to her oil boom and the sensed growth of the economy in the 1970s according to onwuka although nigeria is not as developed as the image of a blessed nation state should the nation state still attracts immigrants from the sub regions the question asked is how skilled are these individuals how can they compliment the nation states labour force effectively for maximum productively as we observe in various nations states in the likes of south africa among others fayomi also confirms the statement revealing also that the 1970s experience in nigeria paved way for nigerian state being a destination nation state due to the crude oil found this created job opportunities and other menial jobs for africans who seek them in addition nigerians also emigrate to europe and other desired nationstates to seek a good standard of living and for better opportunities as various individuals believe that there are better opportunities outside the nation state an overriding factor for explaining the influx of migrants to nigeria and out of nigeria is the sharp economic and political differences between nigeria and the neighbouring west african countries and also between the developed north and nigeria this reveals why most nigerians jump at opportunities given by various countries through visa lotteries push factor push factors are conditions in immigrants nationstate of origin that act as a dissatisfactory and driving tool for international migration or pressure tool encouraging emigration from citizens own nation state this explains that the neighboring west african nation state citizens are dissatisfied with various factors in their home countries these factors can be poverty and hardship in the nation state political conflict famine natural disaster lack of opportunities lack of quality education insecurity dissatisfaction of the standard of living previously or presently experiencing triggers international migration according to idio et al nigerias deficiencies which can stand for push factors are as follows lack of industrial development lack of job varieties discouraging income and above all the absence of various resources for productivity lack of social amenities these are some of the push factors of international migration in nigeria by the middle of the 20 th century emigration of professionals highlevel manpower and skilled workers emerged from the developing world to the developed world brain drains in nigeria were becoming prominent as from the 1960s due to poor working conditions such as poor infrastructural system inadequate social amenities the devalued national currency decreasing standard of education and irresistible corruption in public sectors general insecurity till date to mention a few in nigeria the presence of various political conflicts lack of decent jobs and discouragement of various professional skills of individuals are the reasons why individuals leave their home countries nigerian immigration service also have the following challenges to battle with these challenges are also seen as push factors as revealed by haas these are the lack of security high crime rate high level of corruption and above others the unfavourable atmosphere for investors into the nation state these and many more are the push factors that bring about little or no qualified migrants into the nigerian state in describing international migration in africa nigeria cannot be left out of the discussion as she plays a major key role in africas international migration status international migration and international migration policies laying emphasis on policies migration policies have direct impact on a nation states international migration success migration policy is a guide for the destination and origin nation states in addressing high rate population and in avoiding unwanted migrants and also as sending states to secure their citizens and make sure they get in touch with their home countries for development reasons among others for international migration to be positively impactful in a nation state some migration policies are meant to be managed effectively some of the ways migration policies can be developed are the following but not limited to legal migration policy this policy regulates the out flow and inflow of labour migrant involving two or more nationstates these are the sending and receiving states this type of migration often relates with bilateral relations and other multilateral treaties as one of the instruments that has facilitated international labour migration unilateral bilateral policy is a form of policy whereby nationstates closes their doors in other to discourage entry and exit of individuals most especially that of their laissez faire policy is more of a regional control of movement with no less restriction in west africa it is regarded as ecowas protocol where west african citizens are free to enter a nation state with the use of an ecowas passport and other recognized documents this is just for a free passage in various countries encouraging healthy economic nature and unity among west africans migration flow is also a policy that ensures that migration agencies such as nigerian immigration service should have reasonable quality and up to date information on migrants in other to know the migration status of the nation state and most especially to know when a nation state is losing to brain drain through emigration this policy reveals that international migration information should be gathered as such information should be the education qualifications of the migrants gender ratio of migrants employment status regions that have the most populated migrants in nigeria age brackets of the migrants the quantity of manpower in the nation state and also the expertise that are lacking in the nation state so as to encourage migrants with those expertise into the nation state knowing this information is a good plus for the nation state this policy also includes the observing and studying of remittances coming into the nation state and the effective role of migration institutions as the middle men and initiators between migration investment and labour market which sums up as a demand and supply kind of event this policy lays emphasis on the importance of having a database of migrants information diaspora policy is also not left out as policies like this exist to make sure that the emigrants in their various diasporas get in touch with home in various ways these associations are to unite them together to promote their nation state of origin cultures and traditions to figure out how the home nation state can be developed as these diasporas can market their countries to the host citizens on how they can come invest in the nation state among other things for example in nigeria we have nigerians in diaspora organization these nigerian migrants can also be encouraged by allowing them to take up dual citizenship if they so please they can also be advised on the need to have a team spirit organize programmers that will bring about initiating patriotism in the minds of these diasporas and build more strengthened ties reminding them who they are and how they are representatives of the nigerian image the policy can also encourage easy business registrations in various embassies in various destination countries to enable those who might want to get involved in establishing businesses in the home countries using nigeria as an example nigerian immigration service and the nigerian federal government generally can organize offices and associations that will bring a successful outcome of the diaspora relations with the home nation state other migration policies involves the legal protection of migrants such as right to residence labor law employment protection and social security protected human rights transferability of social benefits and entitlements this is very essential joint effort of the receiving states and sending states on bilateral relations laissez faire among others can make a good international migration benefits to the migrants sending state and receiving state consequences of international migration in nigeria these consequences are discussed as follows emigration as a consequence is associated with brain drain as a challenge which leads to lack of skilled personnel lack of man power and expertise due to the high rate of individuals leaving the nation state for their various destinations when these smart and sophisticated individuals leave the nation state due to these two factors known as push and pull the sending state suffers as it lacks various improvements and developments such as in industries and other sensitive fields in the nationstate all these skills are then benefited and transferred to the destination countries nigeria as a state of origin suffers high rate emigration of highly skilled and intellectual individuals such as doctors engineers lecturers to mention a few majority of these highly skilled nigerian emigrants see it as unnecessary to associate back with their home nation state through investments and most importantly feel reluctant and discourage in bringing their skills to develop the nationstate reducing the low level of industrialization in nigeria literature also confirms that nigerias emigration activities of highly skilled individuals became identifiable in the 1960s as highly skilled and potential skilled individuals as students travel abroad to get their educational experience which often leads to them staying behind as they get attracted to their destinations this has not changed however it has been on its increase the economic crisis in their respective years in nigeria has also led to various massive emigrations of individuals into various nationstates thus a community citizen may enter any member state of the community for 90days without visa provided he possesses a travel document and international health certificate but this protocol has given way for illegalundocumented movements across borders making the nigerian borders a free easy passage without identities or documents this can endanger the socio economic development and political stability of a nation state this ecowas protocol is misunderstood and misinterpreted by and to the public for this reason nigeria has found herself in an embarrassing situation from the borders most especially the northern borders where there are high rates of illegalundocumented immigrants from niger and chad as a result of the economic hardship in their respective countries idio et al also acknowledged that one of the factors responsible for international migration in west africa is the strong force of necessary agriculture needs for various individuals such as farmers nomads known as the cattle readers as they search for water as well as grazing lands for their cattles and cultivation of crops due to the poor conditions of their various environments they migrate to their nearest alternative which is nigeria but the disadvantage is that these west africans cross the international borders with little or no regard for the nigerian regulations though borders must remain open but openness without adequate control allows possibility of threats such as transnational crimes and even terrorism to be successful fayomi validated the statement also that the objective of the ecowas protocol was to facilitate freedom of movement residence and employment however this protocol or policy is now at the detriment of nigerias socioeconomic development and security as the nigerian federal government and migration agency finds it difficult to guide and control criminal activities in this various borders artificial international borders the west african borders were divided by the colonial masters for their own selfish gains without having in mind the culture similarities of the people these similarities are mostly in dressing culture language traditions customs and market days these similarities make it difficult to differentiate a northern nigerian and nigerian or a nigerian from cross river and the cameroonian also these similarities makes it difficult to carry out the immigration laws effectively as citizens of the two different countries can easily switch or change identities these artificial imposed boundaries are unclear and difficult to differentiate as such it gives way to illegalundocumented migrants into the nation state idio et al also confirms the statement that boundaries of west africa which was done by the colonial masters without consulting the local people and their opinions makes migration policies slightly difficult in the west african region due to the mentioned numerous similarities for instance also part of the nigeria western region and part of the republic of benin share similarities of the egun ethnic group part of nigeria and chad share same similarities with the kanuri shuwa ethnic group while the cross rivers and cameroons as earlier mentioned are similar among others having same cultures traditions similar market days similar marriage traditional styles customs and beliefs among others the only thing that differentiates them is the border which is seen as a major barrier so to unite the nation states in this region despite the plans of the colonial masters the ecowas protocol among other reasons was established for the rise and easy passage of migrants in west africa tornimbeni also revealed that the greed and insincerity of the colonial masters led to the improper demarcation of the region through incorrect border position these borders laid the beginning of different nation states in the west african region but being the familiar habit of moving from one place to another by these africans which mostly engaged in trade policies were made to reshape and to build this unity and economic growth again despite the built borders this policy promoted labour international migration inviting interconnectedness and interdependence among the west african states in other words mobility of individuals in west africa and nigeria specifically as relating to this study is traced from the precolonial and colonial period harboring of illegal aliens in nigeria leaders in border communities are revealed to have been an instrument of shield for illegal migrants emphasizing on the security of the borders the border communities has been left out by the nigerian federal government as adetunji reveals that nation states have no intention of investing in border communities due to any form of outbreak of war these are said to be intentional for security reasons but in this case does this refer to nigerian federal government feeling reluctant to develop her border communities and cater for their needs to win them over giving border communities a sense of belonging is a good and advisable strategy as nigeria is concerned this counters the statement of the scholar of this literature harboring of undocumented migrants into the nation state by business employers of labor is not excluded as factory owners see this avenue to cut down cost on their production expenses this is prohibited and can pose risk to the receiving nation state non execution of immigration and the community law the resent flooding of illegalundocumented immigrants to nigeria is due to nation states vast land borders which are not effectively supervised by the immigration authorities due to lack of staff and inadequate facilities which in turn unable them to control the illegal entrance as revealed one of the main factors responsible for the illegal international migration activities is the weakness and corrupt practices of the various agencies in charge of migration most especially the nigerian immigration service and its lack of trained personnel and funding according to the public relations officer of the nigerian immigration service there was a set of thirteen teenage chinese prostitutes in the nation state he revealed that the suspects came into the nation state with business visas and later obtained extension from questionable sources which definitely would be linked to one or two persons in the nigerian immigration service according to haas there will always be irregularundocumented migrants in the globe probably due to the push factors experienced by the migrants this is why migration agencies and governments of nationstates must put together effective ways and policies to control or cut down to a reasonable amount the population of irregular migrants already in the nation state or in the process of entering the nation state according to him haas migration agencies can organize legal ways in which migrants can come into the nation state these ways could be through studying in the nation state green card lottery for qualified individuals who the nation state might need through labour purposes due to their highly valued and recognized skills these consequences of international migration if not properly handled or managed could result to economic implications labour market implications and more of brain drain lack of experts implications to mention a few these mostly affect the developingless developed world when a nationstate cannot manage its migration activities there is bound to be problems these problems are the consequences of international migration idio et al every nation state is concerned about how international migration affects her nation state as high skilled emigration implies a loss of creativity and various socioeconomic developments so also the influx of immigrants with little or no skill implies a loss as they reduce the nationstates capacity and ability to produce productively due to a weak or average manpower challenges of nigerian immigration service according to haas the nigerian immigration service really has a relatively cooperative border control and readmission policies but the main challenge of the nigerian immigration service is the lack of various resources such as infrastructures lack of discipline in the organizationagency most especially the ill quality of leadership lack of manpower and other needed equipments to help facilitate international migration activities in the nation state the service also have the challenge of controlling the massive and porous borders as it has over 147 known borders and other unknown illegal routes into the nation state this literature confirms the statement that nigeria is opened and never fenced this poses threats to her security the literature further reveals that nigerians have a very high population of irregular migrants in various european countries due to the push migration factors earlier explained in this chapter making many imprisoned and detained in their various destinations in some sort damaging the image of the nigerian state the question is how has the nigerian immigration service helped in controlling these challenges have they really been communicating to the nigerian federal government on international migration matters though there are various achievements seen and presented by the service in the cause of this study which are very much appreciated however for the quest of nigerians regarding socioeconomic development and security how has the service been able to invoke change with the awareness and various theoretical beliefs of the natural blessings of the nigerian state how has the service revealed the total packaged blessings of nigeria to investors since they also have the responsibilities to bring in investors into the nigerian state these questions pose further research in the future haas also revealed that the nigerian immigration service is lacking reliable data of international migration activities in the nationstate this information can trigger socioeconomic development and security if only the correct information can be gotten for dedicative and effective use this information of migrants can be a source of direction on what the nationstate needs revealing how it can be derived the necessary pull factors to introduce and the awareness of the push factors that hinders the right immigrants from coming in also not just knowing but consciously knowing who comes into the nationstate this data on migrants can also help the nigerian security agencies in dealing with nigerian security issues the officers in the service carry out corrupt activities most especially at various border check points these check points are meant to check passport and other necessary documents and to also put away illegal migrants for the safety of the nation state but are majorly used by nigerian immigration service officers as an avenue to extort money from migrants ashiru and okadigbo reveal that the corruption rate of the nigerian immigration service is alarming as officials also agree with these immigrants for help in exchange for money today smugglers and human traffickers are able to scale through nigerias borders by simply paying their way through bribes the illegal routes cost less than the legal crossing points according to the former nigerian immigration service comptroller general the nigerian immigration service is lacking in various areas because of its corrupt practices the poor manpower of the nigerian immigration service also makes it difficult to manage the nigerian borders most times the illegal migrants outsmart these security operatives and officers due to the inadequate trainings manpower and equipment the nigerian federal government also lack in providing basic amenities and infrastructures for the border communities this encourage them to involve in cross border illegal activities such as armed robbery smuggling and harboring of the illegal migrants making themselves hostile to the nigerian immigration service and other security agencies there is a need for the nigerian federal government to develop the rural areas where these border communities are situated also border officials collect bribes because they are not well compensated for their hardship postings there was an article in which border security officials explained that they do not even get anything like torch light camp beds and other working materials they have to either sleep outside or rent houses which they pay from their pockets this reveals that the corrupt practices and poor encouragement in the nigerian immigration service are due to mismanagement and bad leadership lack of sophisticated equipments patrol vehicles and skilled manpower can make migrants pass the nigerian immigration service presence with fraudulent documents there have been little results on border infrastructures due to limited funds which can in turn result to the inefficiency of the agency in carrying out their duties some of the lacks in the nigerian immigration service are lack of innovative technologies on surveillance remote surveillance platforms to mention a few adekunle confirms the statement earlier made that there is shortage of manpower in the nigerian immigration service this can hinder the necessary progress of the service in the affairs of the nationstates how has the agency tackled the issue of shortage in manpower for effective delivery to the nigerian state this is a question that desires an answer if the nigerian immigration service can improve more than her present status majority of these illegal activities would be tackled until then nigeria still remains vulnerable to external threats image damage and attacks illegal undocumented international migration is a familiar phenomenon in all nationstates in the globe these can affect the receiving and sending states if not properly managed theoretical framework for the theoretical frame work of this study pull and push migration theory organization learning theory and globalization theory are chosen to understand and explain specific aspect of the above study pull and push migration theory ravenstein was the individual who revealed the pull and push migration theory from one of his popularly known writings revealed as law of migration which was derived from a study focusing on britain in the 19 th century with the use of some information such as birth place of the migrants relating to his study this theory explains the how and why of migration within a territory or across borders and also the importance of international migrations to nation states according to his writing it is impossible to separate development from migration the seven laws he listed in the study are migration depends on distance migration takes place in stages every successful migration process is endowed with a migrating pattern flow most times the natives in their territory have less degree than the fellow counterparts gender of the migrants there is a relationship between the level of technology number of migrants and distance travelled migration has always been influenced by economic motives according to haas other scholars who also made several attempt in applying this theory apart from raven stein are lee donald among others according to donald the forceful desire for opportunities and improvement of ones life most times influences and motivates international migration generally when the pull factors at the destination nationstate outweighs the push factors at the individuals nation state of origin international migration often takes place these push and pull factors according to donald is referred to as negative and positive these push and pull factors by most scholars are demographic economic environmental and social in nature myrdal and prothero opines that only push factors are responsible for international migration while others oppose the statement revealing that the combination of push and pull factors are responsible for the migrants decision in leaving hisher territory according to lee pull and push migration theory are representatives of either a positive migration or negative migration since migration is provoked by two factors which happen to be pull and push lee also identified some barriers that can hinder international migration between the two different countries the barriers he revealed were cultural differences distance differences in language communication and most importantly physical border presence lees contribution reveals why international migration takes place and secondly why majority of individuals find it difficult to migrate as explained with the barriers the hinders migration lee also revealed some hypothesis that explains the pull and push migration theory these hypotheses are the volume of migrants varies in a territory in diverse areas the volume of migration also varies with different migrants also areas where there is similar characteristics as in the migrants origin mostly experience less immigration the fluctuation in the displayed pull factors such as the boom and increase in the economy and the decrease in the economy can also truncate the high increase of immigration bringing it lower than unexpected unless the migration process are checked and properly managed the migration activity will increase in no time migration population vary in states for example developed countries have more migrants than in less developed states lee cited in haas also reveals that migration is selective this selection can be positive or negative it is positive for the wealthy migrant and negative for the opposite individual majority migrants who respond to the pull factors they are selective about their destinations since they are not under any pressure to move they only want to move because of their desire and perceived opportunities out there migrants who respond to push factors are negatively seeking to migrate out to another destination some of these people influenced by push factors are obviously more of the illegal and irregular migrants there are two types of migrants the one influenced by the pull factors in the destination nation state and the other influence by the push factors at the state of origin how high the degree of pull factors at the destination nation state determines the increase in difficulty and obstacles faced in getting into the nationstate due to the high immigration policy in those destinations for development health and security reasons for the state the most preferred age bracket wanted and mostly welcomed by immigration policies in receiving countries are the young and age working set of individuals to make up the population of the labour force than aged individuals the migrants are mostly at the middle of the pull factors of the destination nation state and the push factors of their nationstate of origin in all these they are more of complementing the population of the destination states summarizing lees model and opinion on this theory international migration is influenced by the pull and push factors legal responsibilities of the nigerian immigration service the nigerian immigration service has the legal responsibilities and legal authority backing up their existence these are as follows international migration activities control the nigerian immigration service as gate keepers has the legal responsibility to examine the entry and exit of persons in nigeria the legal authority has been given to the agency to refuse entry of persons who is suspected as a threat to the development and security of the nation state issuance of travel documents such as nigerian passport visa to mention a few the service also has the legal responsibility to issue qualified applicants their required travel documents issuance of residence permits to qualified applicants the service can also issue residence permits to foreigners who have intentions of residing in the nation state however the service has the right to refuse residence permit and another request if the applicant does not meet to the requirements or is perceived as a threat to the nigerian state border surveillance and policing of nigerias expansive borders and her patrol effective team the service also has the responsibilities of policing the borders of the nation state they take surveillance and patrol of every entry thinkable for the safety and security of the nation state such duties are the policing and surveillance land borders the surveillance marine borders and the air patrol they have the right to arrest persons who might have or seen in specific routes that are not legally authorized for entry or exit monitoring control and investigation of the activities carried out by foreign individuals in nigeria the nigerian immigration service has the legal responsibility to monitor and investigate any suspicious activity and movement of foreigners in the nation state for the nation states development and safety inspection of companies owned by foreigners or companies that employs expatriates the service also has the right to inspect foreign companies and also companies that employ foreign individuals they also monitor and investigate these companies from time to time and most especially when there are suspicious movements or activities that can most likely hinder the socioeconomic development and security of the nigerian state administration and implementation of treaties such as the eco was treaty that has to do with the movement of persons according to edet and evans the service also deals with the movement of persons in and out of the nation state it also has the responsibility of implementing treaties for easy movement of persons the service also has the responsibility of implementing bilateral and multilateral relations between nation states enforcement of the nigerian law as regards international migration activities  the service also has the legal authority to deport or punish offenders or violators of the immigration laws through them the immigration laws are been enforced  as entitled with a paramilitary status and viewed as gatekeepers the nigerian immigration service has the function of observing and making decisions on who is qualified to leave the nationstate and who is qualified to come into the nationstate  the service has the responsibility of implementing various migration policies such as multilateral agreements between nigeria and other nationstate as well as other bilateral agreements  one of the main functions of this service is the issuance of travel documents to qualified applicants as they also decide on the cost of these documents  the service as gatekeepers manes control patrols and register a strong presence in various respective borders of the nigerian state not just land borders but the airports and seaports as well  the service also is left with the duty of combating various illegal activities that counters the rules of migration such as theft smuggling and trafficking of persons and other transborder crimes that might arise to their awareness the service also has the responsibility of deporting any foreign individuals who poses his herself as a threat to development health risk and security risk to the nigerian state  the service also have the responsibility of investigating researching creating and shaping migration policies as well as various regulations to meet up the modern day migration trends power vested on the nigerian immigration service according to the federal republic of nigeria official gazette these are the powers vested on the nigerian immigration service the nigerian immigration service which is described as a corporate body having the power to sue and be sued has the following legal powers these are as follows power to refuse or deny passage of an emigrant or immigrant the service has the legal backing of the federal republic of nigeria to deny passage to migrants either entry or exit that does not meet up to the requirements and that also poses threat or damage to the nigerian development image or security power to issue travel documents and to cancel or seize travel documents when there is a need the service also has the legal right to seize travel documents of persons from travelling out of the nation state when there is a need to for example a deported nigerian who committed a crime after deportation heshe would have his her passport seized by the service for some years this also applies to some nigerian government officials who had experienced this in the past power to restrain movement of foreigners the service also have the legal authority and power to restrain movement of foreigners when there is a need to in the nigerian state power to inspect or band ships if there is a need or if the goods does not meet the requirement the service has the legal barking to inspect and band when necessary arrest of immigrant where entry is denied and found guilty of trespassing or breaking the rules and regulations the nigerian immigration service has the right to arrest irregular migrants migrants for the safety of the nigerian state power to prescribe or suggest fees and also power to draft entry conditions for migrants the service has been entrusted the legal power to determine what the requirement are for the migrants the service also determines the fees which anyone who patronizes the service for any purpose is required to pay power to implement policies relating to immigration such as the visa policy the service has the legal power to implement policies which can relate to the immigrant or emigrant iom also supports various literatures on the responsibilities of the nigerian immigration service which are managing of the nigerian borders against external threats creating and undergoing a legal and smooth facilitated movement of migrants updating information on migrants among other responsibilities although the data of migrants may not be as accurate as possible it can be approximately close to its result if effectively carried out migrants information gives direction to the nationstates in sorting the best skilled and expertise for various demanding positions through the migration agency these migrants data can be used to rate and also be aware the nationstates socioeconomic performance most especially when it relates to the movements of skilled individuals transferred knowledge and innovations from the nigerian state to other states in summarizing the responsibilities and duties of the nigerian immigration service vialet revealed that the migration agency has the responsibility of perceiving investigating and researching the needs of the nation state and how it can be gotten through international migration according to literature this is one of the ways the agency can contribute her quota in the area of socioeconomic development of the nigerian state provided the state has various pull factors that can easily attract migrants also the nation state has to perceive the needs of the migrants as well but this act of good will is not encouraged to be at the detriment of the receiving nation states socioeconomic development health and security these migrants are selected for various reasons such as the need for new citizens who will also participate and contribute in building the labor force of the nation state for economic and political growth just as in the united states of america to become a resident the migrant must have something tangible to offer and not become a burden to the american government although the nation state has participated in some humanitarian services such as interfering and taking care of refugees every government of a nation state with the help of the states migration agency has that responsibility of satisfying the citizens considerably by balancing the immigrants and the native born in other not to generate any form of xenophobia feelings among the two parties as observed in south africa the nigerian immigration service also have the responsibility of communicating with the emigrants most especially the experts and highly skilled individuals on their needs as well as why their various destinations are better than the nigeria state and what can be done to make things right this can be carried out by the public relations officer population of the study the population of this study is the nigerian immigration service as a body and the migrants however since it will be cumbersome to study the entire population within the limited time for this study the target population comprises of the nigerian immigration service officials from kano and jigawa and some migrant entering from jigawa katsina and sokoto borders hundred and twelve population was selected out of which 72 was selected from the staffs of immigration services while 40 population from the border communities and migrants from bordering countries of niger libya and mali out of the 112 respondent selected only 100 population was respondent through administration of questionnaire and interviews with the assistant of one research assistance covering maigatari and babura borders while i cover jibiya daura and maikwarayi border in sokoto data presentation and analysis in part the paper would discuss the result of finding receive from the respondents both the immigration service and some borders communities and migrants to suggest best way of addressing the problem of illegal migrants and the issue of insecurity phenomenon in nigeria distribution of biographical data of the respondents the table below discussion of findings firstly nigeria immigration service has a challenges faced on information received from the respondents that the service has a problems in terms of personnels and working materials that may help them in discharging their responsibilities of protecting our borders from illegal migrants that can only create a security problem not improving the socioeconomy of nigeria secondly the nature of porous borders in the country has created a lot of security problem by allowing the chance for illegal migrants to flow in to the country without full knowledge of the securities concern thirdly most of the protocol and convention for migrants is not fully implement by african countries that give chances for migrant without documentation flowing african countries and created a serious security problems conclusion migration is known as the movement of persons this culture has always been part of the feature of humans from the very beginning as they migrate for various reasons such as their desire for safety for abundance and most important with the push and pull factors and so is it till this very day international migration is a global challenge its activities has been a source of concern in the international system as various nationstates try within their power to secure the nation state by shaping their foreign policies setting various structures to make immigration presence in various recognized border post as well as setting of immigration laws to mention a few however international migration cannot be really stopped because man by nature tends to move to where he or she desires and feels comfortable recommendations the recommendation of the above study regarding the nigerian immigration service and her contribution to the socio economic development of the nigerian state requires the collaboration of the nigerian public such as the nigerian citizens nigerian migrants the nigerian government the private institutes the border communities and the institution in question which is the nigerian immigration service the nigerian citizens every nigerian citizen has a part to play in the effective performance of the nigerian immigration service as regard the socioeconomic development of the nigerian state nigerians should be security conscious and aware of foreign individuals living around them who might have some questionable characters if there is any one witnessed they should be reported to the right authorities nigerian citizens should also frown at hosting irregular migrants as it is against the nation states immigration laws every nigerian citizen should also take the responsibility of educating families and friends on the importance of investing in nigeria most importantly highly skilled individuals the nigerian government the nigerian government has a big role to play in the success of nigerian immigration service these roles are as follows providing infrastructures and releasing funds to enable the agency carry out their legal assigned duties efficiently without been truncated by loss of resources as this above study reveals that the nigerian immigration service have various challenges affecting their performance the nigerian government has the responsibility of making the nigerian state very secured to live in by not tolerating any form of violence or political crisis and if there is any it should be properly and quickly handled by the appropriate authorities as security is one of the important pull factors of international migration that sometimes influences a migrants decision on a particular territory the nigerian government also has the duty of providing various social amenities such as good roads electricity supply among other amenities the nigerian government also needs to make simple and considerate policies for investors who desire to come into the nation state to invest the nigerian government should as well try as much as possible to create opportunities and platforms that will attract nigerian emigrants back to the nation state most especially the highly skilled individuals this means that the nigerian government should help in establishing various attractive pull factors that is too good to be true as this among others might be able to persuade nigerians abroad and other potential migrants who might want to be interested in investing in the nation state the nigerian government should also try as much as possible to cut down the push factors which are more of a hindrance to the immigrants and a burden to the nigerian citizens causing them to leave the nation state some of the push factors are corruption insecurity kidnapping to mention a few the nigerian government also has the responsibility of catering for the border communities bringing them closer and creating the feeling of self belonging by providing various social amenities for them in their various communities such amenities can be infrastructures clean water schools health centers and other privileges such as employing their youths in the various infrastructures put in place in the area to discourage the thoughts of the nigerian government abandoning and neglecting them as the study reveals that these border community members collide with these irregular migrants for few amount of money the nigerian government also has the responsibility to communicate with nigerians in the diasporas through various government agencies and delicates for the earned purpose of creating a bond that will make them feel part of the nigerian community at home as well as initiating the idea of coming home to build the nigerian state as well as invest in her these nigerian migrants can also be encouraged to bring the knowledge and skill back home to strengthen the nigerian labour force and also by appointing the best nigerian experts into various nigerian government offices to move the nigerian state forward with their expertise as regard the porosity of the nigerian borders from the information gotten the nigerian government may not be able to fence the nigerian state round due to either the finance or the large total mixture of water and landmass of the nation state due to this reason the nigerian government and the nigerian immigration service should put in place various structures in various suspected entry points into the nation state this avenue can also create jobs for individuals who are yet unemployed the nigerian government should also have a good communication with the nigerian immigration service in drafting out various strategies that will bring about quality socio economic development and security for the desired positive change nigerian citizens seek the nigerian government should be aware that the ultimate success of the nation state lies with them and they should be remembered that various push factors nigeria as a nation state possess today is the faults of the mentioned nigerian government due to the failed inexperienced unqualified and undisciplined leaders private institutions it was observed in the study that most nigerian factory and industry owners and other likely private institutions prefer to employ irregular migrants from the west african neighboring countries due to cheap wages to safe cost the study revealed that labor is cheaper when individuals from the neighboring poor countries are engaged jobs held by these set of individuals are factory workers builders cooks teachers to mention a few these private institutions should try as much as possible to go through the legal procedures of getting their necessary needed manpower as responsible nigerian citizens to enable the nigerian immigration service carry out their work effectively border communities the border communities also have a special role in the socioeconomic development and security of the nigerian state they can be of assistance to the security agencies most especially the nigerian immigration service from the study it is revealed that the border communities host irregular migrants most especially irregular illegal immigrants in their houses in exchange for money the border communities should be aware and also be educated on the dangers of hosting irregular and undocumented immigrants in their houses or their communities in general the nigerian immigration service the nigerian immigration service plays a huge role on the socioeconomic development and security of the nation state around their respective duties and responsibilities just as the study reveals various challenges of the nigerian immigration service the agency should try as much as possible to effectively and always make do with what is at hand as with little much can be done as well but among the challenges of the nigerian immigration service is leadership as revealed in the study leadership is very important than structure in any organization the leaders of the nigerian immigration service consist of all heads of department as well as the comptroller general to mention a few when the leadership in an organization is weak there is bound to be visible challenges in their duties and in the characters of the employees staffs or subordinates in the same direction every seed sown by the head of an organization spreads to his subordinates to the least staff this implies that when a leader of an organization inculcates corruptible habits as other bad ethics whether in secret or in the open it will affect and spread these bad habits to the subordinates this is what describes the

international migration emigration and immigration can be of great benefits to a nation state through agreements and partnerships with others states in the international system as observed from literatures developing countries engage more in international migration than thethis study was to examines the problems of insecurity as a result of internal migration from bordering countries of niger cameroun chad and benin republic as well as observing the duties of the nigerian immigration service nis on revealing that the above mentioned agency has not control the entrance of illegal migrants making the nigerian state as a source and destination for migrants the study revealed the consequences faced by the nigerian state on international migration as a one of the security threat affecting the country the study also shows that the agency of nigerian immigration services nis has various challenges which are the reasons for the level of under performance of the agency the study tends to inform the nigerian public on the gains and loss of international migration this study adopts the expost facto research design taking the shape of a qualitative and quantitative research method as questionnaires were administered making use of the spearmans rank correlation results were also gotten through the chiquare calculations also in checking the validity of the collected data crobach alpha statistics was adopted the major findings of this study reveal that the nigerian immigration service nis has some challenges and these challenges hinders the success of this agency in bringing socioeconomic development into the nigerian state however for nigeria to benefit profitably from international migration the nigerian immigration service nis has to be efficient in her duties and also needs the cooperation of the sisters organization as it relates to socioeconomic development and security functions

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abstrak era digital memberikan dampak yang besar terhadap perkembangan bisnis di indonesia namun pandemi covid19 telah menghantam hampir semua bisnis termasuk bisnis usaha mikro kecil dan menengah yang kini berupaya bertahan dan bangkit dalam situasi pasca pandemi penelitian ini bertujuan untuk mengidentifikasi proses pengembangan bisnis umkm yang menggunakan metode digital dan dijalankan oleh satu kelompok generasi muda dalam situasi pandemic dari perspektif komunikasi interaksional konsep yang digunakan adalah model komunikasi interaksional dengan elemen makna individu terhadap lingkungan sosial dan bidang pengalaman individu metode penelitian yang dikualitatif deskriptif melalui focused group discussion hasil penelitian menemukan bahwa dari proses komunikasi interaksional makna yang diperoleh anggota kelompok terhadap lingkungan sosialnya yang merupakan generasi muda adalah identifikasi terhadap sejumlah persoalan yang dihadapi pemilik usaha kecil dan makna tentang membangun usaha dengan menggunakan media digital untuk pemasaran khususnya seputar pembuatan platform hingga pengelolaan konten bidang pengalaman anggota kelompok yang berbeda membuka kesempatan bagi anggota kelompok untuk saling merespon masalah terdapat peluang terbentuknya jaringan baru dan berkolaborasi dalam mencari solusi untuk membangun bisnis dengan metode pemasaran digital kata kunci komunikasi interaksional generasi muda bisnis digital introduction the covid 19 pandemic has undesirably impacted the sustainability of small medium enterprises based on the survey of lembaga penyelidikan ekonomi dan masyarakat universitas indonesia and the united nations of development program in 2020 more than 88 percent of smes experienced a decrease in profit margins from early of a pandemic until august 2020 from the ministry of cooperative and small medium enterprises data in 2018 the medium enterprises absorbed 3770835 people or about 313 of the workforce meanwhile small enterprises has taken 5831256 people or about 484 workforce and micro enterprises has absorbed at least 107376540 people or approximately 8904 of the workforce smes are the kind of economy that is mostly impacted by covid19 but at the same time are also considered the most adaptable ones with their innovative products this is because some have applied digital marketing in selling their products on another side the industry that was able to sustain during covid 19 is industry related to basic needs like electri city clean water agriculture farming plantation fishery automotive and banking meanwhile the industry that has developed much during the pandemic were food pharmacy information and communication technology one publication regarding small and medium enterprises smes is in krebet tourism village in yogyakarta and the dynamics of its villagers can be identified interesting points found from this study include understanding of citizens about the importance of brands in business activities understanding of collective brands dynamics in building collective brands as a way to develop the potential of the tourist village among those entrepreneurs who tried to adapt during covid19 are young people zgeneration or gen z was born between 1997 and 2012 when digital innovation and information evolved and advanced they found it easy to get information about products and trends on social media generation z is indonesias largest demography making up 2794 percent of the population according to frey as statistics indonesia in the 2020 population census generation z was born during 19972012 according to act no 40 of 2009 on youth young entrepreneurso are 1630 years old and organize factors of production nature workforce capital ability and skills for production to get revenue the significant number of young entrepreneurs in indonesia is a positive sign of the countrys development the data of indonesian entrepreneurs is only 018 of the total population or equivalent of 400000 people in 2010 the total number of entrepreneurs rose to 024 in january 2012 the number increased to 156 or equivalent of 375 million people the digital era has greatly impacted everyday life including the business sphere without big capital and working place everybody can lead their business only by using internet this phenomenon was marked by the robust online business carried out by the young generation by optimizing opportunities and expressing their creative ideas the online business is very attractive for people nowadays everything can be done easily people can just stay at home yet still be able to generate valuable income moreover with the nature of online shopping this online business has even attracted more people the information is also easily accessed by social media channels like instagram youtube tiktok or even searching at google below is the list of the top 10 ecommerce in indonesia in 2020 indonesia owns a broad market because of the benefits of its demography soon indonesia will reach its demographic bonus as the number of youth and productive people peaks however the number of productive age youth also presents challenges as the pandemic disaster strikes the world and the country furthermore the researchers summarized some previous research about the digital business of young people maryati and masriani mentioned in their publication that digital technology has allowed youth to build businesses independently by utilizing social media these young people can run their businesses and get their income to meet their life demands this study recommends that for the economy of society to improve there should be a digital technology training program for the young people in the village that will impact the growing number of entrepreneurs so the villages economy will bloom another study in tabalong regency found that the digital business strategy could be an alternative defensive strategy for smes during the covid19 pandemic by encouraging participation stakeholders like the company local government and universities to partner with smes in digital transformation the smes players are selling their products through ecommerce because todays customers have shifted to the online market product marketing has utilized digital technology or digital marketing to reach more consumers online through delivery order passion to build the business on the three series of entrepreneur are 1 product creation and development 2 business establishment and 3 business development personal environment and attitude influence business passion an important activity in digital marketing is also conducted to shift the students perspective in maximizing the use of technology as a tool to be an entrepreneur by building social media marketing and creating an application that can serve as a business opportunity this should not require big capital because they can join cooperation and be facilitated by kamar dagang dan industri kota tangerang selatan another relevant publication is about communication strategy through digital marketing conducted by the coffee home industry cahaya robusta sumbawa with the internet they also promoted products the effectiveness of using it can be seen through some of the benefits of using digital media marketing for example the easiness in the introduction sales and communication it is expected that digital marketing not only focuses on instagram facebook and youtube but also collaborates with social media by using other applications like websites blog shopee and others sarastutis research that supports the earlier studies was that the marketing communication strategy conducted by muslim fashion by focusing on selling promotion and banner advertising on social media like facebook then visual communication factor and recommendation also influences the increase of brand awareness however there should also be a person in charge of handling the online media another finding regarding digital marketing communication on the amazara brand could complete the previous research some factors have become obstacles in accelerating digital communication marketing like the message accuracy perceived by consumers consumers doubt in accepting information budget limitation and difficulty in integrating marketing communication in each communication channel therefore it is recommended that a longterm digital communication strategy should be created these are related to other publications about promoting digital communication in the tourism context instagram as a social media based on visual sharing features is appropriate utilized as a medium to promote tourism potential especially in yogyakarta given the tendency of its engagement is organic to motivate instagram users to visit tourism potentials as is conducted explorejogja for tourism potential in the yogyakarta region from rositas publication it was concluded that smes are the kind of economic activities that were severely impacted by covid19 pandemic but they were considered able to adapt their businesses with innovative products this happened because they used a digital marketing strategy in selling their product on another side the kind of industry that survived during covid19 pandemic was industries related to basic needs fulfillment like electricity clean water agriculture farming fishery automotive and banking some industries also flourished during the the pandemic such as food pharmacy information technology and communication enterprises practically speaking having a business during the digital era was not simple as many things should be considered one of the most fundamental aspects to consider was the fresh idea as to how to answer peoples demands in a better way to create this new idea creativity also played a vital role other competencies required were the ability to organize and the business system should be taken seriously for example how to manage the supply and consumers in managing social media the business owner should be able to decide how to sell products to attract followers through the picture caption and description of the products offered business owners should also watch for the market situation by analyzing competitors and understanding the price that is adjusted with the target market these ideas were supported by a study about the impeding factors for the entrepreneur some of the most common challenges were the lack of investment the poor economy that caused the slowing down of peoples purchasing power lack of skills tight competition the product or service quality as well as marketing and finding the right place to start the business it was suggested that young entrepreneurs should level up their creative thinking ability to create innovative products other than the condition mentioned above the covid19 pandemic could also be challenging for young entrepreneurs nowadays from one of the earlier studies in agribusiness the covid19 pandemic has stopped the operational activities in agro store for four months impacting a number of problems like the decrease in selling numbers in facing those challenges whatsapps digital platform has become the alternative platform for selling vegetables and fruits online another challenge was the lack of human resources and transportation and customer complaints this study recommended young entrepreneurs stay consistent in using digital platforms as marketing media for fruits and vegetable products as the opportunity to expand the market and improve the selling rate maharani also emphasized how digital marketing significantly improved smes existence in indonesia based on previous studies the digital business phenomenon in the young generation has not been studied from its process this is important to serve as reference for other parties who want to develop a similar business model one of the studies about digital business development can be seen from the communication model approach because the business development process is closely related to the interaction process between individuals and groups therefore one of the communication models that is considered suitable for studying group dynamics of young people in building a digital business is the interactional communication model the pattern of the interactional communication model emphasized the twoway communication between communicators the communication occurred from the sender to receiver dan from receiver to sender the interactional perspective illustrated that someone could be a sender or receiver in one interaction but cannot be both simultaneously other than that the elements in the interactional communication pattern are namely feedback or response to a message feedback can be verbal nonverbal deliberative or nondeliberative interactional communication is one of communication that emphasizes on feedback or response the process happens when individuals use symbols to create meaning within their environment interactional communication is the process in which there were meaning exchange with the feedback that connects the receiver and sender the process of reciprocity in communication is called feedback feedback is communication done by the receiver of message to the sender to show understanding furthermore west and turner also explained the interactional communication model that highlighted the twoway direction process between communicator and communicant which reminded us of how the communication model is always ongoing this interactional perspective illustrated that someone could be both sender and receiver in one interaction but cannot play both roles at the same time in this model it can be understood that when two people are communicating if the first person acts as the sender of the message the second person acts as the receiver and vice versa one of the most important elements in the interactional communication model is feedback feedback for the message can be verbal or nonverbal deliberative or nondeliberatively feedback is also useful to help communicators know whether their message has been understood much the meaningmaking through the interactional communication model the research about young people groups can be explored by using the elements in the communication process therefore it would create a more comprehensive description of how the creation and development of the business process happened the covid19 pandemic experienced the world has enriched the context of communication research on the scope of business processes moreover the disaster situation often has a longterm impact thus more agility was required to survive and bounce back compared to normal situations the interactional communication model has emphasized several aspects according to this model human beings act based on the meaning they have given to their social environment the meaning correlates directly to the social interaction of individual with their social surrounding the meaning was created defended and changed through the interpretation process done by individuals when they are connected with their social environment from the researchers perspective interactional communication is in line with the twoway communication process the twoway interactive communication model is also a model that could pay attention to user segmentation as the development component the melhate opinion highlighted communication development which is also crucial to see the emphasis on grassroots participation or marginal groups one study about interactional communication model in the education context noted that there is an influence between teachers creativity in teaching and interactional communication with the student achievement both creativity and interactional communication simultaneously create a strong influence furthermore there is an explanation from another researcher that the theory of information process and interactional communication have created one effective learning method this model consists of six elements they are principle syntax evaluation planning social system instructional impact and accompanying effect from one of communication research between parents and children who used interactional communication it was found that there was significant positive relation between communication and selfefficacy in terms of work readiness the higher the interactional communication between parents and children the higher the childrens selfefficacy in terms of work readiness the contribution that interactional communication makes to selfefficacy in work readiness is important another research that aligns with the interactional communication model has explored the indicators in which the communication process occurred the message conveyed in education is called feedback when it is a response to the senders message and affects the receivers following behavior interactional communication can be measured through five indicators first response verbal or nonverbal response confidence in expressing an opinion secondly openness which includes teachers willingness to honestly comment on what students have expressed the teachers willingness to acknowledge and accept the students perspective thirdly meaning exchange which includes teachers willingness to listen to students opposite opinion teachers willingness to change position if the situation suggested so fourthly positive attitudes positive attitudes towards students support the students positively fifthly the egalitarian attitude in which there are balance between teacher and student in speaking their minds balance for teacher in listening to the students studies on interactional communication should look at several communication model suggested by schramm this communication model introduced the idea that the similarity in the field of experience and target are the things that are being communicated the particular part of signal is what the source and target believed in the end the field of experience of each person will affect their ability to communicate with others each individual brings their own unique experience to communicate in each episode these experiences will often affect communication between one another the experience will also determine how one person will maintain their relationship with others from previous research this study has novelty in the newly chosen topic of digital business development that young people did during the covid19 pandemic this research uses the elements of the interactional communication concept that focus on the meaning given by individuals towards their social environment and the field of experience they have methods this research uses a descriptive qualitative method by collecting data through focus group discussion this method is based on theinformants characteristics and the problems that will be researched the qualitative descriptive methods used data collection to explain the phenomenon the collection of data sources is conducted with a purposive or snowball sampling technique the collection technique is conducted by triangulation with inductive data analysis or qualitative thus the result of qualitative research stressed more on the meaning rather than generalization in this study there is an issue that has been the needs of the informants which is how to develop business using digital marketing this is in line with the explanation from stacks that the focus group is required to direct the group member on certain issues by asking the problems group members to discuss further and see various opportunities until they find the solution the qualitative approach has several purposes describing reality as it is contextually telling things as they are exploring obtaining meaning finding indepth understanding about something and understanding theory moreover in qualitative research the result does not come from statistical procedures or other quantification methods the fgd members in this research are 15 people 6 out of 15 people categorized as young people these six people are young generation who built their smes a few years before the covid19 pandemic the owners of these business come from a number of places and not only from jabodetabek they are also from bangkalan madura sumatera lombok and kalimantan meanwhile the member of the discussion group is the group of students who live in jabodetabek that has experience in creating platform and as consumers of digital marketing fgd was conducted through four stages the first stage is the identification of the needs of young generation as the smes entrepreneur the second stage is discussion on the creation of digital marketing account the third stage is discussion on content creation the fourth stage is discussion on digital platform that was successfully made by each member result and discussion the research conducted fgd on a group consisting of young people with certain interest and needs to develop digital marketing the age of the members was 1823 comprised of two kinds of groups one with business and another with knowledge in digital marketing management the group of businessmen is six persons who have started their businesses in various fields like muslim fashion photocopy service stationery products and souvenirs this businessman group has an education background at high school or vocational school and has taken entrepreneurship training in one islamic boarding school for half a year they lived in kalimantan lombok sumatera and madura another group member is young people with knowledge and experience in digital marketing this second group has a bachelorss degree and lived in jakarta the things in common with member groups are namely age and experience in education or training institutions from fgd process the first step was about problem mapping that was conveyed by the member of smes member group in the next step of fgd several problems have been identified to be solved by offering the solutions on further discussion there was intensifying interaction at the last step of fgd there was a model of digital business development expected by young entrepreneurs who have the needs to build digital businesses a number of concepts were discussed in the introduction the researcher tried to formulate that this study would analyze how the interactional process took place in a group the method of interactional communication is using the elements of individual meaning toward their social environment and the field of experience of the group members the first element of interactional communication is the individual meaning towards their social environment in the interactional communication model meaning was created defended and changed by the process of interpretation done by individual as long as it is connected with social environment other than that the reciprocity or response in the interactional communication process in which individuals use symbols to create meaning towards their environment on the interactional communication process through the fgd process it was found that each group got the new meaning of digital business the first meaning is a number of troubles faced by the member of the group of smes some have a problem with the lack of capital lack of models in the fashion business tools and equipment that should have created a more efficient business another problem is the availability of raw materials because of some hassles in getting them and not having any work partner regarding product marketing the scope is still limited to the nearby area and they do not have a proper place for a photo product setting when they were about to promote their product online these young entrepreneurs did not have a good signal network and product delivery service there was no expedition service in the area therefore they had to go to another area when they needed to deliver the product these smes entrepreneurs also wanted to have partner who can support their business partner is required to assist them in developing their business because they feel like they did not have sufficient knowledge to expand their business digitally on the other side the pandemic situation has caused a decrease in people purchasing power and somehow that led to necessity to the change of marketing methods from traditional to digital therefore the group has the map about the business development problems that came from an entrepreneur group member two of the member group discussion stated below … we have some problem delivering product to our customer since there are no delivery services around here and we have to go to the town it causes some additional cost to our product so that we cant compete with others another problem is the telecommunication infrastructure that is not supporting us enough compared to other locations especially in jakarta or jawa we need support in connection facilities to our customer or supplier from their statement we could get some description about some supporting facilities they need for their business running the second meaning acquired from interactional communication is that for the discussion group member among university students in jakarta all the problems experienced by the member of business people from outside jakarta were probably unimaginable this is because the business infrastructure in jakarta was sufficient and distribution channels were available including those that can support the speed of product delivery the availability of digital media promotion was not enough if not supported by sufficient distribution infrastructures the problem faced by the entrepreneurs was the delay in product delivery or even the inability to reach customerss in the interactional communication group a meaning was found about the process of small business from the upstream to the downstream from the time product is produced until customer receives them an entrepreneur can see market opportunities if they understand their consumers needs by using digital media marketing now the consumers dynamics can also be understood by producers and marketers from time to time not only that but they can also see the change in consumers tastes and competitors from the same business one of the member group discussions from smes stressed discussion about the business situation in the digital era … in this digital era of course we are very lucky if we could have an opportunity to develop our customer widely we know that from digital or online sales the target customer could see our product easily and fast we also could see what our competitors do at this time this would be very important for us as a businessman for monitoring the customer and competitor the third meaning found was about the motivation for entrepreneurship the process of running a business was sometimes under unpleasant circumstances with no other option to survive with many limitations of opportunity and lack of capital some of businessmen tried to move forward and expand their business on the other side the entrepreneur group also sees that student member group who have the the opportunity to continue their study at the university in jakarta have more chances to get practical knowledge in a more structured way as well as exposure to numerous communities during their study time in university this gives fresh perspective that the future for young generation opens numerous opportunities and plenty of times for them to explore many possibilities the fourth meaning develops from other problems such as how to give solutions for the problems found by choosing the right marketplace that is most suitable for the product offered in some available marketplaces the group members discuss many things and take examples from some marketplaces that have been chosen at this stage the new meaning for group members includes platform making and digital content creation as well as giving solutions to every problem in building a business using digital media the need of group members regarding information about the process of content creation in digital media have been fulfilled from the creation process management and information there are more benefits that the group member can get from digital media rather than conventional media fifth there is new meaning acquired from the interactional communication process about the related symbols regarding the phrases of digital marketing the group members were introduced to various kinds of social media like instagram tiktok and youtube as promotion media how to manage and develop social media campaigns and the creative thinking process using various references besides interactive communication enabled groups to prioritize ethics and good attitude when delivering messages in social media to promote their business and get basic knowledge about design and photography the group member also shared knowledge and experience about how to serve customers which sometimes as businessmen they have to face many pressures of demands and tight deadlines one of the group discussion members of student tw stated … from these discussion process in more than three times we are very thank full in having some experiences from our new friend of the student from university in jakarta our knowledge in business is much more important when we have new information especially in developing on line business another important thing is we have new relation that we could contact for further occasion in asking about on line busines rp one of the student members stated regarding the process of creating media on line … we are trying to share our experience and knowledge in building the on line trading we start by identifying a suitable marketplace for the sme and build some content for promoting their customized product these group discussions give us many new experience in building relation with peers group from different area and different culture in indonesia student ef we are listening to them and this is very amazing they are very tough and strong in building their new business with many obstacles this would motivate us as students in jakarta with so many supporting facilities from the government for creating a busines this research also found the next element of interactional communication related to the experience field they have first even with various experience and individuals backgrounds of different group members all group members have something in common business development through digital media interactional communication has opened opportunities for young entrepreneurs to get good networking collaboration can occur in different social environments because they are willing to share their experience and teach each other about the spirit of building business despite numerous constraints difference social environment also describes that building a business requires continuous efforts persistence and innovation during a hard situation like a pandemic other than trying to survive these young entrepreneurs should collaborate to strengthen each other and to get new opportunities rf from student member stated from our discussion we could see the same perspective even though we come from different backgrounds we are very concerned about online business that exponentially affects many businesses being a part of digital business would be an advantage for us as young generation hopefully we are not only as consumer of online trading but we could be apart of the business player so it is very important to build collaboration between businessmen and content creators secondly from the interactional communication process the group members field of experience was new knowledge for group members about business development by using digital media as marketing development the young generation was considered to have more knowledge and experience in the field of digital business to give opportunities for them to build wider social interaction compared to their current social environment meanwhile even though the student group has not started their business yet they already have experience creating digital accounts to support their business promotion and have experience as digital consumers these students can support each other in developing businesses with digital marketing with the ability to create digital accounts make creative and attractive promotional content and organize groups so that the discussion will run effectively and reach the purpose interactional communication is one of the communication models that emphasizes reciprocity or response one of the reciprocities that emerged is the answer to questions about what kinds of problems took place when entrepreneurs were building their businesses not all individuals in the discussion gave the same response but those who gave minimum responses still got benefits by listening to the groups discussion the communication process in the form of discussion can be utilized by other members with common problems and desires therefore the group can identify about ten issues that have arisen and are faced by young entrepreneurs in the group discussion this would benefit the passive individuals who still want to absorb the information each group member can feel that others also experience the problems they face therefore the communication process could motivate group members to keep building business because the problems they are currently facing are normal things experienced by businessmen thirdly a difference scope of experience can build openness between members of the groups during the discussion everybody can talk about anything especially things that have been a problem for their business in building their smes during the pandemic digital businesses have been among the most popularly chosen by many entrepreneurs a number of problems addressed have become the beginning of the effort to discuss business development by the digital method the openness of the young generation of business owners in the group in interacting with a wider social environment and their willingness to open their minds are really helpful in getting the new meaning of digital business the group also gets a new interpretation that enriches their knowledge about their business even though it was not easy for each individual time and frequent discussion were required to build sustainable interactional communication aj from smes group stated when i meet the student group for the first time i feel not confident but i really want to have the knowledge about online business in the next discussion i felt more relaxed and paid more attention to other entrepreneurs problems i realize that we have to meet people from other groups or from different experiences for some additional knowledge the frequent interactional communication allowed each individual to discuss their field of experience group members consulted each other about the introduction of digital media format discussed the making of applications and interesting digital content and management of digital business in the long term the student group field of experience also enriched more knowledge for the group of smes owner about how to determine how to sell the product attractively through pictures unique captions and the product description offered other than that there is knowledge about how to make competitor analysis and the price tailored to the market target digital communication media have opened the eyes of young entrepreneurs so that they would get convenience in analyzing the weaknesses and strengths that the competitors have fourth the diverse field of experience of the group members has allowed collaboration when the problems were found the main issue during the pandemic was collaborating with another party this would be tough if the entrepreneurs only stayed in the same environment and tended not to develop themselves the process of learning how to use digital media was not doable since they only gathered with the same old community the same community only provided them with the same old information and was not updated with current information contrary to that the interactional process with the new group provided ample perspectives about the value added to the business field or at least each group member would get a further information besides that the interactional communication that took place several times and delivered directly in a form of discussion could give deeper understanding and invoked empathy towards the problems other group members face about the business they are doing rh from the student group concluded with the statement below the point that we get in the group discussion is that we have to realize that building the business needs some learning process we have to open our minds to others and new issues and with one or some group with new experiences otherwise we will be left behind and lack of some opportunity during the interactional communication process through the fgd there was meaning exchange with the feedback that connected the receiver and sender of the message feedback is the communication given to the source of the message to show understanding discussion referring to the previous study it was noted that the motive of young entrepreneurs in online business was because conventional business was down while online business could reach more potential buyers from all over places young entrepreneurs perceive online business as based on mutual trust between business players that finding supported the result of this study emphasizing that in the fgd process the problems in developing smes done by the young generation group one of the basic problems is reaching the potential buyers problems regarding the availability of raw materials and product expedition during several meetings through fgd there was a developing communication situation in the group with varied backgrounds the interactional communication process that has been built allows each individual in the group to have control over their roles during the discussion process each member has accountability to remind each other every group member was involved in the idea contribution and felt that they were part of the group because the group member did not only communicate with their group but also interacted with the members of other groups the messages conveyed in the discussion were responses towards the messages of the sender and affected the next behavior of the sender the debate about this research also referred to the study about teachers and students who have concluded interactional communication was measured through five indicators first response verbal or nonverbal response confidence in expressing an opinion secondly openness includes the teachers willingness to honestly comment on what students have expressed the teachers willingness to acknowledge and accept the students perspective thirdly meaning exchange which includes the teachers willingness to listen to students opposite opinions the teachers willingness to change position if the situation suggests so fourthly positive attitudes positive attitudes towards students support the students positively fifthly the moderate attitude in which there are balance between teacher and student in speaking their minds balance between teacher in listening to the students in this research the interactional communication process between group members with their social environment and with different member groups can provide a chance for the group to respond upon the problems found in the effort of business development there were mutual opennesses between group members to comment on the things expressed by other members and acceptance of the thoughts communicated by each groups therefore there was meaning exchange in the group because of the positive and supportive attitude in accepting the idea of business development through online marketing on further discussion there was even more openness toward the possibility of building new networking collaboration in solution seeking in building business with digital marketing method especially in creating the platform and content management this research is also in line with the study of banuanek and colleagues which showed that conformity happens when there is a status difference inside the group meanwhile the social facilitation took place when the group emerged as the study medium to motivate its member as capacity building on the other side there was no polarization found in the group of pemuda jemaat pniel sikumana because this group was perceived as braver creative and innovative in facing all the challenges in the group this study also found that the interactional communication process built by the young generation group showed conformity because there was a status difference in the group conformity was made by contributing to solutions in business development by using online marketing methods group also presented as a learning medium for all group members from the problem identification phase up to the solution in the form of digital platform and content implementation discussions that have evolved in several meetings have motivated every group member to build capacity as sme players and students in developing their knowledge conclusion communication with the interactional model approach has allowed group members to acquire new meaning for every challenge and the chance to build digital business for smes from the various social environment the young generation in groups gets new knowledge and experience in building a business with digital marketing interactional and sustainable communication can build group cohesiveness therefore it is better to coordinate many challenges changes and drafting of new strategies in business development all parties have been open to communicating their problems and opinions regarding business development by using digital marketing through interactional communication in several time meetings there have been an effort to harmonize and build comfortable communication therefore each individual has the same opportunity to learn the most suitable twoway communication method the choice of this communication model later on could create ease in building cooperation on the next step the researcher recommends that the pandemic situation which has now turned into endemic had given a significant lesson for sme entrepreneurs there will always be a possibility that covid19 or its other variants will emerge as new threats thus the young generation requires agility to build their business and keep on adapting and collaborating the interactional communication process with meaning and diverse field of experience elements could be best utilized to support the adaptation and collaboration process

the digital era has brought a massive impact on business development in indonesia however the covid19 pandemic has crushed almost all small and medium enterprises smes and they are currently trying to stand and rise again in the postpandemic this study aims to identify the business development process in smes by using digital methods carried out by youth groups in pandemic situations from interactional communication perspectives the concept used in this study is an interactional communication model with the element of individual meaning toward the social environment and individual field of experience this research method is descriptive qualitative through focused group discussion fgd the result found that from the interactional communication process the meaning interpreted by the group member toward their social environment was the identification of a number of problems faced by the sme owner other than that there was also the meaningmaking about building enterprises by utilizing digital media for marketing especially in creating a platform for content management groupmembers different field of experience has brought opportunities to respond to eachothers problem there are also opportunities to create a new network and collaboration in searching for a solution to build a business with a digital marketing method

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the pursuit of social economic and environmental justice through evaluation learning from indigenous scholars and the fifth branch of the evaluation theory tree many scientists warn that humanity is at a tipping point in terms of environmental damage and that the consequences of ignoring this escalating problem are more severe for members of marginalized communities such as women people with disabilities people of color indigenous people and those who live in poverty for example the intergovernmental panel on climate change provided this dire statement humaninduced climate change including more frequent and intense extreme events has caused widespread adverse impacts and related losses and damages to nature and people beyond natural climate variability… across sectors and regions the most vulnerable people and systems are observed to be disproportionately affected this brief statement reinforces the connections between environmental justice and social and economic justice this intersection is also evident in the united nations sustainable development goals all un member countries adopted 17 sdgs that address ending poverty protecting the environment and improving the quality of peoples lives through access to education health care and safe living environments these goals are to be achieved between 2015 and 2030 my personal journey transformative and indigenous as nonindigenous evaluator i have advocated for inclusion of the voices of members of marginalized communities not simply on the basis of ethical principles but also because evaluators would enhance their theory and practice by listening to these communities i make the argument that listening to and learning from members of marginalized communities especially from indigenous peoples better positions evaluators to consciously contribute to increased social economic and environmental justice rather than being complicit in sustaining an oppressive status quo i am sometimes asked why i advocate so much for this shift in evaluation i take inspiration from martin luther king jr in his 1963 letter from the birmingham jail he wrote injustice anywhere is a threat to justice everywhere we are caught in an inescapable network of mutuality tied in a single garment of destiny whatever affects one directly affects all indirectly in this article i provide a brief overview of the history of philosophical paradigms and theories in evaluation which have excluded the voices of marginalized communities including indigenous peoples this sets the stage for discussion of the importance of learning from indigenous scholars how to better address issues of social economic and environmental justice on a global scale a brief history of evaluation paradigms and theories in my fiftyplus years working as an evaluator i have come to the conclusion that there is nothing quite as practical as a good philosophical framework that is aligned with commensurate theories of evaluation you might wonder how i came to this conclusion given that many evaluators do not specify their philosophical assumptions nor the theory that informs their work in point of fact the ideas of philosophical frameworks and theories were not included in my academic training as an evaluator however living through the paradigm wars when the evaluation community was embroiled in negative rhetoric about which methods were best⎯quantitative or qualitative⎯led me to appreciate the early work of guba andlincoln in which they asserted that our arguments were not about methods rather the evaluation community needed to focus on clarity about the assumptions that underlay methodological choices thus they introduced the concept of paradigms and their associated philosophical assumptions to the evaluation community an action that has had and continues to have a significant impact on discussions about methodology paradigms are frameworks that are made up of a number of assumptions related to the nature of ethics and values the nature of reality the nature of knowledge and the relationships between the evaluator and stakeholders and the nature of systematic inquiry paradigms and the evaluation theory tree this framework of paradigms found applicability in early efforts to categorize evaluation theories alkin provided a metaphor to describe evaluation theories in the form of a theory tree in the book evaluation roots in the first edition christie and alkin introduced a tree whose three branches they labeled methods values and use these three branches align with three of the recognized paradigms that provide guidance in the evaluation field methods aligns with the postpositivist paradigm values aligns with the constructivist paradigm and use aligns with the pragmatic paradigm this depiction of evaluation theories was useful however it was missing some important paradigmatic perspectives specifically the transformative paradigm and the indigenous paradigm the transformative paradigm was introduced in 1998 and the indigenous paradigm was written about by smith battiste wilson andchilisa the consequence of excluding these two paradigms was the absence of the voices of members of marginalized communities from the threebranch evaluation theory tree the first edition of evaluation roots included 21 chapters that explained the roots of evaluation theories all but one of the chapters were written by white people none of the chapters were written by indigenous people all of the authors were drawn from the united states and europe a second edition of evaluation roots appeared in 2013 and it depicted the same threebranch evaluation theory tree and contained 27 chapters describing evaluation theories all chapters were again authored by people from the united states and europe except for one chapter on evaluation theory by authors from australia and new zealand this chapter was authored by two nonindigenous women and included brief discussions of three indigenous evaluation theorists linda tuhiwai smith fiona cram and nan wehipeihana again no people of color or indigenous people were included as chapter authors alkin and his colleague cardin justified the composition of the tree that excluded indigenous theorists because the nature of formal evaluation work in lmics lowand middleincome countries … is not yet formalized into full prescriptive theory this rationale fails to recognize that the ways of indigenous research are as old as the hills and the valleys the mountains and the seas and the deserts and the lakes that indigenous people bind themselves to as their places of belonging and the rationale fails to acknowledge that the works of indigenous scholars and members of other marginalized communities have been systematically excluded from the academic literature in the third edition of evaluation roots alkin and christie maintain the threebranch structure and have included chapters by hopson and shanker two authors of color cram and chouinard two indigenous women and myself under the values branch hopson and shanker wrote about culturally responsive evaluation cram and chouinard wrote about indigenous evaluation and i wrote about transformative evaluation so more diverse voices are included in the third edition but the assumptions associated with transformative critical liberatory decolonized frameworks are placed under the values branch my position is that until we see a pervasive theoretical lens for evaluation that address inequities and discrimination and that provides a basis for transformative change leading to increased justice for all we need separate branches to represent these positionalities some might question whether the use of a tree metaphor to depict the philosophical and theoretical foundations of evaluation is appropriate since tree branches grow in independent directions and seemingly have little interaction once they have branched out from the trunk others suggest that a forest would be a better metaphor for the evaluation field depicting synergistic relationships between trees that represent different philosophical frameworks wohlleben writes in the hidden life of trees that the symbiosis between trees in forests demonstrates their interdependence elsewhere i have suggested that characterizing the paradigms as ocean currents might be more appropriate as they swirl through their own territories but eventually all mix together in the great conveyor under the ocean its possible to use all of these⎯or none of these whether we use a tree or an ocean metaphor or something else the paradigms are useful to communicate basic assumptions that guide methodological choices the transformative paradigm an umbrella for the pursuit of justice in the first edition of research methods in education and psychology integrating diversity with quantitative qualitative approaches i articulated the need for a paradigm that was missing from the threebranch theory tree one that explicitly represented the voices of those who are marginalized and experience discrimination and oppression in the first edition i labeled this paradigm emancipatory then changed this paradigms name to transformative in subsequent editions of the book later wilson and i presented a tree with four branches methods use values and social justice the social justice branch aligns with the transformative paradigm we acknowledge that social justice cannot be considered without also considering economic and environmental justice if evaluators are to contribute to just solutions to complex problems such as the climate crisis the transformative paradigm was designed to provide an umbrella for evaluation theories and approaches that explicitly address issues of justice and human rights thus it is inclusive of evaluators who work from theories such as human rights feminism lgbtq disability and deafness rights as well as people of color writing from critical race theory and latcrit theory wilson and i also included indigenous peoples under the transformative umbrella based on the rationale that they are marginalized and experience discrimination and oppression and that they were not included in previous depictions of evaluations philosophical frameworks or theories however based on interactions with indigenous scholars and responding to the scholarship that these scholars have produced on the indigenous paradigm we noted in the fifth edition of research and evaluation in education and psychology and the second edition of program evaluation theory and practice the need to change our thinking and for the evaluation community to learn more about the assumptions associated with an indigenous paradigm indigenous paradigm in evaluation several central concepts are integral to the indigenous paradigm and are different from other paradigms the history of colonization means indigenous people share the land with their colonizers resulting in ongoing discrimination and subjugation by colonizers in addition the united nations declaration on the rights of indigenous peoples recognizes that indigenous peoples have a right to selfdetermination to determine their own political status to belong to indigenous nations and to conclude treaties agreements and other arrangements with states these rights have not been recognized by the governments in the lands of all indigenous peoples however for indigenous groups whose rights have been recognized the issue of sovereign government is a distinctive characteristic with implications for evaluation indigenous communities are not monolithic they are complex and manifest a great deal of heterogeneity that needs to be recognized uniqueness is associated with different indigenous groups and also within indigenous groups thus it should come as no surprise that there are differences of terminology describing what has appeared in western literature as paradigms in this article i focus on indigenous scholars from the united states africa australia and aotearoa who provide different perspectives based on their countries of origin an important limitation to be noted is that across the world indigenous peoples come from countries that are not represented here such as india arabic countries persian countries china and japan writings of indigenous scholars that are beyond the purview of this paper provide future opportunities to learn about different paradigmatic perspectives cram tibbitts and lafrance and chilisa find a way forward through the complexity by describing essential assumptions associated with an indigenous paradigm chilisa went further and created a fivebranch theory tree by adding a branch labeled needs and context that aligns with the indigenous paradigm other authors in this special issue provide authoritative narrative on the characteristics of this paradigm therefore i offer only a brief description of this paradigms assumptions and its contribution to evaluators understanding of how to work toward increased justice no matter what community we work with i then address the permeability of borders across paradigms as a means to improving evaluation theories and approaches for all evaluators committed to working toward increased justice finally i present questions that arise when we portray evaluation theories as branches on a tree philosophical assumptions of the indigenous paradigm indigenous axiological assumption axiological assumptions pertain to values and ethics the indigenous paradigm presents a relational axiology that emphasizes the values of relationality respect reverence responsibility reciprocity reflexivity responsiveness and decolonization nonindigenous evaluators can benefit by understanding the indigenous ethical concept of relationality as it explicitly includes reference to the relationship between the human and physical worlds this ethical principle incorporates the ideas of wholeness and relationality leading to the position that the evaluator has an obligation to promote the transformation of all humans and the physical world thus the indigenous assumption regarding ethics calls upon evaluators to consider how they support decisionmaking about the complex problems inherent in the climate crisis that was mentioned at the beginning of this article along with the multitude of related problems the acknowledgment of a need to redress the ongoing negative consequences of colonization exacerbated by sharing land with their colonizers is a unique element of the indigenous axiological assumption for western evaluators this implies a need to be critically reflective and ask themselves if their practice is continuing to oppress people with a history of colonization a team of evaluators from england aotearoa new zealand and canada had the courage to challenge the colonizing nature of a funding program based in england that was designed to create partnerships between indigenous and nonindigenous researchers and evaluators despite language about the intent to develop equitable partnerships between indigenous and nonindigenous researchers and evaluators the power to identify the problems and solutions along with the methodologies to be used in the investigations were predetermined by the british funding agency edwards et al did not passively accept the western offer for funding on those terms rather they produced resources to challenge colonial thinking and provide guidance for culturally responsive relationships between indigenous and nonindigenous researchers and evaluators indigenous ontological assumption the indigenous ontological assumption states that there are multiple realities and it adds two unique concepts of relevance for all evaluators a spiritual reality and the interconnectedness of all living and nonliving things cram et al provide this commentary about spirituality in evaluation of all the components of ie spirituality is among the most distinguishing and challenging for evaluators the presence of spirit a topic that is usually ignored in evaluation or perhaps tentatively broached by those working in some religious context is central to indigenous peoples worldview and thus to ie indigenous wellbeing inevitably involves a spiritual component that may or may not be recognized by western religion a prime example of spirituality is the use of protocols that cover all forms of tribal meetings and gatherings including those conducted for the purpose of evaluation these protocols are about keeping all those who are gathered safe in a spiritual sense research and evaluation protocols that spell out the need for respectful engagement with indigenous peoples often try to put into nonspirit terms the importance of proper spiritrelated protocols however for many indigenous peoples the roots of these protocols are in the recognition of the sacred spirit present in all things the inclusion of a spiritual reality may be difficult for westerners to wrap their heads around given that westerners for the most part have been taught that science and spirituality are two separate things not to be mixed the indigenous philosophical stance looks at science and spirituality as part of the whole universe without a separation between the two as cram and her colleagues make clear spirituality is a highly relevant aspect of reality in indigenous communities nonindigenous evaluators may think they do not need to include this aspect of reality because they do not work in indigenous communities however i see several important implications first if people have a spiritual part of their existence then what risks do we take when we exclude that part of their lives in our evaluation work second how do we give consideration to keeping people safe in our evaluation work and third this concept of spirituality brings us back to the consideration of the interconnectedness of all living and nonliving things as is evident in the last phrase in the cram et al quotation recognition of the sacred spirit present in all things chilisa and tsheko demonstrated how indigenous studies incorporate attention to spiritual realities in their development and evaluation of an intervention to reduce hivaids in young people in botswana rather than make assumptions about what methods would be best for data collection and what intervention should be implemented they began with an elicitation phase to determine how best to proceed the young people were involved as coresearchers in order to embed the ubuntu principles of spirituality love harmony and community building the reality of hivaids reflected in the students experiences was elicited through storytelling and examination of proverbs that were widely known the early data collection revealed the spiritual component of the effect of hivaids on these young people in that they reported a sense of sadness at the loss of so many friends and family members this shifted the focus of the intervention from a knowledgetransmission model to an experiential model that started with the emotional state of the students and how their spirits were affected by the high rates of infection and death the indigenous ontological assumption includes the idea of the interconnectedness of humans and nature with implications for evaluation to attend to that interconnectedness piccioto described this as follows the ontology of indigenous evaluation brings to the table a recognition that humans have duties to land animals and other living things it is a frame of mind that resists the silencing of rivers the destruction of watersheds the razing of mountains for mining the pollution of air water and so forth when this interconnectedness is ignored it can have disastrous consequences many international development agencies have a primary goal of reducing poverty implying that economic development should be prioritized when economic development is prioritized over environmental and social justice people animals rivers and plants suffer for example in west java the government supported the development of a textile plant to create jobs however the textile plant resulted in high levels of air and water pollution dumping 20000 tons of waste and 340000 tons of wastewater into the citarum river every day this is the thirdlargest river in java and is extremely polluted with industrial chemicals plastic rubbish trash waste and dead animals its levels of lead are 1000 times worse than the us standard for drinking water yet 25 million people depend on it for drinking water irrigation of crops and energy production the result is that many people who use this heavily polluted water and breath e the contaminated air now suffer from health problems such as scabies infections and respiratory distress if an indigenous lens had been used to inform the creation and evaluation of economic development interventions the intersection of environmental economic and social justice would have been prioritized local voices would have been listened to and collective decisionmaking would have been employed widianingsih and i developed a transformativeindigenous mixedmethods design in order to address the three types of justice social economic and environmental farmers in west java formed consortiums that had regular meetings at each meeting participants talked about their challenges and solutions in three circles the farmers their wives and young people data from these circlemeetings were used to inform government agencies and policy makers about the types of interventions that they viewed as having potential to preserve the environment generate sufficient income to take care of their families and employ the youth in the rural areas and protect their rights to live in a healthy space the indigenous ontological assumption also has implications for who determines the methodologies through which reality can be known chilisa and chilisa and i describe the relationship between indigenous ontology and methodologies with a made in africa approach the ontological assumption associated with an mae approach holds that africans are to play a greater role in solving their own problems thus questions on who prioritizes initiates and designs community programs and projects are essential all areas of culture living experiences and indigenous knowledge systems must be utilized to come up with a methodology through which the realities can be known reality is contextual and cultural ly bound the evaluator should examine the history of the program the location and its people all connections and interconnections and interrogate how spirituality relational power political discursive sic and historical temporal power shape the evaluand under this assumption the main question addressed by the evaluation is whose priorities and aspirations are addressed by the evaluation the indigenous ontological assumption prompts all evaluators to ask about whose reality is being privileged and the consequences of accepting one version of reality over another this is a critical aspect of both indigenous and transformative ontological assumptions versions of reality come from different social positionalities and some versions of reality lead to continued oppression while others lead to an increase in justice evaluators responsibility is to make visible those versions of reality that can lead to increased justice and to critique those that sustain oppression this raises questions about the degree to which we are inclusive of culture history and context in our evaluations further discussion of the methodological assumptions of the indigenous paradigm appears after the section on epistemology indigenous epistemological assumption epistemologically indigenous knowledge is viewed as relational and inclusive of spiritualty and visions in colonized countries ik and indigenous culture and language have been suppressed resulting in generations of indigenous peoples who are not connected with their roots the effects of this suppression along with political actions that stripped indigenous peoples of their land are evident in the disparities in health education safe living conditions and economic opportunities that continue to affect these communities the indigenous epistemological assumption calls for valuing knowledge that comes from indigenous peoples and developing relationships that consciously address power differences and historical legacies it calls for seeking knowledge from indigenous peoples to inform understandings of their needs and to develop interventions that are culturally responsive thus methodologies are needed that are able to make these realities visible so that the focus of evaluation reflects the priorities of indigenous peoples knowledge is not viewed as simply an objective phenomenon that can be measured quantitatively rather knowledge is imbued with the sense of spiritual connection and is built through an understanding of history and cultural connections wilson clarified the meaning of relational knowledge an indigenous paradigm comes from the fundamental belief that knowledge is relational knowledge is shared with all of creation… it is in the cosmos it is with the animals with plants with the earth that we share this knowledge… you are answerable to all your relations when you are doing research the interconnectedness of humans and nature is a strong presence in indigenous assumptions the need for the inclusion of indigenous knowledge was also noted in the report from the ipcc cited earlier in this article which stated this report recognises the value of diverse forms of knowledge such as scientific as well as indigenous knowledge and local knowledge in understanding and evaluating climate adaptation processes and actions to reduce risks from humaninduced climate change there is a tension associated with characterizing ik as separate from scientific knowledge kolawole reminds us ik is as old as humans existence indigenous peoples created knowledge about the land water plants animals solar systems and human nature to survive for centuries in balance with nature their experimentation with agriculture architecture music textiles and medicinal plants is recognized as having relevance today kolawole recognizes that the significance of indigenous local knowledge in addressing global environmental issues such as climate change and problems associated with inorganic agriculture cannot be overstated many efforts emphasizing the need to move away from chemical agriculture but revert to organic farming or conservation agriculture enshrined in lk local knowledge are already underway this recognition of the importance of indigenous local knowledge and its contribution to scientific thinking can be found in books such as fresh banana leaves and braiding sweetgrass the epistemological assumption is about the nature of knowledge and about the relationships between the evaluator and the stakeholders the relationship needs to be critically examined because of power inequities in this context nonindigenous evaluators can ask themselves how do i address power differences so that those who have been historically excluded are included in respectful ways what strategies are used that clearly value knowledge from those with lived experience in the cultural context in which we work what is the historical legacy that is present in the community in which we work how does our methodology allow us to value communitybased knowledge and ensure that this is the basis for the development or revision of interventions how does the data we collect embody the full range of knowledge of relevance in this context including spiritual knowledge how are we being responsive to the community as well as the earth the sky the waters the plants the animals and all of creation indigenous methodological assumption methodologically the indigenous paradigm includes the use of decolonizing methodologies that make use of traditional indigenous strategies for engaging with community such as talking circles the methodological implications of the axiological assumption of relationality include designing the study to value community strengths and building relationships that prioritize the knowledge that indigenous peoples bring to inform the purpose questions methodologies data collection strategies reporting and dissemination of the evaluation the studies need to be designed in ways that provide reciprocity to indigenous peoples by supporting increased social economic and environmental justice resisting colonizing forces that silence them and contributing to their health and welfare chilisa and i recommend a transformative participatory lens for mixing indigenous qualitative and quantitative methods with western quantitative and qualitative methods waapalaneexkweew and dodgefrancis and chouinard and cram add to the richness of indigenous methodology in their writings about culturally responsive indigenous evaluation they emphasize the importance of collecting data about the historical and legal context especially as it regards the breaking of treaties stealing of land and the sovereignty of indigenous governments for recognized tribes in the united states the crie model includes strategies for inclusion of culture language community context and sovereign tribal governance when conducting research policy and evaluation studies it calls upon evaluators who work in indigenous communities to use traditional knowledge and contemporary indigenous theory and methods to design and implement an evaluation study so it is led by and for the benefit of indigenous peoples and tribal nations nonindigenous evaluators can learn from the indigenous methodological assumptions to be more inclusive of culturally responsive methods no matter what populations we work with we can ask who leads the evaluation effort what measures are we taking to build capacity to prepare community members to be leaders in evaluation how do we design the study to value community strengths and build culturally responsive relationships how do we include strategies for valuing communitybased knowledge to what extent are community members legitimately involved in deciding the purpose questions methodologies data collection strategies reporting and dissemination of the study how do we provide for reciprocity in the form of benefiting the community and contributing to a more just world to what extent have we considered the historical and legal context and the continuing effects of oppression how do we share power with members of communities who have traditionally been excluded from evaluation funding planning and implementation permeability of borders across paradigms learning from indigenous evaluators does not mean that the philosophical frameworks and theories created in the west need to be discarded at the same time indigenous scholars warn against wholesale borrowing from western paradigms and methods indigenous pathways to evaluation should emanate from indigenous world views and philosophies and indigenous knowledge not available to nonindigenous evaluators an evaluation methodology separated from its overarching paradigm is not sufficient for addressing epistemic violence and decolonization of western thought chilisa and i also contend that indigenous approaches especially made in africa approaches are suitable for integration with other paradigmatic perspectives for example the african ethical principle of motho ke motho ka batho holds that evaluators have an ethical responsibility to design their work to support positive transformation in the human and physical world because we are all related this aligns with the pursuit of social economic and environmental justice as an ethical remit in evaluation an assumption found in the transformative paradigm in the mae ethical view there are no boundaries between knowledge systems thus it can be integrative bringing together western and indigenous perspectives it promotes global partnerships of knowledge systems and of evaluation actors and stakeholders it seeks to stamp out decontextualized evaluation and the silencing of nonwestern ontological epistemological and axiological assumptions in evaluation thus there is an argument for permeability across the paradigmatic borders cram and i discussed the added value of putting the indigenous and transformative paradigms together in order to raise different issues through each lens for example the transformative paradigm is viewed as an inclusive umbrella for groups that experience discrimination thus raising the issue of intersectionality in indigenous communities indigenous communities raise issues that are integral to transformation in their communities such as spirituality land sovereignty and decolonization lucero and colleagues conducted an indigenoustransformative evaluation concerning health disparities in native american communities they said that they integrated a mixed methodology at all stages of the research process often revisiting stages to incorporate new knowledge gained from practice we refer to this as an iterative integration approach in which our interdisciplinary team was grounded in an indigenoustransformative paradigm that recognized different ways of knowing at each stage and at critical decision points the project was coled by the national congress of american indians policy research center the university of new mexico center for participatory research and the university of washington indigenous wellness research institute the indigenous lens was used to frame the study by inclusion of data on the history of native american communities institutional racism culture political policies access to funding and the history of collaboration between communities and academics the relationship building process reflected both the indigenous and transformative lenses in that it focused on diversity complexity sharing power individual dynamics such as core values motivations cultural identity spirituality and humility and relational dynamics such as trust safety language leadership power dynamics and participatory decisionmaking the indigenous paradigm was reflected in the researchers stance toward decolonizing the research by acknowledging historical abuses and honoring cultural strengths and community knowledge community members held power in the evaluation to inform the process and bring their indigenous knowledge into all aspects of the study this aligns with both the indigenous and transformative paradigms as a way to support transformations that are valued by the communities chilisa and tsheko illustrate the permeability between the indigenous paradigm and the postpositivist paradigm in their study of an hivaids prevention program for students in botswana the indigenous framework informed the design of the evaluation and permeated every decision made throughout the study part of the evaluation also included a randomized controlled trial of an intervention that had been developed entirely through community consultation it reflected the cultural knowledge and the respectful relationships so important in indigenous communities chilisa and tsheko formed three advisory boards an expert advisory board to address methodological issues a community advisory board that included educators health care workers church members and parents and a youth advisory board that met separately from the others to insure they could speak frankly the development of the intervention was based on feedback from these three groups as well as surveys and interviews with students in order to embody an afrocentric approach data methods were also reflective of cultural practices such as yarning talking circles and storying during the study the experimental group received the hivaids prevention intervention and the control group received a course in improving their health generally at the end of the study the control group schools were then offered the experimental treatment conclusion some indigenous scholars have expressed discomfort with the use of a westerncreated typology to characterize indigenous assumptions about research i agree with held in arguing that paradigms help us make sense of the world as it relates to scientific inquiry by guiding the research process from conception to…dissemination by articulating the four basic assumptions ie axiology ontology epistemology and methodology we are able to clarify beliefs and values that underlie our research approaches this makes conversation across paradigms possible enabling us to learn and expand our understandings the purpose of this article was to illuminate some of the benefits of crossconversation between the transformative and indigenous paradigms the evaluation community was late to the game in recognizing the importance of indigenous philosophies and theories despite recognition that businessasusual evaluations were not sufficiently addressing the crises of our times the transformative paradigm tried to fill this gap by including indigenous scholars because of their shared interest in pursuing justice working toward transformation and fighting systemic discrimination however the transformative paradigm was inadequate to the task of representing the philosophical assumptions of the indigenous paradigm the indigenous assumption about ethics uniquely includes spirituality and relational ethics the indigenous assumption about ontology includes recognition of a spiritual reality and the interconnectedness of all living and nonliving things the indigenous assumption of epistemology calls for valuing indigenous knowledge and forming relationships that are based on cultural respect the indigenous methodological assumption calls for decolonizing methodologies by placing the power for decisionmaking in the hands of indigenous people the evaluation design needs to recognize the history of colonization and land stealing and the sovereignty of indigenous governments in recognized tribes in the united states it also needs to include strategies for providing reciprocity to the communities so that they are better off than before the study and they have mechanisms in place to sustain changes that they value reflection on the indigenous assumptions provides the opportunity for nonindigenous evaluators to learn from the indigenous scholars so that evaluators globally can work toward increased justice for example nonindigenous evaluators can ask themselves about the risk they take when they exclude the spiritual reality of communities the western canon has historically held that spirituality and science should not mix however evaluators work with real people in realworld conditions in which spirituality plays a role in the health of communities both the people and the environment if we focused on the interconnectedness of all things living and nonliving how would that change the design of our evaluations how would we insure that social economic and environmental justice was served by design what strategies would we need to truly value communitybased knowledge and allow that to inform the evaluation process from beginning to end how can evaluators improve their theory and practice by examining the permeability of borders between paradigms these are challenging questions but the planet we live on is in peril we can choose to change our thinking about the role of evaluation to contribute to a more just world but it is not an easy path fortunately if we expand the evaluation theory tree to include a fifth branch informed by the indigenous paradigm we will have additional light on that path that would otherwise be obscured in darkness

the evaluation literature ignored and even disparaged philosophical frameworks of indigenous evaluators because they did not align with the dominant narrative about the nature of ethics reality and epistemology as the world faces increasing numbers of crises in the form of climate damage violations of human rights and inequitable societal structures indigenous assumptions that support strong relationships amongst humans and nature are relevant purpose this critical analysis of literature illustrates how the work of nonindigenous evaluators can benefit by learning more about values that encompass spirituality the interconnectedness of humans with all of nature and building culturally responsive relationships

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introduction on 11 june 2018 vivian lu and mingwei huang circulated a short survey report through the chinese in africaafricans in china research network with the surge in scholarly interest in the dynamics of interactions between china and africa lu and huang attempted to understand how those taking part in chinaafrica studies conduct ethnographic fieldwork including the impact of the politics of field access and exclusion some of the key findings of the authors can be summarised into a thesis that captures the condition under which knowledge on africans in china is produced today their claim is that while many africachina scholars can do ethnography in china or african countries race and nationality institutional positions and locations across continents determine who gets to participate african researchers identified access to chinese visas as a major barrier 1 while the report is limited by its largely descriptive approach it is nonetheless timely and instructive as it calls attention to the spatial grounding of african academics in place posing a challenge to the promise of ethnography in africachina studies since the emergence of china in the geopolitical and economic spaces of africa academics in universities and institutes in both the northern and southern hemispheres have followed the chinese state and business enterprises where they went academics are also fascinated with how africans have moved in the other direction beaming searchlights to understand interpret and predict the dynamics of an unfolding process in this way researchers reached critical mass as knowledge producers on the character of the africachina interactions in many cases the researchers produce knowledge by conducting ontheground ethnographies which often involve some form of crossborder mobility unfortunately academics are not equally mobile for too long the context within which africabased researchers conduct ethnography outside the african continent has not been brought to the fore of scholarly analysis this is due to the fact that a significant amount of studies conducted in african humanities and social science disciplines are locally grounded rarely involving crosscontinental mobility for fieldwork by analysing the intersections of ethnography mobility and knowledge production in africans in china research i seek to highlight the contextual issues that structure the equal participation of africabased researchers in the study of africa in a nonafrican setting i contend that being there fetishised as idealtype anthropology conceals privilege and racial and power dynamics that constrain the practice of crossborder ethnography in the global south essentially i reflect on academic mobility 2 as a distinct form of movement in africachina interactions with an interest in analysing how knowledge production on africans in china is shaped by the structures of constraints and opportunities within which migration for ethnography occur i frame academic mobility as a prerequisite and vehicle for producing knowledge on crosscultural interactions and possibilities and specifically treat ethnography as a knowledgemaking tool that all scholars researching the african experience globally should be able to employ in this autoethnographic account which is based mainly on my experiences before during and after migration to guangzhou city as a doctoral student i reflect on the barriers embedded in the structures within which a nigerian scholar seeks to participate in documenting the lived experiences of nigerians in china this pursuit is motivated by both an invitation and a charge the invitation comes from larsen when she writes that focus should be on how …knowledge is created shaped and changed through its mobile conditions of production the charge on the other hand originates from grgurinovićs intention to open the space for a critical consideration of the uncritical unifying discourse of academic immobility as an aspect of wider politics of science education and knowledge which puts great emphasis on mobility as an important factor in what is vaguely defined as scientific excellence in the rest of the article i adopt a reflexive methodology …in the sense of seeing ourselves in a mirror of ourselves being the object of our thought to think through correspondences with chinaand westbased academics and collaborators while planning my journey as well as my experiences at the chinese embassy in lagos and port of entry in guangzhou reflexivity emphasises the importance of selfknowledge and sensitivity the role of self and impact of positionality in the creation of knowledge advancing reflexivity bourdieu proposes participant objectivation in which our personal experiences can become analytical resources to produce epistemic and existential benefits once we subject them to sociological control through selfsocioanalysis he believes …that scientific knowledge and knowledge of oneself and of ones own social unconscious advance hand in hand to adopt a reflexive approach therefore implies that the researcher is the principal character not just the central character he is his own key informant or simply the researcher and researched are one and the same adebanwi writes that the fate of the knowledge industry is the measure of all progress economic social and political unfortunately the global division of intellectual labour is unequally distributed and it is structured in a way that impacts negatively on the production of knowledge in africa alatas decries the subordinate status of knowledges of the third world which includes most of africa due to the relentlessness of academic dependency even after political independence he argues that intellectuals of the third world rely on and their scholarly output is conditioned by western social sciences in addition to the divisions around theoretical and empirical intellectual labour on the one hand and the separations formed along the lines of doing comparatist versus singlecase studies on the other hand alatas highlights perceptively the division between doing other country studies and own country studies epistemic domination mobility and knowledge production in africa arowosegbe posits that knowledge production on africa happens within a historically determined and ongoing power asymmetry and that the political and economic domination of the african continent by the west has sustained epistemic dependency in african universities other scholars have raised the problem of epistemic domination of africa by western social sciences in different ways keim for instance attempts to explain the marginality of africa in the production of social scientific knowledge by using the centreperipherymodel much in the fashion of dependency theorising and focusing especially on the sociological enterprise he argues that the sociologies of western europe and the united states are at the centre while the global south occupies the periphery in keims model however there is no place for the semiperiphery ake discusses the role of globalisation in deepening imperialism in african social sciences strikingly the question of epistemic domination in african knowledge production space is rarely discussed alongside issues of african mobilities especially academic mobility under the condition of unequal globalisation interrogating this neglect is important because the sovereign right to control who crosses or remains shut out of borders still lies largely with nationstates despite the fact that globalisation is alive and well tighter border controls in the global north were no doubt influenced by the rise in terrorism threats since 911 while the more affluent countries adebayo academic mobility and knowledge production on africans in china are unlikely to transcend their terrorist fears any time soon concerns about economic migrants from poor countries who may decide to stay put after arrival continue to put immigration at the centre of national debates and policy discourses 3 so the borders that globalisation optimists claim have opened up are fast closing again only permitting certain people designated as wanted while keeping out the unwanted others specifically mau et al find that while visafree mobility has increased over the past 40 years not all countries benefitted equally with wealthy countries gaining more mobility rights while the same rights stagnated or diminished for others particularly for african countries in essence stricter visa rules are being deployed as a tool for disciplining people from some parts of the globe through the cost and processing of visa applications and the unilateral powers of the streetlevel bureaucracy to deny visas receiving states are able to end mobilities before they begin this makes globalisation a deeply conflicted process in that unprecedented mobility is accompanied by enforced immobility as a subcategory of mobile people academics are feeling the effects of contemporary border dynamics albeit varied in degrees in spite of the possibility of facilitating the deterritorialisation of knowledge production larsen posits that academic mobility is not possible for all at the same time that the disjunctive nature of global flows creates possibilities inconsistencies and social inequalities still persist owing specifically to … the geopolitical power dimensions of academic mobility and inequalities that exist between and among academics based on race gender class and other contextual factors like other forms of mobility she contends that mobility capital is dispersed unevenly among academics with implications for the character of knowledge produced and circulated in the globalised era african scholars in particular move crosscontinentally under a condition of global academic migration inequality between 2018 and 2019 alone scholarly communities and media organisations in the global north disseminated several sensational statements and reports that capture the entrenched nature of enforced immobility against african academics 4 noting that a significantly high proportion of academic conferences take place outside africa britz and ponelis state that africans travelling on the passports of african countries face strict visa restrictions from most countries in the global north the reasons they insist are geographic financial and political in nature in their words the international traveling problem for academics from africa is part of a wider international vocal debate on immigration that is spurred by not only national security but also by ideology economic interest and negative perceptions national safety and pride as well as own economic interest have many times resulted into narrowing the door for immigrants and as a result translated into legal barriers for traveling scholars this captures the situation of nigerian academics nigerian academics planning to attend conferences and trainings in countries across the global north often find that their mobility destiny is inevitably linked with the destiny of the nigerian international migrant population in an attempt to escape poverty and secure a better life abroad many young nigerians visit foreign embassies with manufactured documents to improve their chances of obtaining a visa many of them are stereotyped at the embassies of the us britain canada and many schengen countries as illegals and absconders who routinely assemble fake documents to secure a visa in the words of obadare and adebanwi the wouldbe migrant is largely regarded by the consular officials as a vagrant and the average western consulate in nigeria is a space of abjection and humiliation it is not unusual for nigerian academics to regard embassies as spaces of abjection as well because the stereotyped image of nigerians is normally deployed when dealing with scholars as akanle et al observe when nigerian academics apply for visas they are usually treated with the same disrespect and suspicion as other nigerians in part because it is difficult to ascertain their true status and because lecturers are not seen as immune to fraudulent visa applications sometimes the embassies request special documents from nigerian academics and visa rejection is fairly common even after supplying the requested documents and paying the necessary fees both to the embassies and the intended academic meetings thereby leading to a waste of resources in an already lowresource environment the visa regime that limits african intellectual mobilities impacts negatively on development creativity and knowledge sharing with implications for the questions of social and epistemic justice akanle et al complain that because of the visa challenge africangenerated knowledge remains at the margins of global scholarship the inability of african scholars to travel because of the inequality in global visa regimes limits the participation of africa in the global knowledge economy this further entrenches the already skewed global knowledge structure into a deeply onesided understanding of the world 5 adebayo academic mobility and knowledge production on africans in china all of this reveals how the dominant narrative of globalisation masks the preeminence of borders which continue to keep some people out based on geography of origin stereotypes and stigmatisation however much of the discussion and many of the analyses focus on african academics who visit the west usually on a shortterm basis to attend conferences and workshops not much is being done to understand african academic immobility in the context of afroasia interactions nor the ways that barriers in emerging powerhouses like china constrain africabased ethnographic endeavours that are oriented towards understanding the lives of africans residing in chinese cities also the centreperiphery model in intellectual labour inequalities overlooks the unequal relations between the periphery and semiperiphery areas with advances in africachina relations i argue that china should be approached as a node of interest for ethnographic and social scientific activities for african scholars for one cities in mainland china host a significant african population there is no doubt that this population is relevant for understanding social change processes in china and africa more importantly chinabound migration is now an aspect of the modern history of africa the documentation of which should involve scholars working from and in both regions and elsewhere in the next section i describe my experience as a nigerianbased doctoral student seeking ethnographic information on nigerians in china the study of africans in the world doing ethnography in china the inflow of african students into china for educational purposes and their experiences in various chinese cities are being documented by africans in china researchers however most of these students are on government bilateral scholarships and enrolled in stem or shortterm chinese culture and language programmes the knowledge produced from participating in these programmes makes little contribution towards understanding the transformations that the african presence in china is bringing about when i decided to study the nigerian migrant community in china i engaged colleagues and faculty members to know what they thought while the former wondered if all the problems in nigeria had been researched most of those in the latter group warned me about the impossibility of my pursuit one faculty member having reminded me of my nigerianness and talking about my placement in the global south and financial status as selfsponsored student told me stories of friends who abandoned phd pursuits midway after wasting their time chasing ambitious research the two groups mentioned above are part of the social organisation within which i would conduct research that had not begun but was already dead on arrival framed as pragmatic advice i was admonished to subject myself to an honest evaluation to think about funding and the demands of crosscontinental mobility particularly however by proposing that i should abandon the original idea for more localised research i noticed that a more fundamental assumption of other doctoral students and faculty is that an african based in an african university is not supposed to participate or is incapable of participating in a debate on africans residing in a nonafrican country 6 certainly the protracted problem of lack of funding for doctoral research has created a culture or tradition within nigerian academe where students have come to believe that engaging in ethnographic research outside the african continent is not possible or wise being at the very early stage of my research it would have been a good time to abandon the idea however i had convinced myself to believe that in choosing to study nigerians in china i would be wellpositioned to participate in constructing a history of africa that is still unfolding a responsibility that western and asian scholars had taken on at the time i was focused on the implications of my pragmatic move whether it would matter over the shortor long term my phd supervisor was on board all the way having taught about sociological theory for many decades and having introduced graduate students to issues in diaspora theorising he was naturally disposed to support my research interest the key research puzzle for me was to understand the gamut of processes social relations and practices with which nigerians increasingly settle as migrants in guangzhou the largest city in south china the first major hurdle for the research was funding many african universities lack access to research funds and the problem is worse in social sciences and humanities disciplines in a chronically resourcepoor setting like nigeria institutional funding for research is almost nonexistent most doctoral students in nigerian universities are selffinanced as the first national university in the country the university of ibadan where i was enrolled is one of the few universities in nigeria that provides some financial support to doctoral students 7 however the funds available within the university are often inadequate to conduct ethnographic fieldwork especially a crossborder kind for transnational ethnographic activity a doctoral researcher is no doubt immobile as a result i was constrained to look outwards for other funding sources some of which you only stand a chance of getting if you are capable and willing to rethink unthink abandon or readapt your research proposal proposition and focus being adaptive in these senses is being creative once the issue of funding was resolved i was confronted with the problem of travel logistics over the course of a twoyear planning and waiting period i learned that academic mobility for ethnographic fieldwork is neither a neutral nor a straightforward process but rather an activity that takes place within structures of institutional inefficiencies and ineffectiveness global inequality and racialised hierarchies of power visa blackmarket economies and mobility informalisation to plan my travel i checked the visa requirements on the website of the chinese embassy in nigeria and found that i was qualified to apply for an f visa which is issued to foreigners who intend to go to china for exchanges visits study tours etc 8 the documents required for the f visa were 1 application form 2 international passport data page 3 original invitation letter of duly authorised unit or confirmation letter of invitation issued by the chinese government departments companies and social organisations authorised by the chinese foreign ministry 4 appropriately stamped invitation letters issued by a relevant unit or individual with information of applicant and inviting entityindividual and details of planned visit 5 letter of introduction from applicants place of work detailing relevant personal information and purpose of visit 6 latest six months bank statements with minimum of n4 million deposit 9 and 7 any other documents deemed necessary by the chinese embassy depending on the number of entries requested and the duration of stay visa costs range from a minimum of n8000 to n24000 also consular officers have the sole right to determine the visa validity period number of entries and duration of stay and may also alter or cancel issued visas without explanation of the documents required for a visa application item numbers 1 2 and 5 were easily assembled as a doctoral student without a job item number 6 appeared preposterous item number 7 is a standard line in almost all embassies to give room for operational latitude this could be ignored for now as its impact on my mobility could not be readily assessed the difficulty with chinese visa applications centres was on item numbers 3 and 4 since both cannot be obtained without interfacing with chinese scholars and education institutions preferably universities being a member of a major africachina research network i reached out to experienced researchers including three senior chinese researchers at universities in beijing guangzhou and wuhan in the two years that i worked on mobility logistics two other senior academics based in european and american universities but with strong ties to chinese universities also helped 10 i exchanged several dozen emails over the two years and the responses were generally good with most people expressing a willingness to help senior academics in chinese universities were particularly responsive and helpful nevertheless many long correspondences met a brick wall as the institutions could not supply me with the document i needed the most i obtained a police clearance and did an extensive medical investigation that included hivaids and hepatitis b examinations and posted all the originals to china via a courier service in all i received five letters of invitation two came from a renowned chinese scholar based in guangzhou two from another chinese scholar the first while he was based in guangzhou and the second when he moved to another university outside guangzhou the last one was issued by a young chinese scholar who recently tenured in a beijing university of course the original letters arrived at different times through courier services also prior to issuing some letters i was told to prepare a plan of daily activities that spanned three months stating where i would be at what time and what specific activities i planned to carry out when i approached the chinese embassy in lagos with the documents 11 i found that my application could not be accepted without an original invitation letter of a duly authorised unit item number 3 the oildau is issued by the chinese foreign ministry and the organisation or individual intending to invite a foreigner ought to apply for it my interactions with nigerians employed to check documents at the chinese embassy and visa agents indicated that no application is processed without the oildau with the backandforth exchanges with chinese professors and helpers the oildau would dominate our discussions and at the same time be a source of disappointment and depression what is this oildau and why is it so obscure and out of reach most of the chinese scholars i worked with were not aware of the socalled oildau one professor approached the international affairs office of his university to make inquiries and was told that it would take several months to get it two other helpers said that the cfm was not issuing the documents to nigerians 12 the more i interfaced with these gatekeepers and those offering assistance in china the clearer it became that in the structure of mobility from nigeria to china the oildau is a bestkept industry secret through the tangled process of assembling travel documents i was advised to pursue other options one of these was to register as a language student or for a yearlong cultural programme that is supported by the government of china in chinese universities i had spent a lot of time on my phd already and there was still no guarantee that i would be selected for the programmes 13 another worthwhile suggestion which i had not thought of was to explore if available the active memorandum of understanding of my home university with universities in china the university of ibadan has an office of international programmes which coordinates such affairs the director of the oip agreed to meet me and my interactions with her showed her readiness to assist 14 unfortunately the office had no mou that would work for me on the one hand my university did not have a relationship with a university in guangdong province where i planned to do research on the other hand existing relationships were applicable to mobilities for exchange programmes targeting undergraduate students informality and chinese visa market economy in nigeria while i explored mobility options i maintained a constant presence in my academic department in nigeria i was stuck and waiting in the sense of waiting out a crisis in fact my directionlessness troubled a professor who tried to help by contacting a friend at nigerias ministry of foreign affairs with his mobile phone on loudspeaker i heard the contact express pessimism about the feasibility of getting the chinese visa the normal way the alternative way he proposed would cost up to n800000 15 for a 30day m visa but there was no guarantee of course from my interactions with visa agents i knew the cost was exaggerated and that i would require less than that amount if i were to patronise the informal chinese visa market still willing to help the same professor offered another way out of my visa problem he encouraged me to pray as only god could resolve my visa problem given the fact that i had funding sources and travel experience he believed my condition could not be left to the physical realm as a strategy for navigating socially inexplicable occurrences the professor suggested prayers this suggestion is not surprising for two reasons one over my years as a graduate student the professor had become familiar with my general disinterest in religion and had at different times tried to get me to turn to christianity second and most crucially religion even in its transnational form is a crucial part of the visa economy in nigeria as obadare and adebanwi reveal migration in nigeria is treated as a spiritual phenomenon needing divine intervention traveling abroad they continue involves the services of traditional juju men islamic alfas and christian pastors and evangelists the reliance on religion they discover is …necessitated by the uncertainties built into both the particular process of getting entry visas…and with emigration from the country as a whole the informal chinese visa market with its extensive link to centres in china is thriving in nigeria researchers studying africans presence in china describe how the restrictive visa regime led to the rise of chineserun semilegal or illegal visa agency services often conducted in conjunction with state officials these agents help with visa renewals and arrange invitation letters for african visa applicants they have a strong network with african visa entrepreneurs in big cities such as lagos and abuja in my case i learned that agents in lagos are well integrated into the chinese visa processing value chain the visa processing framework recognise them officially as brokers whose primary role is to interface between prospective migrants and the chinese embassy i had known the visa agents were a real option from the time i began planning for my fieldwork however i was struggling with whether i could trick myself into accepting an explanation that legitimises the option and that at the same time renders insignificant the potential legal ethical and existential issues arising therefrom some of the questions i grappled with were how do i to justify to myself the payment of 2000 for a service that costs 50 since the agents can only assist with a business visa am i a businessman the second question is especially puzzling because to apply for business visa an applicant must prove that she is a businessperson to make a businessperson out of you and package you for the embassy the agents must manufacture documents especially introduction and invitation letters authenticating an applicants status the oildau from china must also carry corresponding information i was worried that mobility through the informal visa market structure posed a threat to me directly i was concerned that the visa black market economy could potentially invalidate my authentic scholarly identity the uncertainties surrounding my situation at the time and the urgency and responsibility to execute the project i had committed to were being processed as the institutional clock ticktocked to settle into the path i was constrained to take i convinced myself that i was only attempting to move within a moving environment to proceed i rationalised the visa market as visa informality that reconstruction made my decision immediately relatable as with treiber who reasons that informality in migration is a typical mode of action in unprivileged migration i resolved that having a business visa with the help of an agent was built into chinas mobility system it was my way of dealing with the dilemma of exclusion i concluded that is still in treibers understanding i interpreted the informal visa market as something that keeps the world accessible and manageable that it is adebayo academic mobility and knowledge production on africans in china difficult to classify informal praxis clearly into fraud manipulation circumvention or exploitation…that informality has become a decisive trait of unprivileged migration through our brutally asymmetric world once i decided to go with visa agents plans were set in motion of all the seven items listed as part of documentation i submitted just three 16 while the agent sourced the rest incredibly the normal way of obtaining visa took two years and failed the notnormal way produced a 30day business visa in under a month uncertainty and risk entering the field and staying safe in guangzhou city in the informal visa market identityswitching and performance are critical to successful mobility for the interview at the chinese embassy in lagos i was prepped by my agent to take on the identity of a businessman by internalising a set of businesslike questions and their answers surprisingly however these questions were not revealed to me until the morning of the interview until that morning i did not also know that i was travelling to ningbo for business tourism along with four other staff members of a company that i did not know i worked at as a performer in a group interview i had to quickly learn who held which position i learned fast but it was difficult remembering who the director of our fictitious company was between the couple in my contingent our agent was present all the way pacing up and down the waiting area and the interview hall when our time for interview came the agent handed the documents to the consular officer who sat calmly behind a glass barrier even though my queue was short with just four or five persons ahead of me it felt very long my anxiety rose as i moved closer to the interviewer wondering unsure and fearful while struggling to stay alert long enough to remember the information about our company and the staff members on our business tour i was surprised that the interview itself which lasted for about a minute was casual and nonintrusive 17 having collected my visa i presumed i was free however the worst part of the existential burden that follows from the condition of posing as a businessperson lies at the port of entry in guangzhou china the baiyun international airport in guangzhou is one of the busiest airports in the world with connections to many chinese cities through commerce and industry most africans who arrived in china since the first decade of the twentyfirst century came to guangzhou and entered through baiyun i arrived at the airport around evening and the immigration desk was not as intimidating as expected going through this checkpoint was smooth i picked my bags and changed some money from a desk to the left a nigerian copassenger adekunle 18 was by my side as we approached the exit area then a customs officer nudged us to a secondary checking area once the machine had scanned our bags again we started to leave adekunle was ahead of me by a few steps in no time another officer popped up and asked where i came from to which i responded nigeria so youre a nigerian he asked to confirm i said yes again from here on the burden of an appropriated identity confronted me to start there were a series of accusatory probes you know you nigerians swallow drugs and bring into china are you one of them what do you have in your stomach i said food are you sure it is food and not drugs the officer continued with his interrogation noticing my absence adekunle returned to look for me but the officer told him that i was not his business later he asked to know the purpose of my visit and i said business on his assessment i did not look the part for one my outfit was casual i wore a jacket over jeans with a tshirt my girlfriend had given me just two days before as a birthday gift i wore eye glasses and my moustache was long my equally long hair was rough from the long journey to guangzhou everything about my appearance contradicted the identity of a businessman in his doubtfulness about my credentials as a businessman he pressed on with more accusatory questions as follows 19 officer how much money do you have me 500 officer you mean you are here on a business and all you have is 500 me well that is the cash i have suddenly the excitement i felt after passing the immigration desk vanished i was afraid and not being able to show my dread aggravated my anxiety was this the end of my fieldwork i broached the thought of being thrown back on the plane as quickly as i had landed i was prepared to confess to show the letter of introduction i obtained from my university as proof of my real identity and actual purpose in china i was busy in my thoughts while remaining calm giving up nothing after some minutes of interrogation i told the officer that i had nothing more to say to him when i indeed had more to tell him however the officer in his impatience was sure i had illicit items like drugs tucked away inside my belly he ordered me to present my luggage to a bigger machine for further scans while the scan was happening i looked away from the officer but kept him in sight i was then guided to another machine to do a full body scan they needed to check my stomach just to be sure before i stepped in i asked if i should take off my clothes to which the officer responded in the negative by now another officer had joined us with the bodily scrutiny complete the second officer handed over my passport and told me to go the interrogating officer was no longer in sight the trip became smooth again adekunle was waiting for me outside the airport with a cigarette between his fingers the night was cold throughout the bus ride i stared at the secondhand bag i picked up in lagos and wondered how it had transformed into an albatross academic im and africans in china studies a closing reflection in a world deeply unequal where geography position racism stigmatisation othering and power relations determine and precondition the environment surrounding who gets out there to do ethnography the charge against armchair anthropologists demands critical and refreshed scrutiny the reality of borders in modern nationstates consigns to oblivion the essentialised assumptions of academic freedom that the charge of antiarmchair anthropology implies we must acknowledge the global racial and power structure by asking and critiquing how academic freedom should be reckoned in the context of boundary and unequal mobility freedoms and restrictions in this article i have highlighted that in the pursuit of ethnography data certain structural factors and rules both written and unwritten are sources of contradictions african researchers are trapped in a world that is closing as quickly as it is opening the firm grip of states to control who is mobile or immobile strengthens the position of agents operating in the informal visa market the structural constraints that precondition the extent of researchers mobility sustain an economy that imbues the fieldwork process with existential threat i have shown that in the current order of epistemic things academics share important characteristics with migrants generally precisely i showed through my personal experience that academics are not so different after all or instead that some are indeed different i maintain that border constraints impact on the ability of african social scientists to make contributions towards understanding the lives and implications of the presence of africans in the world with chinas growing wealth and increasing presence in global affairs the kinds of people moving to china from africa have diversified migrant flows have come to include trade migrants who hope to reap rewards from chinas economic prosperity and advanced commodity manufacture even more interesting are the economic migrants who have constructed and pursued what some have called china dream this brings more than transient african people it is also producing a distinctive presence that is rapidly altering and transforming the outlook of the cities that africans have moved to in guangzhou where the visibility of africans is high the people in the streets exhibit the extra dimension of africas blackness much like the state local chinese residents are noticing and constructions and narratives of invasion are circulating with the worst forms surfacing online among chinese netizens 20 offline the problem of criminality fuels animosity towards specific african groups despite the dynamic closeness that is occurring through work and interracial marriage as part of the african diasporisation and twentyfirst century histories are constructed in china and other asian countries more issues will arise diasporas of africans are part of the knowledge realm with which african researchers must engage as one scholar observes african studies and diaspora studies must be integrated with one another this view anticipates the need for african researchers to show an interest in and do active research on african diasporas including those currently in formation in asia africans in china studies must also be considered an arm of africas historical formation linked to past and future changes in short the presence adebayo academic mobility and knowledge production on africans in china of africans in china is an aspect of a historymaking process this endeavour should involve researchers working from everywhere not only those privileged by global racial hierarchies or geographies of visa power which place african intellectuals at the bottom of the global knowledge system africans in china is a critical part of africas postcolonial decolonisation project where knowledge of africa is coproduced and debated through multiperspectival lenses efforts should be from the beginning directed at guarding against african intellectuals becoming reactionaries against knowledges on africa in china in the future this is because once documented transmitted reproduced and institutionalised the knowledge so produced becomes a power unto itself which will require equal or more superior and aggressive knowledgepower to dethrone this is not a pessimistic view of africas future as potential knowledge producer rather it anticipates that in the future dissipating intellectual energies on reactionary epistemologies will be a waste especially when opportunities exist in the present to coproduce knowledge moreover the task of centring academic mobility in africachina strategic relations also offers an opportunity to reverse the dominance of the western episteme in conditioning what africa knows about china and other asian countries it would serve similar purposes in respect of what africaafricans knows about itselfthemselves in asia so why wait in all of this african states must be responsible and responsive by funding graduate students and programmes focused on the study of africans in the world 21 a concerted effort is needed to ensure that the funding of higher education is not outsourced as has been done for many decades this step is critical in reducing the academic and epistemic dependency of the continent furthermore there is a need to broaden the scope and content of academic freedom to accommodate academic mobility the traditional view limited academic freedom to the freedom of intellectuals and educational institutions from state repression university closures thuggery and ideological confinements to advance the integration of academic mobility into academic freedom there should be an acknowledgement that africans in the world beyond the african continent are a part of the story of africa we must also agree that the translation of the stories into knowledge of africa must involve the active participation of african researchers especially those based in african universities 22 finally ensuring that african scholarship should not be silenced as mkandawire worries requires a continentwide commitment to opening the world to african scholars and researchers at all levels through advocacy collaboration and social and political engagements knowing the world an attitude which africa must cultivate to meaningfully engage in the rapidly transforming global society demands being out there in that same world notes 1 only eight of the total number of respondents were africans one respondent called for thoughtfulness around the visa challenges facing people from african countries… that this is an impediment to the quality of research to africachina studies 2 this refers simply to ability or capability to move freely across national borders in pursuit of intellectual or scholarly engagements such as conferences collaborative meetings and to conduct ethnographic fieldwork in the case of african researchers being able to move crosscontinentally is emphasised academic mobility in this article should be differentiated from other uses of the term eg sivak and yudkevich where it is used as academic inbreeding 3 this reflects a precovid19 condition of the world the covid19 pandemic will likely worsen the situation and further impose more immobilities on african migrants with the adoption of vaccine certificates in the european union and the possibility that vaccination in many african countries will take several years to reach the mass of the population african migrants in general and scholars in particular will likely remain grounded in place for much longer than their counterparts in more economically advanced societies 4 see for example canadian association of african studies and grounds 5 britz and ponelis résumé ce travail se propose daborder lidéologie de la mondialisation en interrogeant la notion de sciences humaines qui a été appliquée pour étudier le concept pour ce faire il pose la question suivante si lidée de mondialisation était posée à partir de lidée de lhomme et détudes de la nature humaine informées par les valeurs principes et normes qui définissent lidée dhumanité de la vision africaine du monde à quoi correspondrait la réponse quels idéaux pourraient soustendre un tel projet et quelle différence auraitil pour la communauté humaine pour répondre à ces questions larticle situera les humanités africaines à travers ce quil appelle lorientation dominante des humanités en afrique définies comme létude de lhomme dispo introduction much of the literature that discuss globalisation in relation to the humanities discuss the role of the humanities in shaping the discourse on globalisation the literature dwells on how the humanities can widen thoughts on such issues as global migration race citizenship labour etc and addresses such impediments as stereotypes and prejudices that affect global interactions writers discuss issues such as interculturalism transculturalism and whether globalisation should lead to transhumanism or posthumanism in brief they discuss how the humanities can lead to responsible decisions in relation to globalisation although these approaches are worthy they harbour several deficiencies first they assume that the current idea of humanities is sufficient to direct the idea of globalisation they apply the current theories available in the humanities to shape thoughts on globalisation secondly they ignore the fact that the current global world order is the product of concepts and notions in the humanities thirdly they underplay the fact that the current tradition of humanities scholarship is a product of the evolution of a given thoughtscheme and is constructed to respond to a given notion of being human if this is the case this notion of humanities is limited and the current trend of globalisation that arises from it could also suffer this limitation this article sets out to interrogate this state of affairs by questioning the humanities now in vogue in the study of globalisation and by extension the notion of man that directs globalisation the focus of the article is to provide a fresh option for engaging with globalisation through the african thought scheme the article poses the question assuming that the idea of globalisation could be advanced from the idea of man and the study of man as might be seen through the values principles ugwuanyi what should globalisation mean for african humanities and why and norms of another worldview what would it amount to what ideals would drive such a project and what difference would it make for the human community the effort to interrogate globalisation in this way is considered cogent because it is anchored in the assumption that whereas the globe from where the idea of globalisation achieves its meaning is a concept that connects the entire human community the notion of man that should direct this concept has different meanings in different civilisations and cultures the idea of globalisation cannot be free from the forces and influences of these civilisations and cultures it is necessary to interrogate the notion of humankind that is at work and most influential in the idea of globalisation now and the extent to which it can address human needs across cultures in relation to africa it is necessary to locate the extent to which the idea of humankind as rooted in the worldview and thought of african people is involved in the notion of globalisation in vogue now by locating the extent to which this is the case the paper will then proceed to articulate whether there is a need to rethink globalisation through the african worldview through the idea of humanity available in the african worldview it will then interrogate what it would mean if the idea of humanity as rooted in the african worldview was used to define and direct the project of globalisation as well as suggest the expected outcome of this effort to achieve these aims the article questions the idea of man in african humanities through what it calls the dominant orientation of humanities in africa by this is meant the idea of humankind available in the intellectual industry of modern africa and threaded through various subjects studied in the humanities in african institutions this by extension implies the various forms of sociocultural encounter through which the idea of humanity has been registered in the social and political spheres and structures of modern africa thereafter the article will discuss this tradition of humanities in relation to the idea of globalisation and articulate the imperial character of this form of humanities how it amounts to imperial humanitiesit will then proceed to locate the limitations of these humanities and how they function as the imperial humanities by articulating this idea of in african thought and suggesting what it would mean if the idea of man in african thought is applied to define and direct globalisation and how this could direct the project of globalisation to a worthier outcome the method applied is textual analysis and critical deduction questioning the idea of man in african humanities the concepts and theories applied to direct the humanities in africa are mainly those invented through another linguistic and conceptual framework disregarding the alienating power and force of these in influencing and shaping thoughts and ideas for instance concepts such as society slavery war power leadership culture etc which are the driving forces of the humanities are primarily driven by the western notion of the concepts and not by their endogenous meaning and import in the large bulk of literature in the humanities that are taught in africa if the effort is made to decolonise concepts and ideas or rediscover concepts and ideas through conceptual africanisation it will be discovered that some concepts have been forcefully inserted into humanities scholarship in africa and applied to drive and direct the humanities even though they may be in conflict with or negate the meaning of these concepts if they are explored through the african worldview in the same vein the study of man in africa is primarily evaluated through an alien notion of humankind and human experience and not through the notion of humankind or the human experience as they have evolved through the african experience or through the african thoughtscheme as a result of this the cultures and experiences of people in the african world have not served to direct the bulk of critical reflections in the humanities notwithstanding the fact that humankind has different civilisations differentiated from each other by history language custom tradition and most important religion also these different civilisations have different views on the relations between god and man the individual and the group the citizens and the state parents and children husband and wife as well as differing ways on the relative importance of rights and responsibilities liberty and authority equality and hierarchy which should direct the humanities the implication of this is that the humanities apply concepts that may be different from those offered by a particular civilisation when the subject is studied to produce and circulate knowledge thereby marginalising one civilisation in favour of the other and leading to what can be called alienating humanities on the one hand and marginal andor alienated humanities on the other several reasons can be adduced to explain this state of affairs the first is the longrunning notion of a human being as a rational animal and the science and arts of reason that have been applied in favour of this notion although the view that human beings are rational animals is attractive to all cultures rationality is a complex concept because reason ugwuanyi what should globalisation mean for african humanities and why can be both constructive and destructive reason is like fire an immensely useful tool that can very easily destroy if not used correctly the definition of human beings as rational animals also has wider demands on the ethics of reason these demands interrogate the nature of reason and the modes and forms of rationality without addressing these rationality can serve negative ends that affect the ethics of reason a history of the evolution of reason in different cultures of the world suggests that reason has often evolved in different contexts and is influenced by different values notwithstanding the universal definition of a human being as a rational animal who applies this definition and to whom it is applied may determine how it is validated it is therefore proper to suggest that because of the ethnocentric assumptions that have influenced the definition of a human being as an animal its application in relation to africa since the beginning of western modernity is questionable and the extent to which the assumption that a human being is a rational animal can be held to include africans and amerindians is also debatable to present a compelling narrative in this regard it should be noted that the first formal universities in europe came into existence as early as the eleventh century and that these universities which dealt with classics and the works of the earliest thinkers of the western world had the privilege of upholding the definition of man as a rational animal yet nearly five hundred years after this early breath of learning an industrial slave trade with its unimaginable horrors was embarked upon by merchants of the western world whose education was founded on this position but who believed that only those who participated in the western canon of reason should be held to be rational and human africans were denied the status of humanity and rationality and africa became a major centre for this trade this was to go on for about four hundred years carried out by educated people of the western world and products of western universities and cultures of learning where man was defined as a rational animal this severe damage to the ethics of reason and humanity is a severe indictment of the idea of reason that recognises a human being as a rational animal at the academies where man was held to be a rational animal different positions were held by even the best of european minds illustrating that the idea of man was categorised and applied to human beings differently the expression man is a rational animal as applied to the african was different and any study of people in africa was not meant to defend the view that man in its universal meaning and import was a rational animal for instance david hume a prominent scottish philosopher held the negroes to be naturally inferior to the whites and that nature had made an original distinction betwixt these breeds of men similarly the french philosopher montesquieu said it is hardly to be believed that god who is a wise being should place a soul especially a good soul in such a black and ugly body the racist philosopher fredrick hegel was even more blunt of the african he said there is nothing harmonious with humanity to be found in this type of character these are positions that defined man as a rational animal but denied rationality to human beings in africa the summary of my claims here is that the current idea of humankind driving the humanities has not favoured humankind as a whole and that the humanities as they are taught in africa and as they have inherited this tradition amount to imperial humanities the idea of humanities that takes or adopts a single notion of humankind from a single culture and imposes it on other cultures and civilisations this characterisation of human science as imperialism is in line with ake who described social science as imperialism imperial humanities human othering and imperial globalisation in this part of the work i explain the notion of imperial humanities further i then proceed to discuss how this has produced a deficient notion of globalisation the term imperial humanities implies a form of humanities or humanistic studies that applies one culture to interpret humankind disregarding other cultural nationalities or cultural rationalities of the world by cultural nationalities is meant aspects of the world that function through different cultural paradigms and by cultural rationalities i mean different ways reason could function legitimately and be found to be cogent and meaningful when humanities function with an imperial character they essentially function for conquest domination competition and alienation they lead to a reductionist ethics of knowledge where knowledge can only interact with other forms of knowledge through contrast and conquest and not through collaboration and consensus there are at least two ways by which the study of man through the humanities or human science can lead to what amounts to imperial humanities apart from the conceptual and definitional error that can lead to an erroneous tradition of humanities as outlined above there are at least two other paradigms of humanities that can be considered imperial the first is when an aspect of reasoning dominates other aspects of reasoning the second is when the humanities emphasise one aspect of human nature at the expense of others to begin with the first paradigm it should be noted that human reasoning can be technical collaborative emotional empathetic creative conceptual analytical generative constructive critical etc these aspects of reason deserve equal emphasis in the project of reason any attempt to privilege one form of reasoning above others in a manner that compels the others to lose their potential would lead to an improper conception of human nature and a deficient application of reason on human nature for instance when we look at the human mode of being in terms of how a given analytic framework enables us to understand human nature without making provisions for other aspects of human nature that influence this framework we might end up with an idea of human nature that is imperial a view of human nature undermines other views in the second paradigm human nature has diverse needs and demands economic moral political social etc that demand equal cooperative attention these demands emanate from different aspects of human nature any effort or attempt to study and address one aspect of human nature without regard for others will equally be counterproductive it would amount to trying to subdue one aspect of human nature in favour of others and lead to what can be called psychic misbalancing these ways of misapplication of reason are what can lead to imperial humanities an illustration of this is that when emphasis is placed on the spiritual aspect of human nature at the expense of the material or vice versa gains in understanding one domain of human nature may affect the need for similar gains in the other the current imperial character of the humanities also manifests in the nature of the discourse on globalisation globalisation emphasises the linkages among world communities to reflect the ethics of the globe from where the world finds its origin but instead it has become the redesigning of the world for the benefit of certain parts of the world at the expense of others whereas globalisation presumes to intensify the linkages of the world in such a manner that differences are narrowed in favour of mutual forms of social and cultural relations in fact globalisation has largely come to mean the upliftment of the needs and values of certain parts of the world to the detriment of others such that some parts of the world remain fringe players in the process consequently there is an uneven interaction among the world community in areas of politics economy and social relations and the equality of gains of this interaction is questionable while people from one part of the world migrate to the other as cleaners mortuary attendants drivers and candidates for other menial jobs the other portion migrates to the other part of the world as experts while arms are manufactured in one part of the world they are jhearesa vol 18 no 1 2020 heavily applied in another for social destruction while food is in excess in a certain parts of the world hunger is in excess in other parts of the world this nature of globalisation gives it an imperial character the imperial character of globalisation makes the ideology of globalisation a narrative of humanity seeking to reach new heights not as a group but as some citizens of the world forcefully leading others who are compelled to follow them to an assumed goal to which they should all aspire this has made globalisation an alienating and alienated phenomenon an issue of class where some people are global leaders and are necessarily more global than others while others are global followers with unequal links and dependence in the current culture of globalisation market forces define and direct the future of mankind such that the financially powerful are the globally powerful and there is an unholy marriage between people power and market you are human to the extent that you are worth a huge price tastes desires wants needs preferences cultures attitudes beliefs etc are reconstructed to serve the interest of a narrow population of economically powerful members of humanity whose power and influence are considerably technologydriven in this culture of globalisation what an animal eats in one part of the world may be more nutritious than what a family eats in another part of the world yet the industrial globe on which the former operates needs the latter to function the minimum on which the larger percentage of the human race functions is below what can be called the human minimum or capability minimum in the words of amartya sen thus it might be just and proper to call the current culture of globalisation an inhuman globalisation or globalisation against the globe to locate the imperial and deficient character of globalisation at the moment as well as the discourse that promotes it i raise three questions to determine the strength and quality of globalisation what is the goal of the current trend of globalisation in whose favour is a person considered to be global does the culture of globalisation harbour any potential for a just world order in response to i submit that the end to which globalisation functions is clear of ethical consideration outside the of longrunning order and ethics of dominance the goals and desirable outcomes of globalisation are nowhere clear as an articulated panworld ideology whose measurable end can be determined indeed from what can be glimpsed from the literature on the subject including david held anthony mcgrew david goldblatt ugwuanyi what should globalisation mean for african humanities and why and jonathan peratton justin rosenberg and paul hirst and grahame thompson it is safe to suggest that globalisation has not been assigned specific ends or goals as a concept that suggests a shift in the spatial form and extent of human organization and interaction to a transcontinental or inter regional level globalization is neither a singular nor a linear process neither is it final and point of social change rather is best thought of as a multidimensional phenomenon applicable to a variety of forms of social action economic cultural or sites of social activity like the environment whereas the project places emphasis on the intensification of linkage the end which this linkage should serve is yet to be properly spelt out for instance if the aim of globalisation is to make the world better and healthier it is not clear that the world has become significantly healthier as a result of the ideology indeed the question can be raised do we have a more peaceful world at the moment as a result of globalisation and what percentage of the world is living in peace in the era of globalisation especially in its modern version there are grounds to hold that the world has moved further from attaining peace especially if we consider the view that the world has recorded a higher number of wars than before even among human communities like those in africa who hitherto could be said to have had a strong culture of peace from these positions it can be seen that globalisation as it is conceived at the moment does not have the potential for a desirable world order in essence globalisation amounts to internationalisation or multinationalisation of human values and aspirations universal networking of the human community through politics economy and technology to what can be called a supraterritorial village of humanity however these cannot amount to any specific human good until the ends and goals of such human interactions are defined and articulated this position leads us to the second question in whose favour is one considered to be global what is the idea of the global person it would seem from the foregoing that the person who is global is one who is in a position to participate in the networking of the human community through science and technology thus to be global means to be a technocitizen that is one who is involved in the global village and can connect and reconnect with the human community however this connection involves many demands some of which could undermine ones taste identity culture and capacity for instance to be global demands that one has a sizeable amount of income to access information daily and to prioritise this over other basic needs such as food or shelter or to place all these at the same level of need the economic and sociocultural demands of being global mean that not everybody has the capacity to be global or is wellplaced to be global and that some populations of the world need to be economically upgraded and empowered to be global citizens the third question that i have outlined to highlight the weaknesses of globalisation at the moment is as follows does the culture of globalisation harbour any potential for a just world if justice means fairness or allowing the best of something to be or in the classical socratic sense means giving persons their dues in the right manner globalisation does not have the potential to lead to a just world order since it does not respond to any of these notions of justice globalisation as it functions at the moment suggests an ethics of power and domination that makes the poor and weak vulnerable to the rich and strong whether as financial globalisation cultural globalisation globalisation of sports or religion there is an unholy alliance between power wealth and dominance through the ideology of globalisation which cannot lead to a just world order globalisation promotes undue marginalisation of members of the human community through wealth and power a clear example of this is the fact that mcdonalds stores are found in some african cities reconstructing peoples consumption patterns and tastes but few or nothing of what comes from african villages counterpenetrate the originating communities of mcdonalds stores another illustration is when valuable cultural products of african communities such as music suffer extinction by other musical cultures thereby creating cultures of consumption that do not promote the cultural capital of africans in response to the weakness of globalisation as conceived now several alternatives have been offered these include glocisation and glofricanisation glocisation a concept which has a considerable asian origin recommends localisation of globalisation that is allowing human communities to adopt and adapt globalisation in the best manner that suits them while glofricanisation suggests applying the instruments of globalisation to an african advantage by ensuring that africa achieves a coalition that addresses its needs through the instruments of globalisation these options are attractive and need to be considered however a more fundamental option can be explored in an effort to redesign globalisation this can be achieved by exploring the idea of being human that foregrounds the theory of globalisation and by seeking to redesign globalisation through interrogating the concept and modifying it through this effort i suggest that this can lead to a worthier notion of globalisation and a fresh notion of humanities scholarship on globalisation i seek to explore this in the next section of this work ugwuanyi what should globalisation mean for african humanities and why relocating humanities through the african idea of humankind and applying the same to address globalisation in this part of the work i interrogate the notion of humankind that foregrounds thought in african tradition i then apply this to propose a fresh tradition of humanities in relation to globalisation there are reasons to hold that there is an idea of man harboured in african thought that has the potential to reconfigure the humanities in general and that when this is applied to the theory or ideology of globalisation it will assume fresh and different meanings with a richer and worthier outcome to articulate this i note that the africa implied in this claim is subsaharan africa or what can also be called bantu africa the portion of africa that harbours people who live between the sahara desert and the cape i argue that in the thought pattern of people in this area the concept of man is both an ontological affirmation and a categorical moral imperative and has implicit norms that can drive globalisation differently in this scheme of thought being human is a moral demand that necessarily follows from the fact that one is a human entity and in a human community the claim i make is that there is measured value attached to the meaning of man which is not exhausted by rationality but could be located in how rationality serves to reinforce the ethics and beauty of being human among a significant number of ethnocultural groups in africa and that this is inscribed in the idea of humanity available in the thoughtscheme of the people i further submit that this has strong potential to redefine and redirect the idea of globalisation one is not held to be human because of the property of rationality alone but because of the application of reason in relation to others one is human by for and through others this intricate web of meaning implicated in the idea of being human has the potential to configure and humanise globalisation the idea of man implied here emphasises morality as a categorical imperative in such a manner that it has the capacity to lead to an informed conscience one is considered human on the basis of the quality of the response to the notion of being human for this reason this notion of being human has what it takes to lead to a worthier outcome by reinterpreting globalisation and infusing it with some values that can lead to a just world order to illustrate this claim i shall make some abstractions from some ethnocultural nationalities of subsaharan africa i shall refer to the meaning and import of man among the igbo ethnocultural group of nigeria and among the akan ethnocultural group of ghana and support this with concepts available in the thoughts of other ethnocultural groups such as the yoruba and wolof of west africa and the shona and zulu of southern africa in igbo thought the concept of man translates to madu madu can be traced to the formation of two elements the prefix ma and the suffix du ma or mma translates to beauty while du is the verb to be so madu can be interpreted to mean there is beauty a variant of this interpretation suggests that madu translates to mma ndu which can be interpreted to mean the beauty of life madu is an ontological affirmation with categorical moral implications consequently to be seen as madu implies that there is a measured meaning attached to the entity that is held to be human which existed prior to the exercise of reason this measured meaning demands exercising the beingness of the entity in favour of the good the true and beautiful hence madu is expected to be an entity that should embody these values it is for this reason that the igbo would describe someone with strong humane and moral convictions as obu mmadu this is a human being because of the moral ontology that foregrounds the idea of madu any deviation from this ethic could lead to such a question as ibu madu ka ibu anioha are you a human being or an animal this categorical moral imperative that foregrounds the idea of madu can be glimpsed in other ethnocultural thought patterns of african people it is implicated in such concepts as taranga pulaku omoluwabi ubuntu uhnu etc these concepts affirm a notion of humankind that incorporates humanness and suggests that only the humane deserves to be held as human among the akan ethnocultural group of ghana this ethic is an eloquent belief and is illustrated in a number of axioms and proverbs among the akan the values of the african people are not measured in terms of economic production rather as the akan maxims put it it is the human being that is needed and the human being is more beautiful than gold another maxim states it is the human being that counts i call upon gold it answers not i call upon cloth it answers not it is the human being that counts these ideas of being human suggest a notion of human science that could motivate a fresh idea of globalisation what are the implications of this idea of man assuming that human sciences were seeking to rethink globalisation through them if this notion is applied to theorise and to direct globalisation it would mean that the idea of globalisation ugwuanyi what should globalisation mean for african humanities and why would assume the form of an ideology that ethically leads mankind to a humane world order globalisation under this paradigm would assume the feature of a town hall meeting of the human race where they are bound and sheltered by nature under one globe a form of modern village square where all human beings interact for the human ends of the entire human community globalisation would amount to the idea that whatever is held to be a human achievement should promote the goodness of all mankind here cultural products of globalisation could be approved based on who needs them and made available by who has them with less of an eye for gain and interest globalisation would then not amount to a simple domination by science and technology but a loyalty to other factors and forces that define and direct the human community positively globalisation through this formula would amount to a global humanisation of the world with clearly defined goals and standards such as how the beauty of being human comes out best among the human community it would be more of a moral globalisation than political globalisation globalisation that is driven by values that tend to locate mankind with the flowering of a collective ethics of the beauty of the human race and not one that is driven by power dominance and marginalisation globalisation driven by african humanities would lead to a form of globalisation that privileges the core values that define and direct the thoughts and cultures of african people it will be one in which knowledge is driven more by consequence and not by cause only driven and directed by consensus and cooperation and not competition and conquest contrary to the current trend of globalisation which amounts to the globalisation of european norms that advertises inequality and dominance globalisation if and when driven by the african notion of humankind would lead to man fare or human welfare which would reject marginality and exclusionism in favour of inclusion and egalitarianism and an incorporated humanity when this obtains the study of globalisation will not just be about any form of human interaction but about the quality of human interaction the humanities would then be guided by a form of moral epistemology that places human essence as a core value and evaluates its gain by its ability to generate alternative knowledge that leads to this conclusion it is not surprising that despite a long history of investigating the human condition through a wide range of disciplines philosophy sociology psychology literature history cultural studies etc a deficient understanding of human nature persists leading to the persistent problems of humankind that threaten the existence of the human species racism wars genocide xenophobia discrimination etc this deficient notion of the humankind or what i shall prefer to call a disunderstanding of humankind is one that produces knowledge that obstructs members of the human community from engaging with each other profitably this work has attempted to address the theoretical foundations of this problem in relation to globalisation with the view that there is the need for a fresh paradigm in the notion of man that should drive the humanities the work has applied this effort in relation to articulating how globalisation can be redesigned through a fresh notion of humankind that could be applied to drive the humanities it is hoped that this effort will stimulate the search for an alternative approach to the humanities and stimulate more quality growth in the advancement of the humanities and the discourse on globalisation introduction in recent times the call for a sociology of knowledge that can address both transnational social phenomena and international scholarly exchanges has been a key focus of scholars within the multiparadigmatic discipline of social sciences the call was a reaction to the unequal relationship between western centres of social science and the global south in addition to the wholesale application of western methods of studying and learning social sciences to african settings without due adaptation there is yet to be a consensus on the possibility of the emergence of a truly internationalised social sciences disciplines a number of scholars in the global south think that the field of sociology is full of colonial and universalistic premises and subject to the legacy of euroamerican parochialism the pervading assumption of mainstream sociology is that the types of knowledge produced in the west are superior and therefore worthy of emulation the problems of imbalance in knowledge production circulation and consumption between the west and the rest of the world are part of the academic dependency paradigm in the social sciences this is often referred to as captive mind syndrome this term indicates the application of western methods of studying the social sciences to third world settings without the appropriate adaptation of imported ideas and techniques this kind of uncritical imitation of western social science is described by syed alatas as a sign of continuing intellectual domination it pervades all levels of scientific enterprise including problemsetting analysis abstraction generalisation conceptualisation description explanation and interpretation academic dependence as a theoretical tradition has its roots in dependency theory and the cultural imperialism debate of the 1960s but it has continued to resonate in the works of scholars in the global south such as akiwowo alatas cardoso and faletto dos santos frank and omobowale and akanle among others these scholars have interrogated the question of the internationalisation of knowledge and the place of the global souths intellectual communities in the equation and have called for the incorporation of indigenous knowledge alatas drawing from dos santoss definition of economic dependency referred to academic dependency as a condition in which the knowledge of certain scholarly communities is conditioned by the development and growth of knowledge of other scholarly communities to which the former is subjected the relations of independence between two or more scientific communities and between these and global transactions in knowledge assumes the form of dependency when some scientific communities can expand according to certain criteria of development and progress while other scientific communities can only do this as a reflection of that expansion which generally has negative effects on their development according to the same criteria in nigeria in the 1980s akiwowo mooted the indigenisation of sociological knowledge and social science knowledge in general through his postulation of a theory of sociation however this effort has yielded few dividends as inequality continues in the way sociology is practiced in the country in terms of teaching research publication and knowledge construction in general the unpopularity of akiwowos idea could also be attributed to the intellectual dependency of the periphery on the centre social scientists in general and sociologists in particular in the global south have a seemingly strong belief that knowledge from the world centre where there is a concentration of technically trained personnel in the universities corporations and state is more authentic this reflects in practices such as academic travel patronage and sponsorship publication and the formation of research networks where the centre calls the tune consequently the outcomes of such relationships in the form of ideas knowledge terminology and research technologies get exported from the metropole to the periphery in this article i examine this theme in more detail in the context of subsaharan africa based on a review of relevant literature this article examines academic dependency and its manifestations and gives an insight into how academic dependency can be overcome in the global south without discounting the benefits of academic globalisation sections explain social sciences in africa describe the nature and origin of academic dependency identify contemporary issues requiring immediate attention and which are capable of showcasing the relevance of social sciences in africa if well addressed discuss the universalism and indigenisation debate and finally recognise key areas that need attention and correction for the emancipation of social sciences and the realisation of epistemic freedom in africa social sciences in africa generally the focus of social science is on the behaviour of human beings in relation to their physical and social environment variations in social science across the globe are inevitable because human beings live in different environments and environment influences human behaviours but the understanding of people in society can result in notable changes in a society the study of society has enabled the adaptation of people in world societies the formal study of human behaviour in africa began when europeans led by the portuguese came to africa in search of knowledge the coming of the europeans in the fourteenth and fifteenth centuries was not without prior understanding of the indigenous people they encountered their understanding of african societies in particular was achieved through the works of ethnographers and explorers however social sciences as an interdisciplinary area of inquiry did not grow in african countries until few years before their independence and many of the disciplines making up the social sciences were imposed serving the interest of their european masters after independence many african countries if not all probably failed to align their curriculums with the uniqueness of african cultures the present hegemonic position of western social science was not achieved in a day but is the outcome of continuous subjugation of africa and other disadvantaged continents of the world this began right from the time europeans set out to explore other continents of the world through voyages of exploration with this domination and marginalisation the limited roles played by social sciences across the continent of africa have been unevenly distributed for example south africa is now the outstanding research leader in the region and she has by far the highest research output of any country in africa well ahead of nigeria in the west egypt in the north and kenya in the east ajani sociology of knowledge in the era of academic dependency in africa nature and origin of academic dependency academic dependency is the result of the uneven structure that undergirds the generation production circulation and consumption of knowledge within the global system in this unequal relationship the big powers in terms of economic and social resources are also regarded as the core or big powers in the social sciences the social sciences which were created and championed by western scholarship are sources of academic and cultural dependency in a bid to understand the nature of knowledge production and consumption processes one major paradigm has emerged in both academic and popular discourse in recent years scholars of the dependency paradigm have identified the united states of america great britain and france as the dominant knowledge countries african social scientists have decried the existence of dependency both in the structure and practice of social science disciplines in general and in sociology in particular they have at different times joined voices with scholars from other countries in the global south to condemn the dominant eurocentric mode of knowledge production and to call for the indigenisation of social sciences instead according to these scholars any attempt to define academic dependency will result in discussion of a related idea intellectual or academic imperialism academic imperialism was linked to economic and political imperialism which refers to a policy and practice of domination through military conquest and subjugation of colonial subjects by more advanced nations since the sixteenth century as long as the control and management of the colonised required the cultivation and application of various disciplines such as history linguistics geography economics sociology and anthropology in the colonies academe too can be referred to as imperialistic an understanding of dependence is hinged on the origin of the social sciences generally the expansion of social sciences in developing societies is influenced by and is a reflection of its development in the united states and to a lesser extent in great britain france germany and japan according to onwuzuruigbo the bastion of orthodox social science the enlightenment and postenlightenment were entirely a european project and experience this to him is a critical factor explaining why the existing corpus of social science knowledge has continued to arrogate power to euroamerican societies and cultures which are expected to be emulated by all both in structures and processes adopting the same historical analysis alatas indicates that academic imperialism began in the colonial period with the setting up and direct control of schools universities and publishing houses by the colonial powers in the colonies he states that the political and economic structures of imperialism generated a parallel structure in the way of thinking of the subjugated people third world academic dependency means the dependency of ideas technologies theories and concepts academic journals aid and investment in education on the europeans and americans these dimensions of dependency have hindered the growth of scientific enterprise in the third world omobowale et al writing on the dependence on western academic journals as a dimension of academic dependence stated that the structure of exchange between the west and the rest of the world ensures that the scholarly regulatory indices are dominated by the metropolis the majority of the journals with impact factors and that are indexed in highranking databases are western while most of the journals in the peripheral countries are somewhat derecognised making them substandard and of low quality in the westerndominated global academic system having a number of publications in international journals is one of the conditions put in place by universities appointment and promotion committees in africa the desire for promotion makes some scholars choose to avoid the critical review processes of highimpact journals and to patronise instead feecharging and lowquality offshore journals similar to this is the psychological dimension to dependency where the dependent scholar is more a passive recipient of research agenda methods and ideas from the social science powers this is due to a sense of intellectual inferiority compared to the west there is therefore a centreperiphery continuum in the social sciences that corresponds roughly to the northsouth divide because of the perceived superiority of works produced at the centre knowledge from the centre commands more attention and acknowledgement than works produced elsewhere the centre is therefore seen as a place from where influence radiates from the nineteenth century through to the twentyfirst century today emphasis has remained mostly on knowledge produced about countries of the global south rather than being considered as sites of knowledge production and theoretical debate according to beigel academic dependency is nourished in the social studies of science critical epistemology and ontological stance as well as in comparative studies of higher education it encompasses the unequal structure of knowledge production and circulation that has emerged historically along with the international scientific system this structure comprises symbolic material and institutional processes mutually related and which have produced different paths of academia building in the periphery these combinations are the historical result of national and regional responses to internationalisation particularly given the diverse roles played by the state in scientific development and higher education contemporary themes and issues in african sociology of knowledge contemporary societies of the world have indeed achieved great things especially in the field of science comparing twentyfirst century achievements in the field of science with those in early modern society one will find it easy to conclude that a better society has emerged for instance the creation of a global world with the help of the internet and other innovative technologies the establishment of formidable academic discipline and the emergence of international organisations among others are some of the achievements recorded however further comparison of problems of the present dispensation with earlier centuries will reveal the rise of new problems which are arguably beyond the control of science in other words the coming of the new science is not without corresponding problems that are social in nature good examples of these are internet fraud the faster spread of diseases human trafficking and migration problems all emanating from modern transportation dependency on a world scale allowing the centre to feed on the periphery making the latter dependent on trade with the former coups détat as an outcome of modern political structures illiteracy and poverty being the outcome of westernisation among many other social problems given these problems and their particular manifestations on the continent of africa the relevance of social sciences in africa cannot be overemphasised african social problems require african social science it should be remembered that modern european social sciences emerged from the responses to many sociopolitical and socioeconomic problems prevailing at the time such as the industrial revolutions it is therefore vitally important to recognise that a formidable and relevant african sociology of knowledge is required for academic and social emancipation universalism and indigenisation debates universalism and indigenisation debates arose in response to one of the most important epistemological questions in the social sciences and especially sociology which is whether western social or sociological theories and concepts are truly universal the founding fathers of sociology prided themselves in a discipline that would pursue universal theories and methods just as in the natural sciences from this once dominant but now beleaguered standard sociology has at least developed if not matured more in some societies than in others this makes for different flavours of knowledge in diverse societies according to smelser this development may result in western european sociology north american sociology third world sociology socialist sociology or a sociology associated with a specific country or nation such as france china yoruba or zulu smelser considered the indigenisation of sociology unhelpful as it might engender a sociology of nothing losing its initial focus but these different levels of the development of sociology in different societies have generated difficulties in universalising scientific knowledge leading to the indigenisation thesis the general consensus among the indigenisation school is that western social science knowledge is laden with western interests and values limiting its universal applicability oommen stated that the internationalisation or universalisation of social science or sociology is more or less like the ongoing process of moderniation and one rooted in the disciplines colonial origin far from accepting a single dominant methodological perspective oommen argues that indigenous knowledge has been and continues to be an important impetus for creating intellectual freedom in the social sciences while we cannot jettison the importance of colonialism in the establishment of sociology in third world countries and its continued influence on the practice of the discipline a call for the indigenisation of sociology must recognise and address the huge global inequalities in the production and consumption of sociological knowledge writing on the study of sociology in nigeria onwuzuruigbo stated that its history is in part the history of colonialism and the globalisation of eurocentric social science as well as the history of decolonisation politics and the establishment of university education in nigeria this is true because most early departments of sociology were manned by expatriates or westerntrained africans who relied largely on eurocentric curriculums hence he argued for the indigenisation of sociological knowledge need for indigenisation of social science in africa a call for epistemic freedom or the indigenisation of social science in africa continues to grow as social problems become increasingly multifaceted social science remains the hope for the emancipation of africa many problems evident on the soil of africa are peculiar to the continent and social in nature and require social remedies there are levels of social relevance to be applied in solving african problems ajani sociology of knowledge in the era of academic dependency in africa in other words social sciences remain a viable tool for social reconstruction and development there is a need for african social scientists to approach the discipline with the view to making it an instrument of social emancipation and development instead of extending its oppressive and colonial expansionist terrain the following areas need consideration for the liberation of african social sciences from its oppressive and suppressive state teaching new curriculums until african educational curriculums are designed primarily to understand and to meet the needs of african people african emancipation is questionable educationally much was accomplished by the euroamericans to change africans ways of thinking and to undermine africans dignity and pride for instance african students were taught that africa had no past and that it was rescued from its dark state through the arrival of the european colonisers fuglestead quotes hugh trevorroper as saying in the early 1960s that africa had no history until the arrival of the white people african history was only the history of white people on the continent africans grew up to glorify the west and to look down upon african culture and consequently became inculcated with a permanent inferiority complex this notion needs to change by evaluating upgrading revamping and reinventing longstanding educational curriculums that not only praise the north but also downgrade africa this requires loyal intellectuals to design curriculums that suit the unique needs of africans it can be said that the third world nations of the past are the lucrative business empires of the first world the story is true even today colonisation in its new avatar is persistent and it is neverending the developed world with its thirst for economic booty is all set to invade the developing and lessdeveloped in newer forms by expanding its corporate academic schools to avoid this the education system in place for each third world country should take into consideration the culture of its people culture should be seen as a resource because it is the base from which people form identities if our students are still appreciating what is from the west above what constitutes their own we will continue to be seen as lacking direction serious steps toward improving the quality of education are vital this can only be achieved if the didactic and onesided teaching which is common at all levels in the third world is discontinued first teachers need to be better trained and monitored so that they do what they have been trained to do second the provision of more and better learning materials in local languages is required third there is a need for the provision of libraries with supplementary learning material so that school pupils and college students can read around a subject and learn to think for themselves libraries with a range of material that will encourage reading for pleasure and selflearning are essential elements in innovation the starting point is getting all these materials written and published several interactive and innovative teaching methods have come into force yet the developing world is obsessed with monotonous rigorous muggingup methods that purely and painfully try to test the knowledge and memory levels forgetting the reasoning analytic problem solving and interactive skills this results in lack of leadership qualities creativity imagination and common sense among students they are learning purely for the marks grades and getting ready for the job market but have meagre socialising skills to get rid of this traditional system we need to have a proper blend of theoretical and industrial course curriculums there is a need to introduce both practical and theoretical aspects in assessing students professional mentorship some african scholars have made their mark both at the continental and intercontinental levels some notable ones are emerging with the hope of becoming internationally relevant however their relevance will live forever if they are able to transform their professional aspirations to becoming mentors to younger african scholars african scholars are fond of being trained on the soil of africa and delivering their services off the shores of the continent not to serve their people but to serve the interests of their foreign employers this brain drain means africa has lost many resources instead these highly known and upcoming scholars should think beyond the present by sacrificing what they can now for the sake of what later generations will become research relevance it is important to differentiate between practical and theoretical social sciences by practical we mean social science that is capable of influencing policies able to direct policies towards the right course and suitable in meeting the needs of people on the other hand theoretical social sciences are achieved through the publication of scholarly works sometimes without minding whether they are relevant to the needs of the people or not what is needed now is practical social science the one that will enable scholars to come to terms with the challenges facing them and enable policymakers to recognise the kinds of support needed and to redesign research cooperation programmes where necessary this will require the governments of african countries to collaborate with relevant bodies such as university authorities to make funds available for research that centres on discovering and understanding our own society and people from our own perspective and with our own interpretation of reality in nigeria it has been observed that there have been no known federal government efforts since independence to commission indigenous scholars in the humanities to carry out an indepth study of the culture and peoples of nigeria in all its ramifications with the aim of using such information as a benchmark for nationbuilding this experience is not much different from other countries experiences there is a need for proactive and protracted efforts to tackle this one way to address this is to approach it at the structural level where the solution lies in the awareness will and resolve of politicians bureaucrats and administrators the structures of academic dependency cannot be dismantled to decolonise knowledge and academia as a whole southsouth cooperation is a promising way of establishing a nondependent academia rather than depending on the west countries in the global south should intensify collaborative efforts in areas of research and development idea building publication outlets and increased investment in education scholarly publications the area of scholarly publication also needs to be developed compared to the world standard africas contribution to the worlds publications is insignificant mouton has documented africas share of world science as measured in papers published in isiindexes the paper revealed that africas share has been declining steadily over the past decades in his analysis tijssen shows how subsaharan africa fell behind in its share of world science production from 1 per cent in 1987 to 07 per cent in 1996 and the little that is produced is not evenly distributed across the continent with south africa taking the lead one of the possible reasons is that in africa until academics have been able to publish articles in the socalled euroamerican journals they are less likely to be considered for promotion or higher positions this has caused african journals produced by the academics own institutions to be looked down upon while there is not total disagreement with this method of promotion it encourages foreign intellectual domination a new orientation is required especially by encouraging african publishing houses it is important to note that there are several worthwhile publishers that can be patronised on the continent thereby discouraging academic dependence and promoting africancentred scholarship summary and conclusion an attempt has been made to explain the relevance of social science on the continent of africa the nature and origin of academic dependence contemporary themes and issues in african sociology of knowledge the universalism and indigenisation debates and the need for the indigenisation of social science in africa especially in the areas of academic curriculums professional mentorship research relevance and scholarly publications this article argues that a rethink to reinvent african scholarship is important for epistemic freedom from academic dependence this requires reformulating guidelines on the ontological and epistemological foundations of social science in africa training and encouraging mentors that will champion african scholarship on the continent and developing good management of research universities and institutions that will be most relevant to africa and for africans without mimicking the already established knowledge about the west it also requires the introduction of a programme to indigenise the sociology of knowledge in africa and untie it from the ideological imprisonment of western theories lastly it is necessary to learn african epistemological orientations in order to unlearn the dominating ideas of the west so as to relearn the sociology of knowledge that will be most relevant to and for africans this will allow the southern nations to explore and popularise their indigenous knowledge introduction the concept of indigenous knowledge 1 was first used by anthropologists to explain the existence of other forms of knowledge when it comes to development assistance development agencies and international organizations picked interest in the subject matter to explain their homegrown development programs more especially those ones working in emerging economies also stakeholders in the areas of agriculture and environment utilized the concept to explain how local knowledge has been used to address peculiar challenges affecting them however academic debates regarding the subject matter in the academy began much later what is obvious is that in spite of all that indigenous knowledge has to offer humanity it has not gained the recognition it deserves a number of question thus arise in this regard why is this so what are the current realities regarding indigenous knowledge in africa what are the obstacles regarding its place in knowledge production how can the subject matter be further explored and utilized for the benefit of africans and the entire universe delving into this area thus becomes important in this discourse 2 alluding to reij scoones and toulmins submission that much effort is expended on designing and disseminating solutions but too little time is spent on understanding the problem paying attention to this area thus becomes critical this article seeks to explore the realities regarding knowledge production in africa as they relate to the issue of indigenous knowledge the methodology adopted involves content analysis of secondary data sources from textbooks newspapers journal articles and other peerreviewed internet publications the article argues that african indigenous knowledge has suffered neglect due to the impact of coloniality and postcoloniality which completely ignore the lived experiences of those in the global south the article further sheds light on the importance of indigenous knowledge bringing its representativeness to the fore and serving as the moral compass for the collective finally the article maintains that decolonization as pointed out in the literature still remains the major way by which indigenous knowledge can find its grip within the existing body of knowledge however achieving this involves focus determination and resilience consequently discourses around the subject should be properly coordinated and managed at the national regional and continental levels exploring indigenous knowledge in africa until recently indigenous knowledge had been the object of so much criticism and neglect the perception was that indigenous knowledge was raw and unable to meet the complexities associated with modern thinking warren describes it as homegrown ideas which are different from western knowledge often found and generated from public institutions like the university research centres and the likes nyong adesina and osman elasha defined indigenous knowledge as institutionalized local knowledge that has been built omotosho situating african indigenous ideas within conventional learning upon and passed on from one generation to the other by word of mouth different terms have been used to capture indigenous knowledge in the literature some of them include traditional knowledge indigenous traditional knowledge local knowledge indigenous technical knowledge traditional environmental knowledge folk knowledge peoples science ethnoscience local science traditional science village science peasants knowledge and rural knowledge emegwali defined it as the cumulative body of strategies practices techniques tools intellectual resources explanations beliefs and values accumulated over time in a particular locality without the interference and impositions of external hegemonic forces the uniqueness of indigenous knowledge is that it is a representation of people is a summary of their experiences whether past or present and which in turn guide their mode of behavior 3 dei while discussing further the concept of indigenous knowledge emphasized on its relevance in shaping the communitys relationship with their immediate environment it is a combination of beliefs concepts perceptions and experiences of local people with their natural and humanbuilt milieu such knowledge becomes what it is simply because it is a part of the societal survival means it can be modified through new experiences and transferred from one generation to the other indigenous knowledge is a product of longterm habitation in a place by a group of people roberts captures it better when he opined that knowledge is termed indigenous based on the fact that it was accumulated by a group of people not necessarily indigenous who by centuries of unbroken residence develop an indepth understanding of their particular place in their particular world this is of course indicative of the rigor that went into its production in terms of diversity of ideas unbiased analysis of such thoughts which in some instances may be bring dissenting views all in a bid to ascertain its validity and more importantly collaborative nature of nonconforming opinions indigenous knowledge can be grouped into three as analyzed by castellano namely traditional knowledge which is passed on from community elders and goes from one generation to the next the second type he referred to as empirical knowledge is a product of careful observation of the activities within the natural sociocultural environment the last one he termed revealed knowledge the type that comes through dreams insight and revelation hoppers while explaining african indigenous knowledge grouped them into two the empirical and cognitive levels the empirical level was grouped into the natural technological architectural and sociocultural domains for the natural he further unpacked it into ecology soil agriculture medicinal and pharmaceutical he equally grouped the technological and architectural sphere into textiles metallurgy and the rest the sociocultural domain includes music art and conflict resolution among others the cognitive sphere captures the coevolution of spiritual natural and human worlds all the above delineation point to the allencompassing and dynamic nature of indigenous knowledge in addressing humans and their environment dei while discussing the importance of indigenous knowledge highlights some basic features the first one relates to its personalized nature indigenous knowledge has no claims to universality in that they are personal the second feature relates to trust in knowledge being connected to the speakers integrity and perceptiveness others include the mode of transmission of such knowledge which are usually through oral means and their sharing is directly related to considerations of the responsibility in the use of received knowledge besides these indigenous knowledge are a product of subject experiences and the inner interpretations of meanings and interpretations indigenous knowledge is also allinclusive and interpersonal they connect the physical to the metaphysical realms of life they connect economic cultural political spiritual ecological and material forces and conditions also indigenous knowledge provides the strength and influence in physical communication as they are expressive and narrative equally they are symbolic in the use of proverbs fables and tales lastly indigenous knowledge sees collectivism as a manner of thought highlighting the logic of belongingness with individuals and the land they share it is not personalized and detached into a collective abstract it is grounded in a society and a place having explored what indigenous knowledge connotes what then constitutes knowledge production conceptually speaking knowledge signifies all forms of information production including technological innovation cultural creativity and academic advance they are a set of actions and creativities taken to generate ideas it is the application of complex and intermittent events and phenomena to address specific issues it is the process involved in bringing out new ideas about an issue it is an output of a process it is the difference between what is understood and what needs to be understood for project success the production of knowledge as a process reflects the ingenuities and actions embarked upon in order to come up with ideas new ideas or objects within the focus of this discourse knowledge production captures the realities within higher institution of learning in terms of pedagogical knowledge and research while the former omotosho situating african indigenous ideas within conventional learning appears narrower than the former both are intertwined to some extent and both are relevant for realizing the central aim of this discourse indigenous knowledge and the academy some constraints indigenous knowledge emerged within academic debate about thirty years back in spite of its long years of guiding the day to day experiences of africans this of course is a reflection of the neglect the subject matter has suffered over time nel attributed its recognition in recent times to the increased awareness of african cultural heritage the need to situate science within the social and cultural realities of africans and failure of development plans in bringing the desired results at the global level indigenous knowledge has gained recognition among international organizations namely united nations civil human rights movements and others within africa south africa has issued policy documents regarding the relevance 4 the subject matter has equally gained intellectual attention notwithstanding the achievement is insignificant compared to what it ought to achieve the foundation of noninclusion of indigenous knowledge within the academy is hinged on coloniality and postcoloniality which completely ignore the lived in experiences of the global south colonialitys emphasis unilinear and simplistic explanation of society has been cited as part of the undoing of indigenous knowledge the overemphasis on the supremacy of eurocentric values and norms such that all other lines of thought and development outside of this frame of thinking were anaesthetized to the eurocentric apologists indigenous knowledge has no explanation to make in the order of ideas because it is crude unreasonable and lacks rigour the latter came to address some of the flaws inherent in the former but it fell into the same error postcolonialism emerged as a sensible modification to the modern theories in the sense that it rejects the universal simplified explanations of society which saw indigenous knowledge as being somewhat atavistic primordial and backward and the quest for equity dignity respect and accessibility superfluous consequently the theory recognized the complex nature of human experience farreaching oversimplifications may not be able to explain the complex nature of lived experiences of humans there is need to understand the indigenous detailed and uptodate analysis that are beached in spatial and cultural settings postcolonial theory thus raises the issue of identity variance and representation and the problem of decontextualized power in a nutshell it would challenge consensual rationality hierarchy and order that would act as universal systems of thought slemon captures postcolonial discourse as a framework that perceives colonialism as an ideological and discursive formation an apparatus for constituting subject positions through the field of representation while the livedin experiences of the africans should be the centre focus of postcoloniality it has been shifted to the side postcolonial theory has become a metatheory by essentializing difference and thus risks idealizing and essentializing the human subject by privileging the individuation of the self what postcolonialism does is that it gives a false status to the issue of indigeniety through the enforcement of western ideals and principles on the southern realities thus depriving them any right of history and social interconnectedness postcoloniality has therefore numbed the history and identities of africans such that what is left of them in terms of history and social realities is fragmented heterogenous and vague this of course is obvious regarding the back and forth indefinite and horrendous dispositions of stakeholders africans thus become dreadful in telling their stories boasting of its feat in handling its affairs over the years have become a difficult task the history has been made to appear unreal because postcolonialism has taken over the sociocultural and economic realities of africans with explanations that do not in any way capture the realities around them the academy has served as the platform for the entrenchment of these ideals this was the submission of shizha when he submitted that the epicenter of colonial hegemony indoctrination and mental colonization and that the decolonization process entails a process of reclaiming rethinking reconstituting rewriting and validating indigenous knowledge and by implication africas history a fall out of the failures of modern and postmodern theories in conferring the needed recognition to indigenous knowledge is evident in a number of ways one of such is that it has snuffed life out of indigenous ideas regarding the socioeconomic and cultural ways of life a handful of african theorists have postulated home grown ideas regarding the ways of life but they have not become popular as expected the scholarly work of eminent sociologist akiwowo where he propounded the asuwada theory of sociation as a contextual episteme for understanding african social knowledge is a case in point for instance a number of social interaction theories being overused by nigerian students and scholars might not be necessary considering the contribution of akiwowos ideas to social interaction the depth rigor and relatability of this philosophy to the realities of social interaction in nigerian culture and that of africa give it an edge over western knowledge on the topic omotosho situating african indigenous ideas within conventional learning other african scholars like nyamnjoh and others have equally come up with relevant indigenous explanations about african social lives which by now should have become the everyday paradigms for understanding african realities however these have not gained the needed attention what modern and postmodern explanations appears to have done in the long run was to create opportunity for inefficiency poor policy and redundancy within the education sector for african academy and its managers in nigeria for instance postindependence period marked the growth of educational policies meant to popularize and strengthen indigenous ideas but the outcome of this noble cause was frustrated by neoliberal policies enforced on the policy makers for example the nigerian policy on language education states that government will see to it that the medium of instruction in the primary school is initially the mother tongue or the language of the immediate community and at a later stage english primary education the reason was to ensure that african children appreciated their indigenous languages and equally understand whatever knowledge being passed across to them this policy has suffered serious setbacks apart from the fact that the policy did not state precisely the later stage when the child should change from mother tongue to english the policy has not in any way been enforced a number of education administrators didnt see any reason to enforce these decisions teaching children in indigenous language by elites and middle class was seen as barbaric antisocial and parents patronized private schools where their children would be taught in english language as a sign of elitism omojuwa stresses that the minimum basic requirements for a language to be used as a medium of teaching was not met by many african languages these challenges became aggravated with the failure of the policy makers to fund education adequately the popularization of liberal and neoliberal policies across the globe further justified the corruption tendencies of african governments they cut funding to certain segments of education and diverted it to some unknown sectors africa accounts for only 06 percent of global gross expenditure on research and development with south africas share representing as much as 90 percent of this contribution consequently the admission growth within university education continued to outstrip available funding capabilities unproductive application of funds by both government and higher education institutions began to put pressure on available funds there was a cumulative waning in public spending per student and ultimately research and quality investment became unrealistic one major blow postcoloniality dealt the higher institution also relates to the suffocation of some core fields of humanities within the institutions of higher learning in certain parts of the continent in some parts of the continent where such disciplines hold strong influence contentions along race what ought and not to be studied and how it should be also constitute a challenge disciplines like history anthropology and the rest having a core understanding of indigenous knowledge lost their influence significantly anthropologists and historians have played enormous roles in providing the needed guidance and information for colonialists within the continent and elsewhere in this dispensation the contributions of these disciplines are needed more than before to further the interests of african indigenous knowledge unfortunately this may not be so due to the influence of postmodern discourses the interests of young people in the study of anthropology and history in west africa for instance is not encouraging crave for statistical data by development agencies and policy makers to justify postmodernism further made the discipline suffer much attack in nigeria for instance history had to be flavored with other nomenclature like international relations to make it appealing to the students teachers of history had no option to leave the country thus making a study of indigenous ideas for knowledge production more challenging africa has institutions and centres within the universities and research centres devoted to the study of african realities the present realities regarding their proliferation and influence on african academic for knowledge production leaves much to be desired the centres were created to continuously crossexamine epistemological methodological and theoretical lines to the study of africa presenting africa and its people as the focus of such discourses as themes rather than mere items some of these centres in recent times appear to be appendages of social science epistemology that promote western knowledge the establishment of african studies centres within higher education in the global north is understandable and justifiable in my opinion the existence of african studies centres within the higher education on african soils seems not to be fully achieving this aim they appear to serve as avenues to further strengthen western episteme this is evident in the continued proliferation of the centres within institutions of higher learning in africa without its direct influence on western oriented disciplines linking indigenous and orthodox knowledge for nuanced knowledge production extant literature has pointed to decolonization as the sole means by which indigenous knowledge can find its footing within the existing body of knowledge this discourse has been interrogated under different thought patterns ranging from fanons ground breaking work that emphasized on omotosho situating african indigenous ideas within conventional learning understanding the historical process of colonization as a means of changing the order to ngugi wa thiongo s emphasis decolonizing the mind dei for example emphasized the need to challenge imperial ideologies and colonial relations of production that normally characterize and shape academic activities removing indigenous knowledge from the academy makes room for the colonization of knowledge and cultures in local milieu and settings battiste while postulating on the linkage between indigenous knowledge and academy also emphasized that educators must reject colonial curricula that offer students a fragmented and distorted picture of indigenous peoples and offer students a critical perspective of the historical context that created that fragmentation emerging from these trajectories over the years relates to the need to decolonize the academy especially the curriculum however what has become clear is that decolonizing this sector is no mean feat the recent happenings in south africa regarding fee must fall and decolonizing education further attests to this as a matter of fact the decolonization of the african academy remains one of the biggest challenges not only in terms of the curriculum teaching strategies and textbooks but also in terms of the democratization of knowledge and the regeneration and adaptation of old epistemologies to suit new postcolonial realities this of course does not suggest that it is impossible it only calls for a consistent and pragmatic approach one must take into cognizance that decolonization is a process this was corroborated by the argument of laenui that it is in phases namely the process of recovery of identity artifacts language and cultural information a process of mourning for what is being lost dreaming reformulation and invocation of other possibilities for research commitment to including silenced voices and action that includes strategies for social transformation understanding this will therefore go a long way in deploying the appropriate tools and strategies in view of the above it is pertinent to note that decolonization cannot be achieved overnight it didnt come brusquely it was a planned calculative event spanning a period of years before it had its toll on the target community as such addressing it must equally follow the same trend though with a more dogged approach second the spread of decoloniality through indigenizing knowledge for knowledge production within the continent of africa is lopsided indigenous knowledge appears to gain ground within spaces where racism holds sway other parts of africa where there is no physical presence of racism appears to exhibit a false consciousness about it indigenous ideas pervade the nooks and crannies of the continent what however is lacking is the appreciation and support in the same vein a complete decolonization of knowledge may not be feasible at the moment as no idea can exist in isolation what is desirable is the coexistence of western and indigenous ideas consequently debates within the academy regarding the decolonization project must first create the needed awareness that will culminate into a strong identification with the subject matter among academics currently this appears lacking there is a continued reproduction of western knowledge without a recourse to the indigenous ideas changing the curriculum is good no doubt it may continue to meet brick walls when policy makers and education managers do not see the need for it achieving this can only be possible through a consistent gradual process the mind must be decolonized and this happens when there is a strong and consistent debate around the subject matter knowledge thrives when there is communication a situation in which the emerging academia in africa are not aware of the giant strides africans in time past have taken in all facets of life for survival and to move their society forward is dangerous for african identity and existence within the global world both now and in the future obviously debates have been ongoing it is however sectional many of the studies on the topic appears to be concentrated in southern africa and global south this of course does not preclude the contributions of scholars from other regions of africa 5 therefore interrogations around indigenous knowledge should be properly coordinated and managed at the national regional and continental levels revolution at the level of the academy and in the situation of indigenous implies transformation not only in the curriculum but also in instructional plans so that a more collaborative mode of instruction and knowledge balances the teachercentered approach this will be achievable through the moral and financial support of stakeholders education funding is generally poor in subsaharan africa studies on popularizing local ideas thus need the necessary financial support to conduct research and teaching on the subject funders sympathetic of this course must be contacted and encouraged to fund research in these areas also academic activities like seminars and lectures within higher education should be geared towards debates around indigenous knowledge pan african think tanks in africa must coordinate and manage activities and debates around these themes at various levels workshops and conferences on different themes should be organized by these bodies to bring together scholars on this subject areas in order to network and strategize on the importance of the subject it must be noted that africans are the ones to project their ideas nobody will be sympathetic of their cause institutions and centres devoted to the study of indigenous knowledge need to partner the more with higher education this can be done through seminars and omotosho situating african indigenous ideas within conventional learning workshop in partnership with these institutions the sole aim is to create the needed awareness in the academia they should set up special funds for researchers and graduate programmes to stimulate interests in this area concluding remarks undoubtedly africa has a rich knowledge base one thing that is clear and needs to be addressed relates to the sense of ease and smugness in the attitude of scholars within african academy to the use of conventional approaches to knowledge production this in itself has limited africans in their ability to play a critical role in knowledge production based on the fact that these approaches in itself do not in most instances explain our realities as it ought to aside this the global world usually feels they have nothing new to learn from us if what we keep sending to them what they already know while conventional knowledge is a product of colonial influence what is however critical relates to our failures especially in the social science and humanities to break free from these grips or as the case may be encourage and situate our home grown ideas into the conventional knowledge consequently what is needed is a strong drive to pool these massive knowledge together primarily for the benefit of africans and then for the global benefit this will only occur when there is a concerted efforts at making african appreciate the value african scholars need to talk more about their indigenous knowledge younger generations must be made to appreciate this scholars and african institutions have important roles to play in this western knowledge has come to stay in the continent indigenous knowledge must equally stay and the academy has an important role to play in this notes 1 can be referred to as traditional knowledge and sometimes referred to as local knowledge as the case may be according to the introduction formal education changes aspirations and life prospects the experience of formal education transforms young peoples knowledge capacities and values shaping how they see themselves in the present and where they see themselves in the future normatively education also improves life chances notably through employment which in turn facilitates other life transitions necessary for independent adulthood on the african continent the valorisation of education as a vehicle for social mobility has a long history in the late precolonial and colonial periods western education offered new pathways to wealth and social status primarily through expanded opportunities for employment in nascent formal economic and political systems for african countries that gained independence from colonial rule in the late 1950s and 1960s these aspirations were reinforced by a policy rhetoric of education as the master determinant of all aspects of change for nationstates in transition to a modern society this change would happen at both individual and national levels education was to be the making of the nation through changes to the skills and the mindsets of the population institutions of higher education 1 in particular held pride of place as a symbol of a modernising nation expected to produce graduates with the skills to support socioeconomic development however the assumption that higher education credentials denote the possession of skills is challenged by studies in which employers point to a scarcity of employable skills among graduates of higher education the evidence from ghana and elsewhere suggests that employers increasingly attach less importance to formal academic credentials and more to skills 2 in other words employers discriminate between skills and credentials do young people likewise place differential value on the skills and credentials obtained through higher education we know much more about policymakers and employers perspectives than those of young people because there are few studies in african contexts that explore their understanding of the relationship between education and the labour market and of themselves as workers this is a significant area of neglect since trends in education and the labour market are not only the result of actions by governments and by employers but also of the aggregate decisions of young people and their families this article investigates the differential weight that higher education graduates accord to skills and credentials in assessing the ways in which their higher education experience translates to labour market success it is based on survey data from 2036 graduates of ghanaian higher education institutions interviewed during the oneyear mandatory national service period which for many precedes their first or full entry into the labour market the study compares holders of degrees and holders of nondegree qualifications on two dimensions their evaluation of their higher education experience including a selfassessment of skills acquired and their employment expectations while nondegree holders assessed themselves more highly on skills training degreeholders expressed more satisfaction with their educational achievements and more optimism about their labour market prospects moreover the overwhelming majority of graduates across all higher education institutions and qualifications regardless of selfreport of skills obtained expressed a desire to obtain higher credentials these analyses suggest that graduates place a higher premium on obtaining credentials to get work than on acquiring skills to do work literature review the article is grounded in two perspectives on the relationship between higher education and the labour market the human capital theory and the credentialist perspective these do not operate in a mutually exclusive manner nor are they exhaustive however they represent two dominant frameworks in the literature on the higher educationlabour market nexus to use tomlinsons 2008 heuristic the human capital framework is about the skills and knowledge… needed to do jobs while the credentialist perspective is about what is needed to get jobs as is true for many postcolonial african countries ghanas educational policymaking has been underpinned by human capital theory the theory proposes that the more years of education an individual has the more knowledge and skills they acquire and consequently the greater the returns they obtain in terms of employment opportunities earnings and career progression during the era of economic reforms in african countries in the 1980s commonly referred to as the structural adjustment period the world banks policy prescription of drastic reductions in public expenditure on higher education was based on human capital theory and specifically on studies that suggested that higher education yielded higher returns for the individual than the society other studies have indicated that private returns from higher education are greater than primary education this relationship is especially strong for african countries despite these inconsistencies in its empirical support human capital theory has persisted as the ideological basis for educational policymaking in many countries on the continent in ghana the association of education with the acquisition of employable skills has consistently been articulated in policy discourse since the first postindependence government moreover it was explicitly stated as the goal of educational reforms in the 1980s one of the most comprehensive in the anyidoho ghanaian graduates on the value of higher education countrys history three decades later in 2012 the ministry of education described its mandate thus to provide relevant and quality education for all ghanaians especially the disadvantaged to enable them acquire skills which will make them functionally literate and productive to facilitate poverty alleviation and promote the rapid socioeconomic growth of the country 3 in 2021 the website of the same ministry has a statement of purpose that focuses more on the individuals work prospects rather than national development and retains a focus on skills acquisition the moe is committed to ensuring that all ghanaians are prepared to succeed in the world of work it achieves this through the development of an educational system that focuses on promoting problem solving and creativity and building critical skills through academic technical and vocational programs 4 these policy statements are especially pertinent for higher education if education is meant to impart employable skills then individuals who complete higher education would be among the most highly skilled in society and according to human capital theory the most rewarded in the labour market indeed in contemporary development discourse and practice higher education is presented as a central site for facilitating the skills knowledge and expertise that are essential to economic and social development in the ghanaian context human capital theory is called into question by evidence that graduates of higher education institutions have higher rates of unemployment than the general youth population in a country in which economic growth has consistently outpaced employment rates and job creation in particular the formal sector the traditional and preferred destination of higher education graduates has become more constrained formal sector jobs have been growing by an average of 13 per cent while the increase in the populations of graduates has been much higher young people in ghana and indeed on the rest of the continent are aware of the diminishing value of a graduate degree in terms of employment prospects even while they expect higher education qualifications to open doors for them through secure employment they recognise that such credentials do not have as much value as they did in terms of work and general life prospects from a human capital perspective one explanation is that higher education may not be providing young people the skills needed to obtain and to do work there is some support for this in the fact that both ghanaian employers and graduates complain that higher education graduates lack the right set of skills for available jobs to the extent that young people perceive skills acquisition as a determinant of labour market outcomes one would expect that they would show a preference for programmes and institutions that are seen to convey employable skills polytechnics in ghana are public institutions that are set up to train young people with industrial and technical skills that are presumably in demand by the labour market with the framing in ghanaian public discourse that degree programmes are theorybound and that diploma programmes in polytechnics and professional institutes offer more practical and workrelevant skills one might expect that young people would place more value on polytechnic education on the contrary polytechnics have acquired a reputation as a backup option for students who are unable to gain admission to degree programmes in universities universities on the other hand have experienced an increase in admissions that cannot be explained solely by the increase in population size there are evidently limits to the extent to which the human capital approach can explain the demand for forms of higher education that both graduates and employers claim do not provide employable skills the credentialist perspective offers an alternative set of explanations credentialism is a concept with a long history used here to describe the demand for higher education as the pursuit for a ticket into the labour market rather than the attempt to acquire the skills with which to do a job from a credentialism perspective credentials are less indicators of work skills than markers of sociocultural position and advantage credentialism is not a new phenomenon in higher education credentials have always been prized for their symbolic value and as a legitimation of advantages that empower degree holders in occupational and organisational recruitment however there are indications that the phenomenon is more prevalent in contemporary times and is a major driver of the expanded demand for and participation in higher education worldwide the diminished value of a higher degree in the graduate labour market is partly the result of increased participation in higher education as more people gain a higher education qualification it becomes less of a marker of distinction than a basic requirement for a professional job this means a higher education qualification does not convey as much competitive advantage as it used to a phenomenon that is sometimes referred to as credential inflation where jobs that did not previously and may not strictly require a higher education qualification are hard to attain without a higher education qualification 5 people are thus compelled to acquire more credentials to stay competitive in the job market without necessarily adding to the capacity that they need to do work competently credentialism could therefore potentially offer an explanation for the preference of ghanaian students for degrees and for degreegranting universities over nondegree qualifications offered by polytechnic and other institutions that offer professional or technical skills even the body set up to oversee education concludes that young people appear to be more attracted to the social status that goes with being a degreeholding university graduate indeed there is the suggestion that the policy announced in 2016 converting polytechnics into degreegranting technical universities in ghana may have been a populist response to the privileging of university degrees over nondegree qualifications the foregoing suggests that it is important to understand young peoples configuration of the relationship between higher education and the labour market in this study we are specifically interested in which of the two theories of interest better captures young ghanaian graduates understanding of the value of higher education for job market success this study is a response to the gap in the literature on the interpretive frameworks through which graduates view the labour market and themselves as workers and tymon as exceptions moreover it adds to the sparse literature that explores young peoples perspectives on policy discussions of youth employment and unemployability on the african continent research methods sampling and data collection methods the article is based on a survey of graduates of higher education institutions within one year of completing school respondents were from both public and private institutions including universities university colleges polytechnics and institutes of professional studies respondents were interviewed between october and november 2015 during their oneyear participation in the national service scheme which is mandatory for all higher education graduates under 40 years of age the 20152016 cohort from which this sample is drawn was made up of 75000 graduates working in public and private institutions all over the country as we were unable to obtain 2015 data from the nss data from 2014 was used to derive a sampling frame of institutions to which national service persons were posted the study randomly selected 1020 establishments in three of ten administrative regions greater accra ashanti and northern regions given resource constraints the three regions were chosen to represent geographical spread being respectively in the southern middle belt and northern regions of ghana the three regions also absorb 60 per cent of all national service personnel in each establishment national service persons were invited to complete a 45minute interview with trained research assistants respondents therefore selfselected into the study a maximum number of 10 respondents per establishment was set so that none of the establishments were overrepresented in the sample the eventual nonrandom sample comprised 2036 graduate nsps from 454 establishments 7 respondents were informed about the goals of the study and completed a consent form prior to taking part in the survey 8 they were informed about their right to opt out at any point in the interview in addition to questions about family and educational background the structured questionnaire elicited responses about their secondary and higher education programmes and performance including their assessment of the extent of their skills training additionally they were asked about their labour market expectations sample composition the final sample was nonrandom and biased towards establishments that had nsps in 2014 it was also biased towards individuals available and willing to participate in the survey during the period of data collection the data set consisted of 2036 graduates from higher education institutions in ghana the sample was made up of 57 per cent males and 43 per cent females the 1180 degreeholders made up 58 per cent of the sample with the other 856 being recipients of higher national diplomas and other nondegree credentials anyidoho ghanaian graduates on the value of higher education analysis the statistical differences between degreeand nondegree holders were analysed using ttests and chisquared tests both probit and multivariate linear regressions were used to determine the contribution of other variables that might be related to the decision to pursue degree or nondegree programmes findings assessment of experience of higher education overall satisfaction with higher education the question of young peoples satisfaction with higher education is a measure of the value they accord to it the entire survey focused on the transition to and prospects for work and so graduates selfreported satisfaction can be assumed to be with primary reference to the opportunity higher education provided them for employment an overwhelming majority of the sample irrespective of programme of study type of institution or terminal credentials expressed satisfaction with the education they had obtained as further confirmation about 95 per cent of the sample affirmed that if they had it to do all over again they would still choose to get a higher education qualification beyond this broad evaluation graduates were asked specifically to evaluate the programmes or courses they had done and institutions in which they had studied of the 95 per cent of the sample who confirmed their choice to get a higher education about half stated they would choose to do the same course at the same institution another 40 per cent would choose a different institution and 27 per cent would choose a different course what is noteworthy is that nearly a quarter of these students would have preferred to do the same course but at a different institution in other words they discriminated between the content of the course and the credential table 3 displays the responses to the same set of questions but with differences between degree and nondegree holders highlighted the results of a series of chisquared tests indicated no significant difference in the expression of overall satisfaction between graduates with degrees and those without however degreeholding graduates were more likely to affirm both their programme of study and institution on their part nondegree holders were more likely to say that they were happy with their course but would have wanted to be in a different institution further out of the 221 diplomaholding graduates of polytechnic institutions who said they would elect to do the same course but in a different institution 40 per cent gave as their reason that they would want to go to university to get a degree or to get a better or higher credential 9 this tally may be an underestimate as it includes only those responses in which an explicit desire for a degree or for university admission is stated it is probable that similar preferences were implicit in further responses that expressed a wish to explore other institutions or environments the desire to do the same course but in a different institution appears to fit with the credentialist perspective that says that students may place more emphasis on the facevalue of the qualifications than the content of their programmes of study selfassessment of skills training the survey elicited students assessment of skills training they had acquired in the course of their higher educational careers specifically respondents were asked about the extent of training in a number of skill sets the list of skills presented to respondents is not exhaustive and admittedly there is little agreement on the set of skills necessary for the graduate labour market or about their operational meanings nonetheless the list is indicative of the skills that the literature suggests are important to employers consequently it skews towards intraand interpersonal skills relative to technical skills as the literature suggests the former is more valued by employers between 60 per cent to 70 per cent of respondents in each category believed they had the right amount of training in each skill set with the notable exception of technology or it skills there were differences between degree and nondegree holders in the assessment of skills gained but with few consistencies in the extent and direction of the differences out of the eight skills categories assessed a significant difference was observed for five in four cases degreeholders reported that they had received less training than they needed for the job market and in three cases nondegree holders stated that they had received more training than they needed overall degree holders were likely to rate themselves as having less skills training these findings should be interpreted cautiously because of the limited set of skills surveyed nonetheless they do lead to two interesting conclusions first despite employers complaint that young people lack the appropriate soft skills for work on all seven measures a majority of graduates assessed themselves as having received the right amount of training this is at odds with employers evaluation of graduates second given the accepted wisdom in ghana that university degree programmes are more theoretical and technical programmes such as those offered by polytechnics are more practical it is interesting that degreeholders from universities were slightly more positive about their it training than nondegree holders 78 per cent of whom attended polytechnics internships and other such experiences help students to acquire workrelevant skills as well as improving their jobsearch and jobretention skills the lack of which is a disadvantage to young people in the job market the survey therefore asked graduates if they perceived that their institutions had provided them adequate opportunities for work experience while roughly half of each group of respondents reported an optimum amount of such work experience nondegree holders reported having received too much of such experience compared to about 20 per cent for degreeholders while 21 per cent said they had received too little compared to 27 per cent of degree holders here again by their own selfassessment degree holders would appear to have less work experience in the course of their higher education than nondegree holders desire for additional certifications respondents were asked about their desire to acquire further qualifications these figures must be interpreted cautiously given that aspiration and intent do not automatically result in action nonetheless it is remarkable that almost the entire sample expressed a desire for further higher education qualifications with no difference between degree and nondegree holders not surprisingly nondegree holders had a significantly higher desire for a bachelors degree compared to degree holders who already had this qualification what is more interesting is that nondegree holders were significantly more likely to report a desire for a masters degree the survey did not elicit the motivation behind this desire for further qualification however when interpreted against the backdrop of the difference between degree and nondegree holders in their selfassessment of employable skills training these results indicate that skills acquisition may not be the primarily incentive for additional credentials indeed the fact that 61 per cent of degreeholders and 39 per cent of nondegree holders would want a doctorate degree is reasonable evidence that some other calculations are behind their responses given that there are few available jobs that require the specific skills that doctorate training would offer the more likely explanation is credential inflation where young people believe that even higher qualifications may give them an advantage in a crowded job market labour market expectations the survey provided information on three indicators of labour market outcomes the first variable is based on respondents simple selfassessment of the odds of earning an income within the first six months after national service either through a job or selfemployment for the entire sample the mode for this ordinal variable was 5 out of 10 and the median was 7 out of 10 regression analyses were conducted to determine if there were statistically significant differences between degree and nondegree holders in their labour market outlook and also to explore alternative explanations for these differences table 7 shows the results of a probit regression for the selfreported chance of earning income within six months of completing national service and a multivariate liner regression for minimum and expected monthly earnings respectively degree holders reported a significantly higher expectation on all three variables degree holders higher labour market expectations held up even with the introduction into the models of variables that might be expected to influence both labour market expectation and selfselection into degree programmes and degreegranting institutions given research that shows that economic and social advantage is associated with admission into degreegranting universities the variables included the demographic characteristics of sex and age a selfesteem measure using the rosenberg selfesteem index 10 educational background including programme of study and selfreported grades on the nationwide secondary school certification exam a standardised and uniformly graded national examination that largely determines admission into higher education institutions family background variables as proxies for socioeconomic status and social capital and finally paid work experience since secondary school out of these variables selfesteem was consistently significant indicating that regardless of qualification graduates with higher reported selfesteem tended to be more confident about their prospects in the labour market programme of study also proved to be significant across all the models compared with students in all other programmes including business students in stem were more optimistic about their chances of employment and their income levels ssce scores were significant in explaining the differences between degree and nondegree holders but only in relation to income sex age previous work experience and family background variables proved to be significant but not consistently so in sum despite reporting lower workrelated skills training and work experience degree holders generally had higher labour market expectations suggesting again that the type of qualification matters to graduates in evaluating their chances of labour market success anyidoho ghanaian graduates on the value of higher education conclusion although the expansion of higher education is partly fuelled by the personal ambitions of individuals and their families policy discourse and research on higher education pivots around the perspectives and interventions of governments and employers young peoples experiences are underexplored which implies that very little of their voice is filtered into policy this article provides insight into the interpretative framework that young people apply to the relationship between the higher education and labour market participation specifically it examines the relative strengths of the human capital theory and of credentialism in explaining young peoples demand for higher education compared to degree holders graduates with nondegree qualifications selfassessed as having more skills training as well as attachments internships and other experiences that would be expected to provide workrelevant skills if students held to the human capital theory that posits that skills acquisition is rewarded with labour market success then nondegree holders would be more optimistic about their employment prospects on the contrary the study found that nondegree holders expressed less satisfaction with their education with many explicitly stating a preference to have a degree andor to attend university even if they were to maintain the same programme of study this desire by nondegree holders for alternative institutions and programmes despite higher selfassessment of their skills training may indicate that students place more importance on the facevalue of credentials than on skills moreover almost all graduates stated a desire to seek further higher education qualifications with little difference in the two groups of graduates in the extent to which they expressed this desire one may see further evidence of credentialism in the fact that degreeholders generally had higher labour market expectations than graduates without degrees again despite the former selfreporting lower workrelated skills training statistical analyses indicate that the differences in labour market expectations between degree and nondegree holders proved to be significant but were associated with other dimensions of educational and social advantages this is consistent with the theory of credentialism that proffers that educational qualifications both signify and deepen social advantage our findings also suggest a disconnect between two important stakeholders in the graduate labour market graduates and employers ghanaian employers complain about the lack of workready skills of graduates particularly in regard to generic skills but the ghanaian graduate students in our study generally believed their education had provided them with adequate training in the skills desired by the job market they were also generally sanguine about their employment and earnings prospect a finding that is consistent with research in both african and nonafrican contexts their apparent bent to credentialism and optimistic employment outlook both of which appear to be at odds with the objective situation of a labour market that values skills over credentialism suggests that young people may be working on a different model of the relationship between higher education and the graduate labour market than policymakers who by and large subscribe to a human capital approach this implies a need for greater attention to young peoples subjectivities in research and policymaking around youth employment and employability notes 1 i use the term higher education in its broadest sense as referring to postsecondary education in this way it is used synonymously with tertiary education in this article in ghana higher education institutions include universities polytechnics technical and vocational schools teacher training colleges nursing schools and distance learning centres that award academic degrees professional qualifications and diplomas 2 it should be noted that the shift described from credentials to skills and from hard to soft skills is less observed in specialist and technical programmes and occupations 3 homepage of the ministry of education governanceministries331ministryofeducation 30 october 2012 4 ministry of education website 30 june 2021 5 tholen identifies the related phenomenon of graduatisation an increase in the share of labour entrants with university degrees into previously nongraduate occupations 6 based on nss data each establishment had received between 1 and 10 national service personnel in 2014 with an average of 2 per establishment yielding a target sample of approximately 2000 respondents if we had perfect response rates and if the numbers of national service persons posted to selected establishments remained constant 7 we do not have full information from the field on response rates 8 the nature of the survey was explained to respondents beforehand the consent form said the project will study tertiary graduates who are beginning their national service this year the goal is to collect information on the education training and work experience of young adults in ghana in order to understand the employment issues facing todays youth we are asking you to take part in this study because you are a tertiary graduate and we would greatly appreciate you completing the survey questions 9 this finding is based on a simple coding of openended responses 10 we define selfesteem as an individuals overall sense of worthiness as a person and we measure it using the rosenberg selfesteem scale the questionnaire prompted respondents to please indicate for each of the following ten statements which response best describes you we then read a list of statements and asked respondents to indicate whether they strongly agree agree disagree or strongly disagree with each one examples included on the whole i am satisfied with myself and i feel that im a person of worth at least on equal level with others we coded responses from 1 strongly disagree to 4 strongly agree we constructed an index score by reversing the scoring on responses 2 5 6 8 and 9 and then calculating the mean score for the ten responses so that the selfesteem index score ranges from 1 to 4 schmitt and allik examine the crosscultural performance of the rosenberg selfesteem scale using data from a sample of 16998 respondents in 53 nations their sample includes six african countries botswana democratic republic of congo ethiopia morocco tanzania and zimbabwe they find that the scale generally has similar psychometric properties across cultures and conclude that their study provides evidence of the structural equivalence of global selfesteem across cultures supporting the notion that a persons overall evaluation of selfworth is a universally quantifiable human characteristic abstract globalisation entails the process of production and exchange at the planetary level making the world a global village at global epistemic levels it has been dominated by eurocentrism and western knowledge production paradigms and platforms characterised by asymmetrical and superiorinferior relationships between the global north generally and global south in africa in particular virtually all facets of knowledge production utilisation and transfer have been dominated by the west in africa the process of knowledge production has been muddled supplanted and ultimately made subservient to orthodox western education forms and structures of colonial authorities the global political economy of knowledge production has consigned indigenous knowledge to being regarded as traditional unscientific and valueladen using philosophical logical reasoning and secondary data the article critically engages with these issues especially those that pertain to decolonisation of knowledge production in africa in the age of globalisation it provides an examination of pedagogical issues especially teaching and learning methodologies it also interrogates the knowledge of culture mind and self in knowledge production in africa within the global context in addition it appraises research methodological platforms that inhibit africanist solutions with global applicability this is with a view to suggesting interventions that demonstrate the applicability of alternative frameworks of knowledge production in africa résumé la mondialisation implique le processus de production et déchange au niveau planétaire faisant du monde un village planétaire aux niveaux épistémiques department of politics and international relations university of johannesburg south africa and department of political science obafemi awolowo university nigeria email mondiaux elle a été dominée par leurocentrisme et les paradigmes et plateformes de production de connaissances occidentales caractérisée par des relations asymétriques supérieursubalterne entre le nord global en général et le sud global en afrique en particulier pratiquement toutes les facettes de la production de lutilisation et du transfert des connaissances ont été dominées par loccident en afrique le processus de production de connaissances a été brouillé supplanté et finalement asservi aux formes déducation occidentales orthodoxes et aux structures des autorités coloniales léconomie politique mondiale de la production de connaissances a relégué les connaissances autochtones à être perçues comme traditionnelles non scientifiques et chargées de valeurs utilisant un raisonnement logique philosophique et des données secondaires larticle aborde de manière critique ces questions en particulier celles de la décolonisation de la production de connaissances en afrique à lère de la mondialisation il fournit un examen des questions pédagogiques en particulier des méthodologies denseignement et dapprentissage il interroge également la connaissance de la culture de lesprit et de soi dans la production de connaissances en afrique dans le contexte mondial en plus il évalue les plateformes méthodologiques de recherche qui inhibent les solutions africanistes dapplicabilité mondiale ceci dans le but de suggérer des interventions qui démontrent lapplicabilité de cadres alternatifs de production de connaissances en afrique introduction globalisation entails the process of production and exchange at the planetary level making the world a global village global epistemology has been dominated by eurocentrism and western knowledge production paradigms and platforms characterised by asymmetrical and superiorinferior relationships between the global north generally and the global south particularly in africa virtually all facets of knowledge production use and transfer have been dominated by this relationship in africa the process of knowledge production has been muddled supplanted and ultimately made subservient to the orthodox western education forms and structures established by colonial authorities these imposed forms and structures of western knowledge production have been maintained by conscious but subtle cultural changes effected by westernled philosophical justifications notably in language translation methods equivalence and conceptualisation given that globalisation runs on the fulcrum of ideas values and principles that privileges the north over the south the global political economy of knowledge production has consigned indigenous knowledge to being traditional unscientific and valueladen western knowledge has been prioritised over traditional means of knowledge acquisition western relics forms and values products of continuous and sustained domination of africa and its intellect especially in knowledge production are regularly justified and sustained by petty african intellectual bourgeoisie this has led to western knowledge being seen as normal with the continuous production of african intellectuals through the western education grid with resulting outputs unable to understand africas social realities and offer solutions to its problems the problems of western globalisation of ideas and knowledge are felt more in the humanities and social sciences especially in the social construction of the individual and social realities of africans this is because western ideas are culturally incongruent with african social realities to argue that colonisation has no effect on the sociology of knowledge is to ignore the enforced knowledge acquisition mandated by the colonial authorities the very basis of such ignorance doubt and argument especially by african academics shows the success of the embedded liberal ideology and knowledge entrapment of colonialism the current domination of knowledge production in africa is sustained by and steeped in the idea and practice of globalisation an offshoot of capitalism knowledge is seen as a commodity that can be sold and bought this in essence is the commodification of knowledge the commodification of knowledge has been championed by western financial institutions and adopted in several ways within africas educational systems particularly with the introduction of exorbitant school fees and the rationalisation of academic staff world bank loan conditionalities are founded on the same commodification of knowledge and are the principal vehicles to achieve the institutions objectives an abnormality within the african context it is the abnormality and dysfunctional issues in liberal knowledge production in africa that this paper engages with and seeks answers to the paper is divided into six sections the first is this introduction followed by attempt to situate knowledge production between globalisation and decoloniality the third section examines epistemicide and the disarticulation of knowledge in africa and the following section looks at african scholarship towards knowledge production the next section presents the drivers of knowledge production systems in africa while the final section provides a conclusion by examining the possibility and feasibility of africa breaking the dominance of western knowledge production in a globalised world situating knowledge production between globalisation and decoloniality establishing the linkages the idea of globalisation references the interconnectedness of economies states and cultures it is a process that connects and integrates people governments and other nonstate actors while primarily economic in nature globalisation is driven by liberal ideas and knowledge of how the world should be shaped this fits in with nazombes definition of globalisation as the interlocking of national economies into an interdependent global economy and the development of a shared set of global images this set of global images is conditioned and promoted by western values and ideas that are taught and instilled in western and nonwestern societies as natural orthodox knowledge production systems the direct relationship between globalised economic systems and dominated african knowledge enterprises is best seen in the works of harvey who believed that land dispossession lies at the root of capital accumulation while land dispossession and forceful occupation of african societies were the initial efforts of globalisation in africa continued economic exploitation of african economies has been made possible by dominated african epistemologies through western knowledge production in africa in view of the history of africa concepts such as colonialisation decolonisation and decoloniality reflect the lived and shared experiences of africans colonialism as used in this study refers to a forceful subjugation and occupation of a territory by another state or political power which imposes its will and administration on that territory known as a colony in knowledge production colonial authorities imposed their preferred method of education on the colonised territories principally through western missionaries and colonial administratorspaid educators decolonisation is needed to eradicate the effects of colonialisation therefore decolonisation involves doing away with the structures values and vestiges of colonialisation it is apt to state from the onset that issues of colonialisation and decolonisation are steeped in controversy and are affected by ideology race culture history and knowledge this is in turn affected by different societal nuances and mediations that shape the conception and production of knowledge however decoloniality goes beyond decolonisation as it argues that coloniality still exists must be understood in its modern form and must be dismantled for the global south to develop associated with mignolo the concept of decoloniality has come to be associated with various structures forms and vestiges of coloniality that continually shape african images of self identity and memory therefore decoloniality is born out of a realisation that ours is afolabi globalisation decoloniality and the question of knowledge production an asymmetrical world order that is sustained not only by colonial matrices of power but also by pedagogies and epistemologies of equilibrium that continue to produce alienated africans who are socialised into hating the africa that produced them and liking the europe and america that rejects them while decoloniality does not subscribe to a single school of thought it is however premised on three ideas first is the concept of coloniality of power this explains the construction of the current global political order and the international power structure second is the idea of coloniality of knowledge that interrogates epistemological issues knowledge generation politics and the source basis and purpose of knowledge third is the idea of coloniality of being emphasising questions of who an individual is subjectivity versus objectivity colonised versus coloniser with answers in the negative for africans this negativity is seen in the commodification objectification of africans within the global production system of knowledge economies and development decoloniality seeks to epistemologically transcend decolonise the western canon and epistemology decoloniality is a platform and indeed an africanist agenda that seeks to transform various methods pedagogies and sociocultural influences that render africans secondclass citizens in a globalised world epistemicide and knowledge disarticulation in africa every tribe race and nation has its own epistemic foundation on which its values ideas and educational systems are founded whether called traditional or modern valuefree or valueladen the reality is that each society is run based on the knowledge system to which it subscribes but that is more theoretical than practical in africa through formal colonialism and informal coloniality western knowledge system dominance has resulted in the debasement and near extinction of african knowledge systems indigenous knowledge systems in africa have been relegated to secondclass because of western pretensions about epistemic diversity and the insistence on its knowledge system as being scientific universal and monolithic for achille mbembe the western knowledge system is encased in the eurocentric canon that attributes truth only to the western way of knowledge production it is a canon that disregards other knowledge traditions the western knowledge system views african knowledge production as primitive barbaric and descriptive the effect of this has been to downgrade african epistemologies during the colonial era and through what we have earlier referred to as the coloniality of knowledge to actively create knowledge disarticulation in african knowledge systems disarticulation of knowledge or knowledge disarticulation occurs when the main activities of knowledge and its end products such as enlightenment and development are contradictory to and divorced from learners social realities in most cases disarticulation of knowledge results in irrelevant knowledge that is disassociated from the needed trajectories of development in africa disarticulation has continued apace as african studies frequently neglects to conduct serious investigations into the origins of disciplines into epistemicides into how knowledge has been used to assist imperialism and colonialism and into how knowledge has remained euroamerican centric endogenous and indigenous knowledges have been pushed to the margins of society africa is today saddled with irrelevant knowledge that disempowers rather than empowers individuals and communities beyond this is the argument that the relational dichotomy that colonialism and imperialism has engendered has not only been racial and psychological but produced a class structure that is not only well developed but also found among africans of different classes influenced by access to and cordiality with coloniality and imperialism epistemological foundations in africa were also destroyed by the continuous denial of the suitability and usefulness of african knowledge systems enforced knowledge production became the acceptable way of life through cultural assimilation and the labelling as unscientific of indigenous knowledge systems this created a colonised power of knowledge relationship where the values and ideas of euroamerican systems were in an asymmetrical superiorinferior nexus with african systems having created this demarcation between possessors of knowledge and ignoramuses through the force of conquest an unequal relationship developed and has been nurtured by acts of neocoloniality it was easy to demonise and condemn other knowledge bases as irrelevant bad and in many cases superstitious this rhymes with hall and tandon who posit that the act of creating oxford and the other medieval universities was an act of enclosing knowledge limiting access to knowledge exerting a form of control over knowledge and providing a means for a small elite to acquire this knowledge for the purposes of leadership of a spiritual governance or cultural nature those within the walls became knowers those outside the walls became nonknowers knowledge was removed from the land and from the relationships of those sharing the land the enclosing of the academy dispossessed the vast majority of knowledge keepers forever relegating their knowledge to witchcraft tradition superstition folkways or at best some form of common sense afolabi globalisation decoloniality and the question of knowledge production the evils of disarticulating african knowledge systems are still prevalent today as african traditional philosophies are seen as inferior as well as viewed with suspicion and disdain by mentally colonized africans and the west this shows the importance of decoloniality to africas emancipation from its dominated position in a globalised world the economics of globalisation have played a prominent role in maintaining the epistemicide of african knowledge and its usefulness even when efforts are made to challenge the epistemic enterprise of western scholars by launching a philosophical inquiry into the usefulness of all knowledge systems such efforts are rebuffed by both local intellectuals who are ignorant of the dynamics of the power relations of knowledge between the global north and south and by western scholars who describe such efforts as unscientific lacking in universality and therefore substandard african scholarship towards knowledge production it is noteworthy that knowledge production is not all about gloom and a bleak future africans have contributed immensely to charting a new course in knowledge production discourse within the continent this is evident in the abundance of scholarly works on african knowledge production there is a plethora of scholars committed to the pursuit of indigenous production of knowledge including the late abiola irele ngũgĩ wa thiongo and simon gikandi some academics believe that the turning point for african knowledge production happened at the time of the meeting of worlds in which one subordinated or eviscerated the other hountondji believes that the shortcomings of scientific and technological activity as practiced in africa today can be traced back to the history of the integration and subordination of traditional knowledge to world systems of knowledge olufemi corroborated this saying that knowledge production existed in nigerias remote past before the advent of the alien historical movements which disrupted their capacity for autochthony autochthony here denotes the condition of originating knowledge in a natural setting against this background it is established that the mode of african knowledge production is not a new or emerging concept some contributions of african scholars to the production of african knowledge are discussed below pio zirimu and austin bukenyas orature the term oral literature denotes forms of oral art such as folktales epic poems songs myth spells proverbs riddles etc which are transmitted orally ugandan scholar pio zirimu and his student austin bukenya coined the term orature in 1977 to describe the use of utterance as a means of literary expression this presupposes that literature is fluid and can be verbal pio zirimus contributions to the production of african knowledge are also evident in his efforts to bring about the curricular legitimation of african literature as an academic discipline at the makerere university in uganda micere githae mugo african orature and human rights in her 1991 paper micere githae mugo attempted to establish a nexus between african orature and human rights mugo believes that orature is a tool used by africans especially peasants and workers and is the product of a socioeconomic and philosophical environment she uses the agikuyu people of kenya as a model to explain the composition and structure of orature and the emergence of human rights she uses the example of the right to education and connects it to how nonformal education employed orature as a medium of knowledge transmission the basic argument in mugos paper is that orature conveys the human experience which also includes human rights concerns chiekh anta diop precolonial black africa a comparative study of the political and social systems of europe and black africa from antiquity to the formation of modern states diops book is a magnifying lens through which africa can be reimagined outside of the colonial gaze the book decolonises the history of africa while stressing that africa is not a product of western imperialism it offers instead an africancentred gaze into the narratives of precolonial africa and its societal structures in which great kingdoms of mali songhai and ghana were urban centres of civilisation what diop has done is to construct the evolution of african history in tandem with european history this is monumental because african history has always been in the shadows of the west and is almost always a victim of eurocentricity the caste system as conceived by diop can be likened to the european bourgeoisie and proletariat system or that of feudal lords and the serfs the difference in the african caste system and in its european counterpart was that the superior caste had a duty towards the lower caste in which they were not expected to materially exploit them ngũgĩ wa thiongo decolonising the mind the politics of language in african literature ngugis book marks his final departure from writing in english the central theme of the book is language ngugi believed that language has a dual character it is a means of communication and also a carrier of culture and both are products of each other language particularly through orature carries culture and culture carries language with both transmitting the entire body of values by which we come to perceive ourselves and our place in the world african languages have long assumed the role of the other in relation to the english language which has become the standard of communication between and among cultures in african society many individuals who received their education in africa can attest to the depiction of african languages as vernacular in relation to the english language ngugi believes that language the english language is a legacy of colonialism ngugis book is persuasive in its message of decolonising language in the african setting but it also provides a deeper understanding of how in the past the colonial languages drew an invisible barrier between the colonialists and africans and how in the present that barrier exists between educated literate africans and those who cannot read write or speak in those languages while accepting the importance of ngugis return to his linguistic roots one is tempted to ask if in doing so he is not also marginalising other africans who cannot understand his gikuyu language additionally will he not also run the risk of having his writings decontextualised in the process of translation to english biodun jeyifo the nature of things arrested decolonization and critical theory biodun jeyifos work focuses mainly on the emergence of african literature as an academic discipline and the traditions of critical discourse on african literature which we have inherited the traditions whose premises frames of intelligibility and conditions of possibility have been yoked to foreign historical perspectives jeyifo writes that a decolonisation of african literature has taken place in which african literature has emerged from the woodwork into the academic curriculum in african universities and schools however this has led to the emergence of two distinct groups of scholars the nationalists and the africanists the nationalists emphasise extraliterary and nonliterary concerns and argue that african literature has to go through a threestage process where it takes on an apprentice role in european traditions protests romanticisms and idyllic nostalgia and a revolutionary phase of fighting literature the africanists on the other hand are ideological and are concerned with objectivity rigour formalism and literary norms of evaluation jeyifo writes that the africanists have become the purveyors of african literature and that african literature emerging from the decolonisation processes has mostly catered to the foreign gaze as simon gikandi attested in an interview with brittle paper african writers living in africa often believe that validation of their writings must come from outside not from within the continent arjun appadurai disjuncture and difference in the global cultural economy arjun appadurais essay looks at the world through a single system with complex subsystems he believes that the problem of globalisation is the tension between homogenisation and heterogenisation appadurais global world consists of five main scapes of global culture which are interdependent and influence each other in fundamental ways ethnoscapes technoscapes finanscapes mediascapes and ideoscapes each scape appadurai believes represents a particular dimension of global flows which are at the same time disjunctive interdependent and interrelated the term ethnoscapes describes the flow of ethnicities technoscapes refer to the flow of technology finanscapes looks at the fluidity and flow of capital mediascapes and ideoscapes describe the flow of images symbols and ideas in the context of entertainment and enlightenment respectively however unlike the three scapes mediascapes and ideascapes build on the disjunctions of the others the flows are not only disjunctive but also chaotic in character vy mudimbe the invention of africa gnosis philosophy and the order of knowledge mudimbes contribution to african knowledge production is his famous work the invention of africa which examines the foundations of african philosophy as constructed by the west and appropriated by african critics and scholars within the continent the book poses fundamental questions what does it mean to be african is philosophy an african concept over the course of five chapters he traces the history of african religion and philosophy from herodotus to western history missionary rhetoric anthropology and contemporary developments his major thesis identifies african philosophy as gnosis that is methods of inquiry and knowing which emphasise a higher and esoteric knowledge under specific procedures for its use as well as transmission he challenges the western discourse by western and african scholars on african worlds which attempts to distort african modalities through the use of nonafrican languages henry odera oruka sage philosophy indigenous thinkers and modern debate on african philosophy this project analyses the role of individual thinkers in the historical development of african thought for oruka sage philosophy is the expressed thoughts of wise men and women in any given community and is a way of thinking and explaining the world which fluctuates between popular wisdom and didactic wisdom the folk sage represents the former while the philosophic sage is a symbol of the latter orukas work is geared towards the preservation of african indigenous thought which is why he separated the philosophic sage from other sages he believed that the philosophic sages are the reservoirs of the indigenous intellectual integrity of african heritage what oruka has tried to do is decolonise the concept of philosophy away from the western thinkers and to show that african philosophy and philosophers have always existed it might be reductive to limit sage philosophers to the preliterates in the traditional community does it mean that an educated african philosopher does not qualify as a sage because of hisher western links simon gikandi african literature and the colonial factor simon gikandi offers an extensive overview of the interconnectedness between african literature colonialism and decolonisation gikandi writes that modern african literature is a product of colonialism this is because modern african writers who established the tradition of what is known as african writing both in indigenous and european languages were trained and nurtured by colonial institutions gikandis essay highlights the existence of premodern african literature which did not come in contact with colonial institutions these existed in oral literature or better put orature and precolonial writing in arabic swahili and other african languages gikandi believes that this points to the existence of a thriving literary tradition in precolonial africa however modern literature which is now considered the heart of african literature has its identity tied around the traumatic encounter between africa and europe why is it so founders of modern african literature were not only trained by colonial institutions they were also colonial subjects and this informed their worldview this is why colonialism and decolonisation has occupied a central theme in african literature discourse globalisation coloniality and drivers of western knowledge production systems in africa it is necessary to point out that the western knowledge system has its drivers in africa and many parts of the global south without which it could not have been sustained this as explained is referred to as coloniality or neocolonial structures and values in the continent after africas socalled independence the structures and values of coloniality come in different forms and include sociocultural associations such as the commonwealth for anglophone africa and communauté français for francophone africa this is in addition to other westernled financial and economic organisations to which africa belongs in the beginning colonial authorities imposed their preferred method of education on the colonised territories we talk of the colonisation of knowledge or western education in africa after independence as being the basis of neocolonialism in africa the period after independence has since metamorphosed into the continuation of dominance through the production of western values and knowledge the neocolonial dominance of the west over african knowledge production has continued and even accelerated due to globalisation in a number of ways especially in africas ivory towers the following are the drivers a journals and publishing firms are classified and rated in a way that imposes western and capitalist standards the works of nonwestern scholars that do not meet these ideological standards that is works that are critical of the west and put forward a socialist perspective are often rejected for publication on the basis of nonconformity with the journals ethos b the preference of some foreign institutions to establish african research institutes and centres outside africa mostly headed by nonafricans these institutions often hide behind unfounded superiority over african research centres believing that the generous funding they receive from their home countries gives them the platform to dictate how knowledge is generated produced and used on the continent c research funding that creates incentives to produce knowledge that does not understand nor proffer solutions to african realities often such knowledge production is out of touch with africas needs in terms of poverty alleviation reducing child and mother fatality development communal cooperative economic growth and space for africas own thinking d reliance on western research methodologies that are tools of gatekeeping much of the data generated using western developed tools are adopted and used uncritically in africa for instance scholars in africa have used western knowledge production methodology ethics which fail to take cognisance of african cultures and peculiarities such as communalism and extensive social networks this renders it unable to provide useful explanations of and solutions to africas problems e methodologies that are inappropriate for understanding african problems through faulty researchdata gathering methodologies that miss the cultural linguistic and conceptual contexts in africa this includes the problems of language teaching communication abstraction and interpretation western methods of gathering data communicating and imparting knowledge present a challenge in essence these drivers have served to sustain the structures of coloniality or neocolonialism in africa however more than this is the realisation that the solutions put forward by western knowledge production systems by western scholars and their african academic collaborators are often ideologically coloured and bear little or no resemblance to individual and social realities solutions prescribed and offered are mostly unable to address africas problems as they are out of touch with african realities they therefore provide little or no solution towards africas development in knowledge production this failure is traceable mainly to the adoption of western curriculums its methodologies and the teaching of these in african universities the interlink between the old colonialism and the modern ways of dominating africa and much of the global south through coloniality has served to ensure and preserve the continuities between the colonial and the postindependence periods through the commodification of knowledge and objectification of humans outside the western knowledge systems hence neocolonialism coloniality points to a new form of colonisation that is maintained even after colonies gained formal independence old colonial powers continue to dominate former colonies in economic political cultural and educational spheres with the aid of globalisation that has tied african economies to the dictates and influences of the western economies in what could be argued is an associated dominated relationship the associated dominated relationship only permits knowledge production that reflects the west dominant epistemologies and not africas dominated and much deride philosophies africa in a globalised world concluding remarks as earlier pointed out decolonisation has to do with the conscious and deliberate dismantling of colonial structures and values while decolonisation of knowledge is at the core of this endeavour neocolonialismcoloniality is maintained through the continued teaching and production of western orthodoxy therefore the question of africa reviving its fortunes and breaking free from the stranglehold of western knowledge systems raises the issue of the possibility seriousness and restructuring of knowledge production platforms in africa to answer the question of whether africa can break from its dominated state one would first need to acknowledge the dominated state of the continent in a globalised world second we must acknowledge the continued coloniality of self knowledge and identity the seriousness of this quest it appears to be modest as most of the issues of knowledge production are buried in the politics and economics of survival these modest signs of serious intent diminish the prospects of restructuring with african governments devoting less than 3 per cent of their combined budgets to education it is not yet uhuru more worrisome is the lack of government investment in and commitment to education and knowledge production through research encouragement and funding there is however some hope of the possibility of engaging in epistemic discussion of the havoc wrought by western knowledge systems on knowledge production in africa with the epistemic pursuits of why and how knowledge is produced on the continent while south african universities and colleges have imbibed this possibility and have focused on decolonisation particular on decolonising the curriculum there is not much activity in this regard in other african countries the decolonisation effort in reshaping the curriculum in south africa is both welcome and desirable but examined deeply even this amounts to a scratch on the surface as implementation is poor beneath this effort are questions of what is taught what we learn as well as the question of how we learn and researchthe question of methods methodology and research ethics these questions are germane to as seek a decolonised knowledge production in africa the efforts by african scholars and writers in engaging in and espousing various ideas of indigenous knowledge production is a step in the right direction and showcase robust african interventions in the decolonised knowledge production debate when thinking about decolonising methodology we need to consider methods of gathering data teaching environment and language of instruction for example is the classroom setting the best space to impart knowledge given the superiorinferior teacherstudent relationship indeed the globalised practice of teacherstudent hierarchy as an economic transaction of sellers and buyers in the stratified marketplace of knowledge has denied access to many africans who do not have the economic power to transact money for knowledge such individuals have been alienated from the process of selfdiscovery and knowledge acquisition by the monetised nature of western knowledge production systems greater still for those who can afford it or who have been afforded the opportunity of education the knowledge acquired has served to alienate them from their african roots through epistemicide and incomplete eurocentric knowledge that promotes western orthodoxy while demonising african knowledge systems as superstitious primitive and barbaric at present african languages are seen as vernacular and are taught as such to african students thus african languages as mothertongues are forbidden within many school premises at the pain of punishment especially in many primary and secondary schools across africa there is also the need to critically engage more in questioning the philosophical foundations of orthodox methodologies in africa for instance are western methodologies particularly ethnography appropriate instruments of data gathering given its noted problems of reliability validity and cultural relativism when we examine pertinent questions of globalisation and coloniality in africa as has been done in china and japan and in brazil in latin america then we can start the process of creating enabling environments and frameworks for knowledge production that are beneficial for africas development this should be the starting point of the discussion on africa disentangling itself from its dominated state in a globalised world the feat of decolonising african knowledge production systems is achievable and in fact present efforts in this regard can build upon past works in spite of the current situation on the continent introduction la fin de la guerre froide peut se lire sur le plan discursif comme un moment ayant mis fin à la camisole de la double pensée unique pensée universelle dont chaque camp voulait imposer la légitimité de son récitses récits ici et ailleurs cette double pensée se réfère à la confrontation idéologique que chacun des deux camps de lest et de louest a déployée entre 1945 et 1990 cette double pensée participait en fait à une confrontation entre des acteurs à lintérieur dun même monde « le monde atlantique » un monde dont la volonté de puissance imposait quil se mît en position de dominer les autres alors que planait sur le système international cette guerre froide se mettait en mouvement linitiative de contestation de ce monopole épistémique cette résistance épistémique dans le champ du savoir nest pas seulement le propre de ceux de la périphérie soit du sud nous en trouvons des traces aussi au centre michel foucault en retrace les linéaments lorsquil parle de la difficile tâche déchapper à hegel en cherchant à lévacuer du piédestal de la pensée philosophique en occident cette contestation proviendra des chemins de la pensée que vont emprunter les gens occupant une position de dominés et dont la voix était inaudible chez ces derniers ce travail a commencé dabord sur le plan politique avec la quête de lindépendance à travers lentreprise dénommée décolonisation sur le plan scientifique la décolonisation a commencé tôt dans le sud global avec des aléas divers dans cette trajectoire pour se défaire de « lodeur du père » plusieurs pistes se sont offertes et des voix se sont fait entendre de telles voix sont nombreuses en afrique comme celle de frantz fanon ngugi wa thiongo samir amin mudimbe etc en amérique latine comme celle de walter mignolo etc et en asie comme tshibambe propos sur un « bandoeng » épistémique celle de partha chatterjee ou de dipesh chakrabart les penseurs précités ont dégagé le diagnostic de ce malaise dans le savoir ce diagnostic va être lénonciation de « la captivité de la pensée » ou de « leurocentrisme » tandis que pour paulin hountondji le mal à extirper est « lextraversion de la pensée » « la colonialité épistémique » devient la camisole qui dans le champ du savoir enferme subrepticement le sujet colonisé dans des manières de faire qui le conditionnent et laffectent autant dans ce quil pense que dans la manière dont il pense ayant pris la mesure de cette « occidentalisation du monde » lafrique sest engagée dans cette tâche den sortir en sengageant dans un processus dynamique fait davancées et de rétropédalages en fait dans les années 1990 le conseil pour le développement de la recherche en sciences sociales en afrique à la suite dune entreprise de réflexion sur la décolonisation des sciences sociales en afrique a produit un rapport ayant un titre évocateur un programme inachevé lépithète « inachevé » donne la mesure de létendue de la tâche à entreprendre peuton subsumer le sort de lafrique sous cet inachèvement une telle passe darmes estelle une oeuvre qui prend des « chemins qui ne mènent nulle part » ce texte continue ce débat pour analyser ce que fait lafrique dans la quête de la libération dans le domaine de la production du savoir en sciences sociales ainsi nous voulons commencer par cerner la signification du savoir et de la production du savoir lafrique ne peut participer à la production du savoir que si ce savoir est nettoyé de la gangue qui en fait des « langages en folie » cet exercice de découverture du savoir est fait dans la deuxième section à la suite du courant de pensée de la décolonialité épistémique nous voulons démontrer que lafrique devrait se lancer dans ce travail libérateur tout en en appelant à un bandoeng sur le plan épistémique bandoeng en 1955 a été un moment fondateur dans la matérialisation de la solidarité et du réveil des peuples des « trois a » moment qui leur a permis de se faire entendre et de déclencher le combat conduisant à la décolonisation sur le plan politique ce qui constitue la matière de la troisième section la reconnexion entre les parties prenantes du sud global ne résout pas tous les défis sur ce champ du contrôle de la production et de la circulation des connaissances surtout quen cette ère de la globalisation digitale la production de la connaissance étend ses horizons tenir compte de ces limites fait lobjet de la dernière section de la production de la connaissance les mots et la chose en distinguant les mots de la chose nous voulons prendre la mesure du décrochage qui se crée lorsquà travers les mots on veut définir la réalité cette dernière peut avoir une densité que les mots ne sauraient rendre à leur juste valeur tâchons néanmoins de procéder au nettoyage conceptuel de ces deux expressions dont le contenu sétend actuellement questce que la connaissance et questce que la production de la connaissance pour rufus pollock « la connaissance est ici utilisée au sens large pour signifier toutes les formes de production dinformations y compris celles qui sont liées à linnovation technologique à la créativité culturelle et au progrès universitaire » 1 ainsi la connaissance élargit lhorizon du possible tel est le cas de linformation générée par la découverte et quon applique dans différents domaines de la vie comme en mécanique en médecine ou en informatique de même la connaissance concourt à laccumulation des matériaux théoriques et méthodologiques en tant quoutils de lacte du savoir la connaissance et le savoir participent en fait à un même socle étymologique en latin 2 considérant cette homologie des termes il nest que de passer à la définition de la deuxième expression celle de la production de la connaissancesavoir la production du savoir se déploie sous la forme des discours qui portent sur des objets et se dénouent en disciplines « formations discursives » développements « disciplinaires » tels sont les constituants de la connaissance du savoir ces constituants vont se manifester sous i une dimension instituée ii en ayant des dispositifs propres à eux et iii en recourant à des circuits dont les canaux vont se multiplier grâce à des kits « technétroniques » la dimension « instituée » du savoir découle du fait quen notre époque ce nest pas dans les bosquets que lon trouve le savoir ce dernier est produit à travers certaines institutions universitaires et non universitaires il y a actuellement une compétition dans la production de la connaissance entre les institutions universitaires et des institutions non universitaires comme les institutions financières internationales certaines institutions publiques ou privées et des organisations non gouvernementales aux étatsunis il existe des bureaucraties de recherche en fait des think tanks ayant pignon sur rue capables de produire du savoiraction cest le cas notamment de la rand corporation ou du council on foreign relations si le savoir est institué il est de bon aloi de retenir quil y a une catégorie de professionnels qui ont mandat de lénoncer et de le produire cette professionnalisation se manifeste par la création dassociations savantes tshibambe propos sur un « bandoeng » épistémique et de métiers de recherche lassociation internationale de sociologie lassociation internationale de science politique ou lassociation des études internationales 3 deviennent ainsi des organisations portées à conserver la tradition disciplinaire dans ses continuités et discontinuités la deuxième dimension du savoir renvoie à des dispositifs propres qui en sont des rampes ces dispositifs participent ainsi à des questions ontologiques méthodologiques et épistémologiques devenant des marqueurs pour chaque discipline et permettant détablir des passerelles entre diverses disciplines foucault en dit quelque chose lorsquil écrit « une discipline se définit par un domaine dobjets un ensemble de méthodes un corpus de propositions considérées comme vraies un jeu de règles et de définitions de techniques et dinstruments » cette dimension est liée aux modalités dexpression sinon de communication car le savoir produit doit se transmettre et cest en circulant quil joue son rôle la troisième dimension subséquente à la deuxième est relative à des circuits de communication et de circulation du savoir ces circuits deviennent de plus en plus complexes appuyés par des kits « technétroniques » que lon utilise dans la production et la circulation du savoir en cette ère de la digitalisation on produit le savoir lorsquon est capable de publier des livres et des articles dans des journaux évalués par des pairs à forte audience internationale on produit le savoir lorsquon le fait à travers des publications dont les auteurs bénéficient de partenariats de collaboration avec des chercheurs dautres pays ou dautres régions du monde enfin ces publications doivent être cotées non en bourse mais sur des sites propres ce qui va influer sur la visibilité de luniversité des notions d« effet dimpact » de rankings dindex de citations sont propulsées dans la littérature et donnent lieu à une compétition aveugle la recherche étant devenue une marchandise quon offre sur le marché « la scientométrie » et « lanalyse bibliométrique » deviennent ainsi des pratiques objectives dans le processus de la production de la connaissance dans cette « influence globale de la recherche » le rôle de langlais en tant que lingua franca du savoir est de plus en plus prégnant la production du savoir se résout dans des publications dans des revues avec des pairs évaluateurs 4 le syndrome de publish or perish devenu un cauchemar pour des chercheurs individuels dans les pays développés se répand à léchelle mondiale et sempare de la vie des universités et des nations si actuellement tous les chercheurs du nord et du sud sont engagés dans le savoir en sciences sociales à la production duquel ils sefforcent de contribuer il suffit de rappeler que ce savoir a dabord été produit quelque part pour quelque chose la découverte de ce lieu démergence des sciences sociales soit loccident permet de considérer que ce savoir nest pas neutre il a été et est au service d« une énergétique dun devenir » pour accompagner la volonté de la conquête du monde walter mignolo dit mieux quand à ce sujet il écrit que lémergence des sciences sociales en europe au cours du xixe siècle précédée par la pensée sociale européenne pendant le siècle des lumières est déjà largement connue et acceptée les sciences sociales se sont répandues dans le monde entier elles sont devenues les compagnes de lempire elles ont fait partie intégrante de la construction de la civilisation occidentale et de lexpansion impériale occidentale concomitante 5 ainsi considérées la connaissance et la production de la connaissance dans le monde globalisé continuent à soulever des questions sur la contribution de lafrique dans ce domaine et sur la pertinence de ce savoir dans laffranchissement et lempowerment de ce continent aborder ce questionnement conduit à parler de la « colonialité épistémique » des sciences sociales sortir de la colonialité épistémique état des lieux la colonialité épistémique est la gangue subreptice et silencieuse qui obstrue tout effort de développement du savoir et surtout de production du savoir dans les sciences sociales en afrique un savoir qui soit porté à éclairer la société pour son devenir assumé questce que la colonialité épistémique avant de répondre à cette question il importe de noter que cette expression est utilisée dans une synonymie avec les termes « eurocentrisme » « métrocentrisme » ou « pensée captive » tous ces termes renvoient à un même soubassement sinon à un même piège celui qui consiste à enfermer la manière de penser dans linterprétation du monde taillée sur la mesure déterminée depuis le siècle des lumières par les européens ceux du « monde atlantique » selon samir amir la colonialité épistémique est lexpression de leurocentrisme cestàdire « de luniversalisme tronqué des propositions offertes par lidéologie et la théorie sociale » pour lander le problème de leurocentrisme dans les sciences sociales ne réside pas seulement dans le fait que ses catégories fondamentales ont été créées en fonction dun temps et dune place particuliers et par la suite ont été utilisées de manière plus ou moins créative et rigide pour étudier dautres réalités… le problème réside dans limaginaire colonial sur lequel les sciences sociales occidentales ont construit leur interprétation du monde tshibambe propos sur un « bandoeng » épistémique les ravages de la colonialité épistémique sont importants sur les sciences sociales en afrique ils se manifestent par lempilement des asymétries sur le plan du savoir et de sa circulation dabord il se dessine une division du travail scientifique par laquelle une partition des tâches se met en mouvement à des chercheurs du nord revient la tâche de producteurs des théories et des méthodes ils bénéficient des appuis financiers de leurs centres de recherche et sont capables aisément deffectuer des recherches sur le terrain situé dans le sud global des chercheurs du sud on attend quils récoltent des données de terrain et quils appliquent testent sinon reproduisent des théories et des méthodes élaborées outreatlantique un autre versant de cette partition se lit à travers le fait que les chercheurs du nord peuvent écrire sur les pays du sud global et en devenir des experts rarement les experts du sud global peuvent publier sur des questions du nord et en devenir des experts écoutés ensuite il y a lieu de parler du silence que lon maintient sur lafrique lafrique est absente dans la problématique de la modernité à laquelle on pense quelle na en rien contribué un autre silence découle du fait que les grands auteurs euroaméricains sont indifférents aux auteurs africains quils ne citent quà peine dans leurs écrits alors que dans les écrits des africains cest la compétition sinon une course effrénée que lon fait pour citer des références des auteurs euroaméricains pour le cas de ces auteurs les top writers il suffit de rappeler michel foucault samuel huntington francis fukuyama qui citent à peine quelques auteurs africains 6 enfin il suffit de citer le piège de lenchantement créé chez les chercheurs du sud global en quête de publications dans des revues internationales bien cotées sur le plan global ce qui relève de leffet impact ces revues à lexemple des cahiers détudes africaines revue tiers monde archives européennes de sociologie review of international studies african affairs politique africaine etc appartiennent aux centres dominants du savoir situés dans le monde atlantique elles sont cotées par ceuxlà mêmes qui exercent subrepticement le contrôle hégémonique sur les canons du savoir position qui leur permet de filtrer les productions des prétendants et prétentieux chercheurs du sud global analysant le ravage de lenvie dentrer dans la cour des grands que lon trouve dans la communauté des chercheurs au nigeria omobowale akanle adeniran et adegboyega ont démonté cette mécanique dattraction que les publications extérieures payantes et prédatrices ont induite sur cette périphérie paradoxalement les chercheurs nigériens se font duper et naccèdent pas à des avancées significatives en fait de recherche tshibambe propos sur un « bandoeng » épistémique de lasie et de lamérique latine en asie comme en amérique latine les préoccupations de la quête de la décolonialité étaient au centre de la discursivité des intellectuels et des chercheurs cest en amérique latine que déjà dans les années cinquante raul prebisch élabore une analyse expliquant le sousdéveloppement du tiersmonde à laide dun cadre conceptuel du centre et de la périphérie ce cadre conceptuel sera récupéré par légyptien samir amin qui développera la théorie du développement inégal en asie des auteurs variés développeront des analyses pertinentes portant sur la remise en cause des généalogies des pensées occidentales étouffant les pensées et les récits locaux à ce sujet on peut citer partha chatterjee dont un texte sur our modernity sera publié conjointement par le sephis et le codesria un autre indien mérite dêtre cité il sagit de dipesh chakrabarty qui popularisa un courant danalyses portant sur la compréhension de la dynamique des exclus de la société quon dénomme les subaltern sudies ce dernier auteur a publié un livre fort intéressant intitulé provincializing europe « il énonce dans cet ouvrage la thèse majeure du mouvement subalterniste indien à savoir la mise en question de la prétention de leurope à gouverner le monde au nom de la raison universaliste et la nécessaire provincialisation qui en résulte cestàdire sa réduction au statut dune aire culturelle quelconque » des conversations stratégiques sur les savoirs entre les africains et les autres partenaires du sud global pour réduire les effets et les illusions du monde atlantique vont se multiplier et prendront les chemins de la coopération institutionnelle durable une sorte de commission tricontinentale 8 sera créée ainsi le codesria signera des accords de collaboration avec le conseil latinoaméricain des sciences sociales basé à buenos aires et avec lassociation asiatique des études politiques et internationales dont le siège est à kuala lumpur en malaisie entre le codesria et le clacso vont être organisées des activités scientifiques autour des thématiques qui conduisent à la tenue des conférences intercontinentales sur ce chapitre des initiatives mutuelles il importe de citer lappui qui sera apporté au codesria et à dautres platesformes du sud global engagées dans la décolonialité épistémique par un programme financé par les paysbas cest le sephis sur cette lancée il est tout indiqué de relever les percées que les intellectuels africains et du sud global ont réussi à faire en « pénétrant » les cercles du savoir dominant cette pénétration a été opérée lorsquen 2006 lassociation internationale de sociologie a organisé son congrès à durban cette épopée est narrée par sitas lorsquil parle de la détermination des sociologues africains à inscrire un agenda pour la mise en oeuvre « dun projet de sociologie globale de lafrique » portée et limites dun bandoeng épistémique bandoeng épistémique est déjà une réalité il est issu de la convergence objective de la communauté des chercheurs originaires des « trois a » cela explique les différentes initiatives que le codesria a engagées pour nouer des partenariats avec les pairs de lamérique latine et de lasie même au nord il y a ceux qui militent en sopposant à la colonialité cest le cas de sephis un programme financé par le gouvernement hollandais la mise en mouvement de ce bandoeng épistémique répond à une contrainte objective celle dégagée par gordon lewis lorsquil affirme que dans le processus de la décolonisation on ne peut réussir que si tous les concernés vivant dans cette situation se déterminent à agir ensemble et dans le même sens ce bandoeng épistémique a permis de porter haut le flambeau des formations discursives fustigeant la colonialité épistémique et en appelant à une décolonialité épistémique en vue des pensées alternatives ce « border thinking » traverse actuellement plusieurs domaines du savoir en relations internationales ou en sociologie en afrique dans la discipline des relations internationales leurocentrisme est encore lhorizon théorique incontournable que ce soit le concept de la souveraineté de la puissance de lintégration ou même de létat le champ constitutif de ces termes repose sur des « généalogies occidentales » excluant celles de lafrique de lamérique latine et de lasie cest la tâche à laquelle sattachent des auteurs différents comme amitav acharya yaqing qin et melisa deciancio deciancio a déconstruit le mythe sur lequel sappuient les études des relations internationales lorsquelles sappliquent à analyser les états de lamérique latine en sociologie les chercheurs du sud global ont élevé leurs voix et ont investi certains cercles où on parle de la sociologie à travers les voix des maîtres du monde dont ils tentent de contester la portée discursive cest le cas de archie mafeje mignolo sitas ou patel ils ont réussi à en appeler à un projet de sociologie globale de même ils ont réussi à faire inscrire dans des problématiques légitimes des questions concernant la vie réelle des peuples africains la prise de conscience de la nécessité de la décolonialité est évidente ce travail herculéen continue les limites de ce bandoeng épistémique découlent du rapport de forces dans léconomie politique internationale du savoir les ressources financières sont un ingrédient dont il faut prendre la mesure tshibambe propos sur un « bandoeng » épistémique avec la digitalisation dans lindustrie des écrits la dépendance technologique de lafrique a besoin dêtre corrigée lamérique latine se dote doutils de publications à travers tous les gadgets technétroniques pour un espace propre des publications sur le web avec des possibilités sur « lopen access » lafrique éprouve encore des difficultés pour avoir lespace dautonomie pour ses propres publications elle dépend en grande partie des partenariats scientifiques du nord conclusion la connaissance et la production de la connaissance évoluent dans un environnement dont la géopolitique du savoir démontre une partition des rôles entre un nord simposant constitué de plusieurs centres de savoir dominants et un sud global consommateur sinon reproducteur des idées dautrui cette situation se traduit par une colonialité épistémique sortir de cette colonialité est une tâche qui a commencé depuis longtemps cette tâche se déroule avec des aléas de toutes sortes mais avec détermination dans le sud global commencée en amérique latine et en asie cette résistance épistémique a trouvé des échos en afrique dont des auteurs ont entrepris la contestation de la persistance « des langages en folie » lorsque le codesria une fois créé soffre comme une plateforme de discussions et de production de connaissance il inaugure des synergies avec des platesformes dautres continents du sud global pour chercher à créer dautres lieux et espaces de production de connaissance ce bandoeng épistémique est en marche son épopée est en train de se dérouler avec des aléas divers la communauté des chercheurs africains cherche à jouer un rôle mais ce rôle trouve ses limites dans des contraintes financières et technétroniques la dépendance de lafrique sur ce double plan ne saurait lui permettre de se déployer de manière autonome dans le champ de la production de la connaissance mais lavenir est ouvert il appartient à lafrique dengager des moyens pour appuyer les ressources humaines qui sont nombreuses de sorte que les circuits de la production et de la circulation de la connaissance aient une énergétique propre à ce continent notes note 1 the author is aware that the term man is no longer an acceptable way to refer to humanity as whole because of its sexist and patriarchal implications among other reasons the term has been used in this article where it became inevitable and in the sense of capturing the idea of being human with no specific reference to a particular gender academic im

rtf attachments by email avoid excessive formatting of the text camera ready copies of maps charts graphs are required as well as the data used in plotting the charts and graphs please use the havard reference system authordate for referencing eg it is interesting to note that… the word for tribe does not exist in indigenous languages of south africa mafeje 1975254 it is essential that the references section lists every work cited by you in the text an abstract of 150 to 200 words stating the main research problem major findings and conclusions should be sent with the articles for translation into english or french articles that do not follow this format will have their processing delayed authors should indicate their full name address including email contact academic status and current institutional affiliation

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coupling human behavior urbanization and flood risk urbanization occurs as a result of two processes urban dynamics inside the city boundary and urban dynamics at the city boundary each of which is influenced by individuals behavior some individuals who seek housing prefer to live within the city boundary while others select newly developed housing in the suburbs therefore modeling these two processes is essential in understanding the role of human behavior in urbanization herein we develop a behavioral urban growth model that employs abm as a class of computational models for simulating the interactions between autonomous entities in the form of agents to investigate their consequences on complex systems and networks 28 our behavioral urban growth model consists of two submodels the relocating model which simulates the dynamics within the city boundary and the growth model which mimics the dynamics at the city boundary as illustrated in fig 1 these two submodels are connected through the supply and demand of the real estate market further information is given in material and methods section of the paper and in supplementary information as the interaction of sellers and buyers in the real estate market shapes the dynamic inside the city boundary the relocating model consists of three agents real estate agent seller agent and buyer agent the real estate agent provides an estimation of housing price using a hedonic price model 29 and assists the negotiation process between sellers and buyers this agent can capture the effect of flood risk on the real estate market by modifying the hedonic price model the seller agent is the other effective entity in the relocating model that participates in this process by providing housing options within the current city limit and adding them to the real estate market as available choices the seller decides to relocate or leave the study region with the aim to maximize its profit in this study we have not evaluated the effect of flood risk on the decision of the seller to relocate therefore the seller agent adds its housing unit to the market regardless of its intention the buyer agent is the third component of the relocating model accordingly buyers represent the households who seek housing that can maximize its expediency whether or not buyers consider the flood risk on their decision they decide where to locate according to two behaviors risknegligence and expected utility 30 individuals with risknegligence behavior do not consider flood risk in their decision as they may or may not be aware of such risk on the other hand individuals who take the expected utility attitude aim at maximizing their utility while considering future flood risk the information regarding modeling the behavior of real estate agent seller agent and buyer agent is provided in material and methods section the growth model on the other hand simulates the process of converting undeveloped lands at the city boundary to developed lands which causes the expansion of the community over time this process occurs as a result of interaction between developers and buyers in the real estate market hence this submodel implemented using cellular automata also consists of three main agents real estate agent developer agent and buyer agent each of which has been described in detail in material and methods section and supplementary information the developer agent can also show two types of behaviors developing under risk and developing without risk based on the flood risk and the expected return from buying undeveloped lands these behaviors are also comprehensively described in material and methods section using the aforementioned urban growth model we propose a framework that accounts for the role of urbanization influenced by human behavior on future flood risk the overall framework consists of fully integrated models behavioral urban growth flood hazard and policy implementation in this study we defined two potential nonstructural flood mitigation measures in terms of socioeconomic incentives these measures include policy i building new educational facilitates and shopping centers in the northern part of the city and policy ii creating green spaces and water bodies in the southern part of the city the details of each model and the aforementioned policies can be found in material and methods section using this framework effective nonstructural flood risk mitigation policies in terms of socioeconomic incentives can be devised that take human behavior into account such policies are more likely to be accepted by the community and will be more effective in shaping urbanization toward safer and less vulnerable areas to floods to the best of our knowledge this is the first framework that incorporates the urbanization dynamics both inside and at a city boundary this point will assist us in evaluating the role of human behavior in shaping urban growth explicitly and at a very high resolution model application the city of boulder shown in fig 2 was selected as the testbed of this study boulder is located in colorado which is among the states that have experienced a high rate of population growth from 2010 to 2020 boulder is an upper middleclass community with approximately 100000 inhabitants 31 home to a worldclass research university a mix of key industry clusters major government research facilities visionary entrepreneurs and a highly educated population boulder has experienced a significant urban expansion in the past halfcentury due to population and economic growth boulder is susceptible to flooding due to its geographical location on the eastern front range of the rocky mountains which contains many streams and creeks the citys assessment of exposure to flood risk reveals that there are about 10000 people and 3600 structures with an assessed valuation of 1 billion within boulders 100year floodplain 31 the city has imposed restrictive regulations in new development and redevelopment activities however the city is still expected to continue to grow as the population estimate for the year 2040 is about 123000 inhabitants if this growth occurs within floodplains it poses further potential risks by adding more exposure to floods and changing the floodplains current regulations do not restrict the redevelopment of properties within floodplains but do require suitable structural and or nonstructural flood protection however these properties would still be subject to flood damage from larger flood events that appear plausible under the effects of climate change in this study we estimated urban growth using the ca model according to the steps outlined in figure s4 in supplementary information effect of flood risk on behavior of driving agents in urbanization using the proposed behavioral development framework summarized above we seek to evaluate the changes in urbanization caused by changes in the behavior of the key actors as influenced by flood risk we first assess the effect of floods on the real estate agent to investigate how flood risk can change the housing prices in the market next we examine how vulnerabilities to floods influence buyers decisions on where to locate we perform statistical analysis to identify the factors that most influence buyers decisions on their locational choices finally we employ this information to identify policies that promote urbanization toward less vulnerable areas to floods in the community using socioeconomic incentives and effect of flood risk on the real estate agent as a first step we performed two sets of analysis examination of historical sale transactions from 2010 to 2020 to train the abm model prediction of the sale prices for 20202040 as illustrated in fig 3 these analyses were calculated by the real estate agent using the hedonic price model introduced in material and methods section the historical data revealed that the housing prices inside both 100year and 500year floodplains are lower than the housing prices outside the floodplains since the real estate agent behavior was trained based on the historical data future projections inside 100year floodplain are expected to reveal the same trend as shown in fig 3 the results of the historical analysis and the projection of sale transactions from 2020 to 2040 for housing inside the 500year floodplain are presented in supplementary information this fact raises a question whether these lower prices will ultimately promote settlement in the floodprone areas compared to less vulnerable regions which will result in rising flood risk this question will be answered in the upcoming sections effect of flood risk on the buyer agent we next performed analyses to assess how individuals decisions are influenced by flood risk with this aim we analyzed the buyers choices on a historical basis for the period of 20102017 under the two behaviors risknegligence and expected utility we calibrated the model for this period by comparing the actual sale transactions to the results from the model for this historical period to validate the model the buyers decisions for the year 2020 were estimated and compared to the actual sale transactions in 2020 the results of historical analysis of the buyer choices under these two behaviors are presented in supplementary information finally we calculated the projections of sale transactions for 2020 to 2040 illustrated in fig 4 to investigate how these interactions between buyer seller and real estate agents would affect the vulnerability to future floods as shown in fig 4 eastern boulder is more vulnerable to floods and this area is selected the most by risknegligence buyers due to lower housing prices inside the floodplains however the northern part of boulder is less susceptible to floods and this area is selected by most expected utility buyers even though housing prices tend to be higher table 1 summarizes the percentages of sales within 100year and 500year floodplains under these two behavior scenarios for the historical records and future projections these results show that when the individual decision is simply based on price implying risknegligence behavior it will result in more choices in floodplains and an increase in future flood risk because the housing prices in the floodplains are less than housing prices outside the floodplains this fact will increase the popularity of such housing within the floodplain policies such as buyout and acquisition would be more challenging for policymakers and local authorities to implement as shown in table 1 the projections of housing choice by buyers reveal that nearly 17 and 29 of the sale transactions under risknegligence behavior are inside the 100year and 500year floodplains respectively while these numbers decrease to 2 and 15 if the choices are made based on the expected utility behavior this means that if the individuals seeking housing are aware of the risk and make a fully informed decision having full knowledge about their choices and their consequences future flood risk can be mitigated since exposure will be reduced this information can be beneficial for policymakers to plan for enhancing the resilience of communities in floods as will be explained in the next section policy implementation as the previous analysis has indicated individuals make more informed decisions in their housing choices regarding future risks when they consider flooding consequences on their locational choices this will reduce the attraction of housing in those regions susceptible to floods therefore the local authority can perform buyout and acquisition with less social and economic consequences thus as a first policy toward enhancing the resilience of communities to floods buyers seeking housing should be informed about potential future flood events and the social and economic consequences that they may incur in the future this information can be provided through the real estate market or other educational programs there have been some initiatives that prove the effectiveness of such programs for example first street foundation a nonprofit organization that provides flood risk at us national level has collaborated with realtorcom a website that provides housing information to buyers this work has resulted in revealing housing information along with their susceptibility to flood risk to buyers 32 such initiatives could gradually increase the knowledge of people about the flood risk and its consequences in a buildings lifetime on the other hand when individuals adopt a risknegligence attitude toward flood risk they decide to purchase a home solely based on the housing price which simply represents a bundle of building and environmental characteristics acreage building age square footage number of bedrooms and neighborhood quality in this study neighborhood quality is defined as the accessibility of the area to highways education facilities city center water bodies and lakes parks and green spaces one may ask which of these features have a higher impact on the decision of individuals the answer can help planners to impose policies that are compatible with peoples behavior resulting in enhancing resilience in a community and using a bottomup policymaking process to protect future generations in flooding events the subsequent section will help to answer this question driving factors in buyers decisions to adopt policies that are compatible with human behavior we should have information about the factors that most influence buyers decisions on where to locate assuming that the buyers are not fully informed about the vulnerability of a property to flood risk they decide their housing location solely based on housing price using a risknegligence behavior explained in material and methods section the housing price is a bundle of bedroom numbers square footage acreage building age and neighborhood quality here we investigate the importance of each of these characteristics on housing price and consequently the buyers decision on their locational choices such information can help to adopt suitable socioeconomic incentives in less susceptible regions to shape the urbanization on creating sustainable communities and cities in floods accordingly we performed three statistical tests to find the relative importance of the aforementioned housing characteristics on the housing price the first statistical test is an analysis of variance to investigate the different weights that the critical featuresbedroom number square footage acreage building age and neighborhood qualityhave over the housing prices using eq explained in material and methods section and trained for the buyer agent the independent variables in this equation are excluded from the housing price model one by one and the change in the coefficient of determination which is a statistical measure indicating how much variation of a dependent variable is explained by the independent variable is determined the results presented in table 2 indicate that the neighborhood quality term has the highest impact on r 2 in other words the neighborhood quality term is more responsible for the housing price variation in comparison to the other factors considered above the second statistical test involves a 2d heatmap shown in fig 5 that indicates the correlation between the features influencing the risknegligence behavior of the buyer agent and housing prices as fig 5 illustrates there is a strong positive correlation between the housing price and neighborhood quality as found previously the next most influential variable is building age which has a negative correlation with the housing price it is interesting to note that square footage and acreage are only weakly correlated to housing prices the third and final statistical test is a principal component analysis a dimensional reduction technique used to reveal strong patterns in a dataset 33 in simple words pca is a method of extracting the most influential parameters in a dataset first the dataset needs to be standardized for overcoming scaling impacts and other features that may inaccurately affect the analysis second the number of principal components is calculated by drawing a horizontal line at an eigenvalue equal to one the number of components with an eigenvalue larger than one equals the number of main principal components the pca reveals that housing prices consist of two main principal components which are responsible for about 40 and 30 respectively of the variation in housing prices the results of this analysis are provided in supplementary information the pca analysis was used to construct the biplot graph illustrated in fig 6 in which the size of each vector represents the importance of that variable on the housing prices while the angles between the vectors describe the effect of each variable on the others smaller angles indicate a stronger dependence moreover the angle of each vector to the xand yaxes represents the importance of that feature on the main principal components figure 6a shows that neighborhood qualitydefined as accessibility to highways education facilities city center water bodies and green spacesis the characteristic among housing features that is most important to identify the dominant contributor to neighborhood quality among these terms we construct the second biplot graph illustrated in fig 6b using pca figure 6b shows that in rank order accessibility to education centers highways city center water bodies and green spaces are the most critical features impacting neighborhood quality effect of flood risk on the developer agent our next step is to assess how flood risk affects the behavior of the developer agent and how the policies extracted from the previous step can be applied in the future urban expansion of the community by the developer agent at the city boundaries to achieve sustainable development we evaluate the projected growth of boulder for the year 2040 under the four different development scenarios identified in table 3 and fig 7ad these scenarios are explained in detail in material and methods section these figures show that if the developer agent makes a riskinformed decision for buying undeveloped lands and converting them to developed lands she selects northern boulder instead of eastern boulder for future development due to a higher expected return since the lands adjacent to eastern boulder are more susceptible to floods moreover as the previous analysis of policy implementation has shown the most important factor governing household decisions as to where to locate is the neighborhood quality accordingly we define two policies to increase the neighborhood quality on northern and southern lands adjacent to the current city boundary that are less vulnerable to flood events based on policy i we build educational facilities as well as shopping centers in northern boulder policy ii focuses on building parks and water bodies in southern boulder projections for policies i and ii are illustrated in fig 7cd revealing that adopting these policies will direct the future development toward the northern and southern regions at boulder where are less susceptible to future flood scenarios table 3 also summarizes the percentage of each development scenario falling within the 500year floodplain these results show that if the developer does not consider the risk on the initial analysis it will result in the highest percentage of future development in floodplains and consequently increases the flood risk in the future discussion the framework developed in this study enables planners to investigate the role of human behavior in achieving resilient communities susceptible to floods through sustainable development this framework is a holistic toolset that helps a community to adopt risk mitigation policies that are compatible with human behavior such policies will be more acceptable to people than other nonstructural flood mitigation measures such as acquisition and buyout that require large social and economic investments the core strength of the proposed framework is the behavioral urban growth model which is the integration of the relocating model that simulates the dynamics of urbanization within the city boundaries and the growth model that mimics the urban expansion at the city boundaries this feature helps us to understand household locational choices table 3 percentage of future residential buildings that are inside the 500year floodplain scenarios percentage of growth inside the floodplains normal behavior 16 riskinformed behavior 7 policy i 5 policy ii 13 the analysis of the real estate agent has revealed that for the testbed used in this study the housing prices are lower inside the floodplains compared to the prices outside the floodplains leading to more sale transactions in the floodplains if the buyer agents exhibit risknegligence behavior such behavior increases housing choices inside the 100year and 500year floodplains to 17 and 29 respectively up to 2040 on the other hand if the buyers exhibit expected utility behavior to make riskinformed locational choices housing choices inside the 100year and 500year floodplains will decrease as much as 2 and 15 respectively this result emphasizes the need for educating individuals who are seeking housing about flood risk to different properties over time this will reduce the popularity of properties in areas susceptible to floods and allow policymakers and stakeholders to implement measures such as buyout and acquisition with less social and economic costs and political resistance neighborhood quality defined as the accessibility to green spaces water bodies highways education facilities and the city center favors areas leading to more choices by the risknegligent buyers in such locations neighborhood quality is most influenced by accessibility to education centers highways the city center water bodies and green spaces these findings encourage planners to adopt socioeconomic incentives according to this rank that promote urbanization in less vulnerable areas in floods leading to reducing future flood risk to the community one point to note is that this rank order may be different for other cities and the detailed proposed framework in this paper can be used to extract the most influential variables in people decisions on their locational choices and be imposed on the community as socioeconomic incentives to shape urbanization toward building resilient communities in floods finally the developer behavior at the city boundary itself can result in safer communities if flood risk is included in their estimation of their expected return all models have limitations and this model is no exception for example in this study we have not considered the geomorphological and hydrological changes in the region brought about by the combined effect of urbanization and climate change which could increase the extent of the floodplains 34 also to model the decision under risk we have assumed that the agents behavior is rational and make a fully informed decision about their locational choices future work will expand the current behavioral study to that of decisionmaking under limited information another avenue of further work could include the role of climate change and how repetitive floodinglearning by experiencemay affect the decision of households under risk finally the current study has been performed for the case of flooding as the dominant hazard in the region but we see no reason the current framework could not be expanded to other hazards as well conclusions in this study we have focused on investigating the effect of human behavior as one of the underlying factors that affects urbanization over time we also examined how perceptions of flood risk can change the decisions of individuals as to where to locate and what characteristics of a neighborhood entice households to make such decisions this information was used to weigh the merits of various nonstructural mitigation measures for flooding in terms of socioeconomic incentives to move urbanization toward creating sustainable communities that are resilient to flooding our proposed framework employs a behavioral urban growth model that uses abm to evaluate the effect of human behavior as influenced by urbanization on community vulnerability to floods the observations from our analysis addressed some of the longstated challenges in considering the human behavior factors that add nonstationarity in future flood risk and render employed disaster risk reduction measures less effective the results demonstrated when individuals make an informed decision about their housing choices housing choices inside the 100year and 500year floodplains are reduced by 2 and 15 respectively moreover under the proper socioeconomic incentives derived from the preferences of individuals on their housing choices the percentage of future urban growth of the community inside the 100year and 500year floodplains can be reduced from 16 to 5 by the year 2040 for the selected testbed in this study we aim that this study will initiate a dialogue in a new direction of quantifying the role of human behavior in flood risk assessment of communities our framework enables policymakers and local authorities to achieve a more accurate picture of the future of their communities to employ mitigation measures for protecting cities from flood hazard and to perform tradeoffs between costs and benefits of future land development in investing in sustainable and resilient communities material and methods behavioral urban growth model urbanization is the process of landuse change that is affected by the interaction of social biophysical economic and political entities 35 individuals behaviorsellers buyers real estate and developersand their interactions affect urbanization over time these behaviors can be influenced by perceptions of flood risk modeling human behavior and its effect on the built environment is a complex endeavor as individuals do not make decisions randomly but decide based on their knowledge characteristics and resources 36 the question that may arise here is that how we can model human behavior abm is a technique that can be used to simulate behaviors of autonomous entities and has applications in geographic and urban systems such as pedestrian modeling traffic simulation residential dynamics and urban growth models of cities and regions this modeling technique provides an opportunity to study the behavior of entities and their heterogeneity on urban systems and their role in shaping their environment 36 the employed behavioral urban growth model in this study uses abm to capture human behavior and its impact influenced by flood risk on urbanization over time this model consists of two parts relocating model which is responsible for simulating the dynamic of urbanization inside the current city limit and the growth model that mimics urban expansion at the city boundary over time these two models are connected through the supply and demand of the real estate market some buyers may prefer to live within the city boundary while others select new housing in suburban areas thus the presence of these two submodels is essential in simulating the urbanization process over time accurately relocating model this model simulates the interaction of real estate seller and buyer agents to assess how the interactions of these agents shape the dynamic of urbanization inside the city boundary to do so the real estate agent provides an estimation of housing prices using a hedonic price model 29 which is a function of the structural neighborhood and environmental characteristics as below the function h trans is assumed to be a linear function of different variables that range from housing charac teristics to proximity to amenities to hazard level the coefficients β are determined by ordinary regression analysis this function is trained using historical datasets from 2010 to 2020 the structural variables used in this model are building age bedroom number bathroom number and square footage the neighborhood and environmental variables considered are accessibility to highways green spaces water bodies city center educational facilities the sale transaction year and the existence within 100year or 500year floodplains as the simulation proceeds the successful transaction will be added to retrain the regression and reassess the coefficients to account for the dynamic of the land market and changes in the housing prices through the years the last two variables in table s1 fld 100 and fld 500 have been added to the hedonic price model to evaluate how the floodplain presence affects the real estate market after training the model with the historical dataset the real estate agent predicts the housing prices in every time step of the analysis this agent estimates housing prices with and without considering flood risk due to the housing location if it is within or outside the floodplains more details of the real estate agent can be found in supplementary information section 111 the seller agent is the other effective entity in the relocating model that participates in this process by providing the housing options and adding them to the real estate market the seller decides to relocate or leave the study region regardless of the incentives she aims to maximize profit for modeling the sellers behavior we need to calculate the number of sellers and the location of sale within each time step the number of sellers is calculated using the yearly number of historical sale transactions within the study region from 2010 to 2020 these numbers are used to determine the mean and standard deviation of a normal distribution then using the distribution characteristics we generate random numbers as the available housings within the market at any time step the location of sale is also calculated randomly from the available housing in the study region more details regarding the seller agent can be found in supplementary information section 112 the buyer agent is one of the most critical components of the relocating model accordingly a buyer is a household that seeks housing that can maximize its utility whether the buyer considers the flood risk on their decision or not she decides where to locate according to two behaviors risknegligence and expected utility these two behaviors are considered to account for a full range of possible actions from the buyer within the market risknegligence happens when a household does not consider risk when she searches for a property to buy this point does not mean that she is unaware of the risk in fact flood risk is not considered as a substantial factor when she wants to offer a bid price therefore their decision about the locational choices is limited to housing prices she forms a utility for a property based on hedonic analysis of sale price that is a bundle of structural and neighborhood characteristics 30 in this scenario the buyer utility function is calculated as below where x i is a vector consisting of housing characteristics that play a role in locational choices by buyers in this study this set includes bedroom number square footage building age and neighborhood quality neighborhood quality is the residual of the hedonic price model for each housing and is defined as accessibility to highways education facilities city center water bodies and lakes and parks and green spaces also a i is the coefficient of such characteristics that shows heterogeneity in the preferences of different people on housing features the summation of a i should be 100 indicating that variation in the sale price is considered in this way we can consider the heterogeneity in agent behaviors that can make the modeling approach more realistic the other behavior representative of household decisions under risk is expected utility initially this is based on the assumption that the economic actorshouseholdsmake a fully informed decision based on the perfect information they have for all of the available housing options in the region in other words expected utility is based on the assumption that households are fully rational agents then based on this theory it is assumed that the households form a utility expectation for each housing unit and they select the unit with the highest utility to reach their ideal preferences to consider the flood risk and decision under a risky situation the utility for a property in floodprone areas is calculated based on eq as below in this equation the coefficient of 025 accounts for the average insurance damage claims which is equal to 25 of the property values 37 this value serves as a benchmark for the average property loss in the case of flooding which households decide on their choice in buying the property moreover u 0l represents the utility of a property without considering the risk to consider the probability of the flooding in the average length of residence which is equal to 10 years in this study eq are used as below h trans h lnh trans β 0 n i1 β i x i u 0l a i x inorm u l 025 u 0l where p is the annual flood probability and n is the number of flooding that can occur within the residence length in this study we assume that each property can experience only three flooding events at most in their life then the utility for properties under flood risk is calculated based on eq as follows where in eq u nloss is a utility gain for a property for a specific number of flood events some details of the buyer agent have been represented in supplementary information section 113 the real estate seller and buyer agents in the relocating model interact through the negotiation process buyers and sellers set an expectation of their bid and ask prices to register a successful sale transaction these expectations should be within a specific threshold using the actual housing prices in the market the real estate agent will provide feedbacks for both buyers and sellers and help to achieve a successful sale transaction if the buyers and sellers stay in the market and experience unsuccessful sale transactions they adjust the expectations of their bid and ask prices to maximize their utility and their profit respectively comprehensive details of the negotiation process are explained in supplementary information section 114 growth model this model mimics the dynamic of urbanization at the city boundary resulting from converting the undeveloped to the developed lands and expanding the city boundary this process occurs because of interaction between the developer real estate and buyer agents the real estate and buyer agents are identical to the relocating agent model on the other hand the developer agent is responsible for providing the housing options as a result of buying undeveloped lands and covert them to developed areas to maximize its profit for modeling the developer agent behavior we use a cellular automata described in detail in supplementary information section 121 cellular automata is a powerful geosimulation tool that has been previously used to model complex geographical systems with nonlinear and evolving characteristics it uses a set of mapssuitability accessibility zoning and neighborhood mapsin a 2d spatial rectangular grid to calculate the transition potential as the probability that defines the evolution in time a transition probability vector is determined within each time step for each cell using the probabilistic function presented in eq 38 in which a t k is accessibility to the transportation network s t k is intrinsic suitability z t k is the zoning status and n t k is the neighborhood effect of the interested cell for landuse k at time t the parameter ϑ is the scalable ran dom perturbation number at time t calculations for these terms can be found in supplementary information section 121 here we modified eq to account for the role of developer agent as shown in eq in this equation the developer preferences are considered as a map adding to the set of suitability z accessibility zoning and neighborhood maps to examine the role of the developer agent and its preferences both in a normal situation and by considering flood hazard if the developer agent considers flood risk in its expected return where d t k is the developer map for landuse k at time t the process of assessing the developer map with and without considering flood risk and the model implementation is thoroughly explained within supplementary information sections 122 and 13 respectively flood hazard module the flood hazard in this study is measured by its frequency intensity and the extent of flooding known as the floodplain we use the coupled hydrologichydraulic analysis in the flood module of hazusmh 39 a loss estimation platform developed by the federal emergency management agency to calculate the floodplain characteristics for various flooding scenarios including 100and 500year return periods based on a review by banks et al 40 hazusmh was identified as the best tool for the flood damage assessment compared to other available tools such as mike flood water ride hydrologic engineering center flood impact analysis in addition tate et al 41 suggested that the results obtained from the default hydraulic analysis in hazusmh are suitable for regional analysis which further confirmed the suitability of using hazsumh in our study since we focused on regional analysis as well it should be noted that uncertainties in the floodplain characteristics calculated by hazusmh are large due to the simplifications in the model moreover changes in surficial geology and hydrology due to urbanization are not considered 11 some studies have quantified these changes by coupling more detailed hydrologichydraulic software such as hechms 42 and hecras 43 to landuse projection models however since the objective of this study is to investigate the effect of human behavior on urbanization and exposure to risk and to introduce a methodology for evaluating different nonstructural strategies in terms of socioeconomic incentives and landuse policies hazusmh is sufficient for our purposes p t k ϑ × a t k × s t k × z t k × n t k p t k ϑ × a t k × s t k × z t k × n t k × d t k policy implementation module in this study we focus on nonstructural flood mitigation measures in terms of socioeconomic incentives that are designed to be compatible with human behavior the behavioral urban growth model reveals information about the critical factors in peoples decisions on their locational choices this information is used to design socioeconomic strategies encouraging households to the safer location gradually with time as the developer agent is responsible for simulating the growth of the community over time the first two scenarios normal behavior and riskinformed behavior are considered to investigate the behavior of the developer agent behavior on urbanization additionally we define the policy i and policy ii scenarios according to the information revealed in the statistical analysis to be applied as the future development plans by the developer agent to shape the communities moving toward resilience each of the development scenarios is explained below • normal behavior this policy is designed to evaluate the developers behavior when the agent does not con sider the flood risk on their decision accordingly the developer preferences are considered using a map calculated by equations s6 and s7 this scenario simulates the situation where the developer agent does not consider the flood risk on how the city expands through years and how the developed areas are selected by buyers • riskinformed behavior this policy is defined to evaluate how the consideration of flood risk by developer agent will change the city expansion over time equations s6 and s9 are used to assess the developer map and expected return based on this scenario • policy i as the statistical analysis has revealed accessibility to educational facilities is the most influential aspect of buyers decision on where to locate after that commercial facilities highways parks and water bodies are important the most based on policy i we build educational facilities as well as shopping centers in northern boulder to promote urbanization in this direction these incentives will affect the suitability term of eq • policy ii policy ii focuses on encouraging urbanization in the southern part of boulder by constructing parks and lakes this will also impact this process by increasing the suitability of southern boulder where is less susceptible to flood events compared to eastern boulder again these incentives will affect the suitability term of eq data availability the data that supports the findings of this study are available from the corresponding author upon request the digital elevation model input for hazusmh software can be obtained from the landuse maps and geospatial information were obtained from the city of boulder and openstreetmap that are already provided in this study code availability the model components have been described in the paper and supplementary information the code required for analysis are available from the first author and corresponding author on request competing interests the authors declare no competing interests additional information

floods are among the costliest natural hazards and their consequences are expected to increase further in the future due to urbanization in floodprone areas it is essential that policymakers understand the factors governing the dynamics of urbanization to adopt proper disaster risk reduction techniques peoples relocation preferences and their perception of flood risk collectively called human behavior are among the most important factors that influence urbanization in floodprone areas current studies focusing on flood risk assessment do not consider the effect of human behavior on urbanization and how it may change the nature of the risk moreover flood mitigation policies are implemented without considering the role of human behavior and how the community will cope with measures such as buyout land acquisition and relocation that are often adopted to minimize development in floodprone regions therefore such policies may either be resisted by the community or result in severe socioeconomic consequences in this study we present a new agentbased model abm to investigate the complex interaction between human behavior and urbanization and its role in creating future communities vulnerable to flood events we identify critical factors in the decisions of households to locate or relocate and adopt policies compatible with human behavior the results show that when people are informed about the flood risk and proper incentives are provided the demand for housing within 500year floodplain may be reduced as much as 15 by 2040 for the case study considered on the contrary if people are not informed of the risk 29 of the housing choices will reside in floodplains the analyses also demonstrate that neighborhood qualityinfluenced by accessibility to highways education facilities the city center water bodies and green spaces respectivelyis the most influential factor in peoples decisions on where to locate these results provide new insights that may be used to assist city planners and stakeholders in examining tradeoffs between costs and benefits of future land development in achieving sustainable and resilient cities floods are among the costliest natural hazards and threaten the lives and livelihoods of millions of people worldwide 1 2 3 4 5 the annual cumulative losses due to various types of flooding are higher than those from largescale disasters such as earthquakes 6 the consequences of flooding are intensified by climate change and socioeconomic development urbanization as a direct result of socioeconomic development exposes more people and their livelihoods to risk 7 8 9 10 11 12 the united nations has projected that 68 of the worlds population will live in urban areas in 2050 compared to 50 in 2020 13 urbanization occurs mainly in lowlying floodprone areas due to accessibility to recreational facilities and agricultural development 14 therefore the interaction of more intense and frequent flooding events due to climate change with the increased exposure brought by urbanization may lead to catastrophic social and economic consequences in the future if not addressed 121516 as a result the united nations has emphasized the importance of sustainable development by building resilient cities and communities subjected to natural hazards including floods as its 11th sustainable development goals sdgs 17 people and their perception of flood riskcollectively human behavioris one of the most significant factors influencing urbanization therefore achieving sustainable development requires a comprehensive understanding of human behavior and its impact on flood risk 18 households real estate developers government and their interactions can create favorable or unfavorable socioeconomic conditions and consequently encourage

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introduction unemployment rates in british columbia canada have risen from 47 in 2019 to 75 at the start of 2021 12 although unemployment rates have slowly started to decrease towards the end of the year there still remains over 160000 people in the province struggling to secure employment 3 sustained unemployment is associated with a number of negative health and social outcomes including financial hardship labour market detachment social deprivation psychological stress mental health concerns and mental illness 145 conversely sustained employment can improve quality of life and satisfaction with life by providing individuals with structure security a sense of purpose and opportunity for increased social support and inclusion which collectively contribute to improved mental health and stability 4 5 6 moreover studies consistently show that despite experiencing numerous challenges and barriers to employment the majority of people with mental illness want to be working 7 8 9 10 in response supported employment programs have continued to expand throughout north america and worldwide 11 supported employment refers to the assortment of programs and services available to help people with disability secure competitive work 7 individual placement and support is an evidencebased supported employment model targeted specifically to help people with severe mental illness or disability obtain and sustain employment 12 13 14 to date ips programs are seeing greater employment outcomes compared to traditional vocational rehabilitation across populations with varying mental illnesses such as those experiencing depression ptsd psychosis andor schizophrenia 67 15 16 17 18 ips programs are also seeing greater employment outcomes across different subpopulations such as with veterans youth and individuals experiencing or atrisk of homelessness 151920 in addition to improved employment outcomes for this population there is evidence to suggest that ips programs also benefit a variety of secondary outcomes related to quality and duration of employment 17 however there is recognition that a fuller range of outcomes needs to be investigated given that those who experience mental illness are also likely to experience a range of other physical social and socioeconomic barriers that impede the likelihood of sustainable employment one of the core principles of the ips model is the intentional integration of employment services with broader mental health treatment 12 in canada the first point of contact for someone struggling with mental health problems is commonly their primary care provider 21 at this time it is not typical that employment status is a priority in the primary care setting despite the positive health and social outcomes associated with sustained employment 22 by integrating employment services directly within primary care patients may receive convenient access to a variety of healthcare and social service professionals such as family physicians nurse practitioners psychologists and mental health specialists occupational therapists and employment specialists who can work collaboratively to support their overall wellbeing although this integrated approach in primary care is promising for supporting populations with mental illness we are unaware of any research in this area notably within the canadian context 22 opportunity exists to understand the effectiveness of ips programs embedded within primary care to address the health social and employment goals of this population including those who may experience other complex barriers such as food and housing insecurity poverty trauma and low education and literacy in british columbia individuals who face a disproportionate number of barriers to employment may receive a designation by the government as persons with persistent and multiple barriers individuals with ppmb status have a persistent health condition and may experience any combination of other health and social challenges including but not limited to homelessness or risk to homelessness food insecurity unsafe housing and marginalisation as well as need basic skills or language training for employment readiness 23 a health condition may be physical or mental which includes any andor a combination of depression anxiety ptsd schizophrenia bipolar disorder and neurodivergence although the current body of evidence supporting ips has led to an increased call in the province to provide ips programs to help support our most vulnerable populations 24 how best to integrate and evaluate this service within existing health services is unknown study objectives our overarching objective is to contribute new knowledge of ips embedded within primary care to inform decision making and guide practice and policy related to employment supports for vulnerable populations across british columbia specifically our research aims are to 1 assess the effectiveness of the ips program for securing employment for individuals with ppmb status 2 assess the impact of individualized and integrated primary care supports provided through the ips program on health and social outcomes for individuals with ppmb status and 3 gain an understanding of the experiential process of the ips program from individuals accessing the program as well as from healthcare professionals and staff involved in its implementation materials and methods this is an ongoing prospective quasiexperimental study that will run for 18 months from february 2021 to september 2022 the evaluation is designed as a mixedmethods process that will assess the impact on employment health and social outcomes of the intervention links to employment is a novel supported employment program targeted at promoting the wellbeing of vulnerable individuals within metro vancouver british columbia a diverse city of 26 million people located on canadas west coast within vancouvers downtown core exists a neighborhood called the downtown eastside often described as a community with a complex set of social issues including high levels of substance use homelessness poverty and crime 25 our intervention includes those living in the dtes key features of the links to employment program include time unlimited services access to ips trained and trauma informed program staff embedded within a primary care team involvement of an integrated care team that includes clinicians located within the same primary care setting and ongoing focus on health and wellbeing simultaneous to vocational support continued consideration of environmental needs and mental and emotional wellbeing is also a critical component given the vulnerability of the target population by engaging a variety of professionals in a coordinated way including a vocational counsellor occupational therapist job developer case manager and primary care providers the program is able to provide greater integrated health services and supports to support individualized employment and health goals the links to employment program is designed to support complex populations primarily those who currently have little to low employment readiness throughout their entire employment journey this remains an unmet need for a large portion of those living or accessing services in the dtes for this population existing vocational services targeted to those with moderate to high employment readiness are not sufficient or effective sites the links to employment ips program is operating out of two central sites located within primary care settings the three bridges community health centre located in vancouvers central downtown area and the reach community health centre located adjacent to vancouvers dtes recruitment to ensure consistency in recruitment we have developed a recruitment protocol to engage clients in the ips program for the research study the initial introduction to the study is made through ips program staff who provide a brief summary of the study to their clients and seek permission for them to be contacted by research staff if clients are interested program staff also provide a copy of the detailed study information and blank consent form program staff them contact the research coordinator who will contact clients via their preferred method of communication within 1 week all potential participants have multiple opportunities to engage with the research coordinator prior to providing their signed consent a traditional or digital signature is accepted sample size sample size of participants will depend on the capacity of the ips program and client turnover within the program based on ips fidelity standards 26 we anticipate a 30client capacity at any given time as well as a 30client waitlist we expect to engage with a subset of these groups enrolling 1020 participants from the program and a comparable number of those waitlisted safety given the observational nature of this study there are no direct risks associated with participation as individuals will continue along their natural employment service trajectories while some of the questions included in the assessments may trigger negative feelings or discomfort for participants we attempt to mitigate this by providing a list of local mental health resources and contacts alongside each assessment as well as collaborating with their broader care team as necessary data collection given the complexity of the study population current covid19 pandemic public health restrictions and diverse nature of the research questions a mixedmethods approach will be used for data collection the quantitative assessments will be used to capture demographic characteristics about the population enrolled and waitlisted for the ips program as well as objectively measure their employment health and social outcomes over time the qualitative assessments will be used to capture a more indepth and detailed understanding of the experiential process including program feedback from those who received servicessupports through the ips program as well as those involved with implementation drawing from multiple sources for data is a form of methodological triangulation that allows us to investigate different but complementary aspects of a phenomenon to gain a more exhausted understanding of it 2728 for example through quantitative data we may learn that a participants levels of anxiety has steadily decreased over time through the complementary qualitative data we may learn what factors have contributed the most to the decrease in anxiety seen fig 2 below illustrates the study flowchart participants will be assessed at 4 points in time over the course of one year these assessments include a combination of surveys and interviews dependent on whether a participant is already enrolled in the ips program and has been receiving servicessupports at the start of data collection or whether a participant is just entering the ips program for those already enrolled in the program a baseline interview will be conducted by the research coordinator to allow participants to reflect on their experiences to date as well as provide estimated measures of their baseline wellbeing individuals new to the program will complete a baseline survey package consisting of 6 questionnaires that assess their general demographics employment barriers and health and social wellbeing after baseline assessments all participants enrolled in the study will complete the same research activities at their 3month 9month and 12month assessments should a participant elect to exit the ips program after securing employment or for any other reason they will continue to be assessed as part of the research study following the same trajectory of activities participants who elect to leave the ips program and the research before the completion of one year will be offered the endofstudy interview to ensure capture of their experiences to date should a participant be loss to followup we will be transparent in our data reporting and address the challenges and limitations when working with vulnerable and hardtoreach populations in all publications reports and knowledge translation materials in addition to data collection from those who participated in the ips program a subset of individuals who remain on the waitlist at 12 months will complete an assessment of their current employment and wellbeing all program participants will be compensated for their time receiving an honorarium for each research activity completed up to a total of 20000 canadian service providers involved in the implementation of the ips program will complete an openended survey there will be no compensation for this activity demographic data data on socioeconomic characteristics will be collected as part of the baseline assessment this information includes but is not limited to age sex at birth gender level of education language spoken ethnicity selfreported health condition and current living situation employment outcome the primary outcome of interest is the proportion of study participants who secure employment over the course of one year in addition to this employment quality and sustainability will be assessed through both quantitative survey questions and qualitative interview questions participants will be asked to provide detailed information about their employmenttraining and selfrate their employment satisfaction as well as have the opportunity to provide their indepth experiences and reflections around their current or past employment health and social outcomes secondary outcomes of interest include measures of both health and social wellbeing over time the gad7 29 phq9 30 cprom 31 reqol10 32 and swl5 33 are all established questionnaires with established psychometrics within this population that will be included as part of each survey package each questionnaire provides unique insight into the health and wellbeing of an individual the gad7 and phq9 are screeners for anxiety and depression respectively cprom is a measure of client recovery reqol10 is a measure of quality of life specifically for people with mental health challenges and swl5 is a measure of overall life satisfaction qualitative data to complement the employment health and social outcome data described above qualitative data will be collected from both 11 semistructured interviews and openended survey questions including questions about how ppmb status was determined program participants will have the option to complete their interview inperson over the phone or through the video conferencing system zoom service providers will complete their survey electronically the decision to use an openended survey rather than conduct interviews with service providers was based on the anticipated time commitment the selected approach allows for capture of indepth qualitative feedback with minimum disruption to workflow both instruments were developed based on existing evaluations for ips and the ips model and discussed across a multidisciplinary team to ensure contextual appropriateness the qualitative data collected will provide a better understanding of how the ips program was experienced and key strengthsweaknesses to its implementation as well as continued barriersgaps in supports sample questionsprompts from the interview guide for program par data analysis quantitative data will be analyzed using version 402 of r software a language and environment for statistical computing 34 descriptive statistics will look at the mean or median and frequency of demographic characteristics and employment health and social outcomes in addition chisquared tests and independentsample ttests will be performed to compare demographic variables such as gender and employment status for those who received ips program servicessupports compared to those who did not after one year and paired ttests or wilcoxon signed rank test to compare health and social outcome measures for program participants outcome measures at each of the 3 points in time following baseline will be compared against baseline and the previous timepoint to determine if there is a significant difference qualitative data will be analyzed using version 12 of nvivo pro 35 interviews will be audio recorded and transcribed with participant consent and thematically analyzed using an inductive approach 36 this will allow themes and significant ideasconcepts around barriersfacilitators and experiences to emerge from the raw data all analysis will be performed by at least two researchers to ensure consistency and minimize individual bias the emergent codebook will support a more deductive approach in future assessments of this program discussion there is widespread recognition and a strong body of evidence that ips is an effective approach for improving employment outcomes for those with severe mental illness 67 15 16 17 18 however there is limited literature on ips within the bc or canadian context and integrating this as a core service within health to support complex vulnerable populations with both their health and employment goals the majority of supported employment studies are based in the us and europe where different systems and infrastructures for care exist 1117 additionally the majority of studies have focused exclusively on those afflicted by a specific mental illness rather than considering the broad spectrum of mental illnesses that may be present in a highrisk and vulnerable subpopulation the context in which they receive and access services and their personal goals and needs this study is inclusive of any mental illness or combination of mental illnesses and considers changes in health and wellbeing an important indicator of employment readiness and future employment success as such this study includes a variety of interim outcomes not related to employment but rather employment readiness or general wellbeing lastly while supported employment programs are often integrated into a variety of community settings 7 this study will evaluate an ips program embedded within primary care settings which we hypothesize will allow for more intentional integration of healthcare and employment teams to work together in a systematic personcentred and strengthfocused perspective there are potential limitations to this study protocol first the study is quasiexperimental rather than randomly controlled given the known needs of the population in vancouvers downtown and dtes and pilot rct work led by our team there were ethical considerations around assigning highrisk individuals to traditional vocational services that are not designed for people with severe mental illness 37 and proved harmful to mental wellbeing during an initial pilot second measures of fidelity are not included as part of this evaluation as the program is newly developed and there continue to be revisions to its structure staffing and implementation given the correlation between high fidelity and employment outcomes 1126 fidelity reviews will be built into the evaluation process for future assessments for the time being our focus is on understanding the implementation process and organizational necessities for successful adoption of ips a number of implementation barriers that cut across the levels of government organization and program administration have already been recognized 738 through this study we hope to better understand the experiences of those directly involved with the program and its delivery to identify and address any implementation barriers that may be applicable within our local bc context the results of this study will be disseminated through a variety of different mediums targeted to our range of stakeholders and audiences knowledge translation activities include but are not limited to academic publications and conference presentations community and government reports community engagement activities including world cafe ´s and traditional medialsocial media activities in conclusion the novel findings from this research will provide insights into the impact and effectiveness of ips embedded within primary care this will contribute to ongoing strategies and practices for addressing the employment and wellbeing needs of british columbias most complex and vulnerable population additionally findings will be used to inform decision making and guide policy around employment supports at local provincial and federal levels writing original draft amanda kwan writing review editing jonny morris skye p barbic

employment improves mental health and wellbeing by providing financial security daily structure a sense of identity and purpose and social engagement however securing and sustaining employment is exceptionally challenging for vulnerable populations who experience persistent and multiple barriers such as mental illness homelessness food and housing insecurity and marginalization evidencebased supported employment programs most notably individual placement and support ips are becoming a more common approach for addressing the needs of these highrisk individuals the aim of this paper is to outline the protocol for evaluating an ips program in vancouvers downtown and downtown eastside dtes this prospective quasiexperimental study of persons with persistent and multiple barriers to employment will use a mixedmethods approach for evaluating a novel ips program the evaluation will consist of survey packages and interviews that will capture outcomes related to employment and wellbeing as well as the experiential process of receiving individualized and integrated supports through the ips program a mixedmethods approach is appropriate for this study as quantitative data will provide an objective assessment of program impacts on employment and wellbeing outcomes over time while qualitative data will provide an indepth understanding of continued barriers and experiencesthe results from this evaluation will contribute evidence within a local british columbian bc context that may increase access to meaningful employment for those with longterm

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background high blood pressure is one of the most important risk factors for death and disability in canada and globally 1 the cardiovascular health awareness program is a communitybased patientcentered hypertension prevention and management program targeting key modifiable risk factors and aimed at older canadians chap connects community resources with health system actors to improve participants cardiovascular health during chap sessions held in familiar settings such as pharmacies places of worship and other community spaces participants blood pressure is measured following hypertension canada recommendations and their cardiovascular disease risks are assessed trained volunteers help participants understand their risk profiles and provide information on locally available resources and support programs with participants permission bp readings and cvd risk profiles are shared with their physician 23 chap was previously successfully implemented and evaluated as a clusterrandomized controlled trial in 39 midsized communities in ontario and was associated with a 9 reduction in annual hospital admissions for acute myocardial infarction stroke and congestive heart failure 2 it has subsequently been adapted and implemented in multiple settings and for different populations such as interdisciplinary primary care clinics patients on a waitlist for a family physician ethnocultural minorities and younger people 3 4 5 6 recently chap was adapted to target older adults living in social housing buildings in ontario and quebec and its effectiveness is being evaluated in a crct 378 this adaptation of the chap program included for the first time groupbased monthly educational sessions aimed at increasing cardiovascular health awareness to promote healthy habits and selfmanagement among residents 3 older adults living in social housing represent a vulnerable population and are more likely to be affected by multiple chronic conditions such as cvd and diabetes 3 have more falls 9 and have poor health literacy 10 implementing a health promotion program targeting older adults in subsidized housing poses many challenges 7811 for instance program success could be influenced by the dynamics within each building depending on residents characteristics and turnover 78 previous chaplike initiatives in subsidized housing showed differences in participation between buildings ranging from 14 to 52 7 despite efforts and multiple followups high proportions of participants did not attend or were lost during the program 7 social network analysis has proven effective when applied to support health program implementation or policy making by describing relational dynamics in networks of community organizations 12 13 14 15 16 sna shifts the object of study from individuals to their relationships with others 17 initially developed in the 1930s sna methods rapidly proliferated in many research fields such as physics epidemiology public health and medicine 1718 several studies have shown that the effects of an intervention can vary according to the beneficiaries social network dynamics 13 19 20 21 22 23 which mediate whether people benefit from the program or not 121322 for example programs implemented by community members identified as opinion leaders have been shown to be more effective 132425 than programs offered by external organizations 142226 identifying wellknown and appreciated leaders from the community who influence opinion is crucial as their support is critical to successful program implementation 12 because of their deep understanding of their communitys dynamics and needs 12 13 14 they can serve as key informants to help adapt the program to the local environment and thereby have an impact on its sustainability 1214 identifying the wrong person as a key agent to implement a program can interfere with the programs benefits 1218 diffusion theory can help explain how new ideas and behaviors spread within communities and among groups 2728 in the fields of health education and health behaviors it has been applied to study how a new idea or practice penetrates 27 and spreads into a group 29 through interpersonal communication 28 and peer leaders 30 sna is thus ideally suited to evaluating the diffusion within a network of behaviors such as attending chap sessions 1317 despite its strong potential and obvious application to communitybased programs sna is not sufficiently used in communitybased program planning and evaluation yet it has the potential to shed light on why people attend programs in their community or not 12 13 14 the analysis of personal networks in relation to program participation is often neglected due to the difficulties of setting up sna 12 13 14 sna can generate a relational portrait of the environment 11 in which chap is implemented and help explain the effects of interpersonal interactions on differences in attendance across settings neighborhoods may play a very significant role for the older population 31 32 33 34 proximity and involuntary relationships appear to represent the main types of interactions 31 such ties appear to generate conflicting relationships particularly in or near poor neighborhoods in large urban areas 183135 thus rather than being a source of support some relationships can have a negative impact on a persons health 18 35 36 37 38 positive and negative aspects of neighborhood relationships produce distinct effects such as withdrawal and isolation or participation and feelings of belonging even when a relationship is a source of distress it may sometimes have positive aspects that can be an important motivation to maintain it 343538 in this context older adults will develop different proximity and distance strategies with neighbors 3134 by identifying interpersonal dynamics among residents of buildings participating in the chap program this study was intended to complement existing knowledge about the effects of social networks on the implementation of health promotion programs in the specific context of subsidized housing our aim was to better understand how such interpersonal dynamics can influence an individuals decision to participate in health promotion activities so that more effective recruitment strategies might be developed to enhance attendance to this end we used sna to evaluate whether relationships and social structures affected residents participation in the program and could explain the betweenbuilding differences in rates of attendance at chap sessions the specific objectives of this study were to 1 describe the dynamics of relationships among residents in subsidized housing who attended chap sessions and 2 examine the effects of these dynamics on program attendance rates methods research design social network analysis we aimed to describe the social networks in two buildings one with a low and one with a high chap attendance rate sna combines quantitative and qualitative research methods to study and measure relationships by analyzing different linksie who is connected to whomas objects of study 2639 the network data we collected were composed of several measures used to identify whether there was a person or a group who had the power of influence such as network opinion leaders or bridging individuals ie individuals who are instrumental in reaching disconnected subgroups 1840 we also used the network data to identify the diffusion potential of an innovation in a network 41 the qualitative data complemented the identification of leaders and clans but also provided information on interpersonal behaviors setting the implementation of chap in subsidized housing for persons aged 60 years and older was part of a crct in 28 buildings in quebec and ontario the present sna study was conducted in the quebec arm of the rct the chap sessions took place once a month in community rooms of the buildings participating in the program between september 2018 and june 2019 the 3h chap sessions conducted by volunteers trained in assessment protocols privacyconfidentiality and consent were supervised by a research nurse participants moved through a circuit of six tablesstations for bp measurement anthropometric measures and canr isk and cvd risk assessment all of which required 2040 min the remainder of the session consisted of groupbased educational activities in the form of workshops or conferences facilitated by different organizations or partners that addressed a different theme each month diabetes wellness paramedic services preparing for a visit to a family doctor chronic pain diet physical activity hypertension and pharmacy services participation in the chap sessions was voluntary and on a free dropin clinic basis in collaboration with the residents association or a volunteer living in the building all residents were invited via several recruitment strategies meetings with social housing representatives or with residents associations posters flyers doorknob flyers and automated telephone reminders 3 participation was defined as attending at least one chap session rates of attendance in quebec varied across buildings from 235 to 491 data collection the sna data collection was conducted between april and may 2020 ie towards the end of the programs implementation period two buildings were selected based on attendance rates and similarity in overall settings given that the building with the highest participation rate also had ideal conditions according to the literature we instead selected the building with the nexthighest attendance rate whose setting was more comparable to the second building all residents of the two selected buildings were eligible to participate for a total of 150 persons we informed residents about the study through posters and our presence at chap sessions and we recruited them directly at their door data collection was done at their apartment or in the community hall and lasted approximately 60 min per person the study involved two data collection phases quantitative and qualitative that were conducted concurrently the quantitative phase consisted of gathering data to examine each persons relationships to all others in their own building 4042 this methodology involved interviewing at least 25 of all building residents to ensure centrality measures as indegree group membership and total degree as indicators of network position 43 network information was collected through sociometric questionnaires developed for this study supplemented by coding grids indicating the names of residents identified by the respondent and the types of relationships to assess the quality of these relationships respondents were asked to designate each named person as a friend acquaintance neighbor or like family to identify opinion leaders and generate a portrait of the relational dynamics among residents respondents were specifically asked in relation to each named person about shared activities confidences advice or information service exchanges trust conflicts and other themes of potential interest 2425283742 44 45 46 qualitative data were gathered on relationships as well as on proximity and distance strategies between neighbors for this second phase we targeted our recruitment based on information from chap guided by the principle of content saturation 47 we aimed to interview five to seven persons from each of the following profiles 1 attended three chap sessions or more 2 attended one session only 3 did not attend any sessions the qualitative interviews were recorded and supplemented by coding grids topics covered included everyday life solitude loneliness and relationships with neighbors family friends and acquaintances because multiple factors can influence the establishment of ties with other residents such as the presence of strong external ties 3144 we included information on relationships outside the building in our analyses analysis for the quantitative phase the data were analyzed with ora using a structural analysis method 121337 this software measured clustering centrality and other significant network measures relevant to assess network dynamics the qualitative phase was subjected to thematic analysis 47 performed with nvivo using the deductiveinductive method table 1 summarizes the measures used for the analysis 242528404849 results from the two buildings 69 out of 150 residents participated in the study table 2 summarizes the respondents profiles maps of complete networks using the quantitative data to identify the people in their network and links with other known neighbors even if they were not close to them 4550 we mapped the connections for 75 of building 1 residents and 92 of building 2 residents the network maps of the two buildings present a type of visualization based on individuals positions in relation to each other their identification of leading individuals and the designations they attributed to other persons node names represent gender and number of chap sessions attended the maps in figs 1 and 3 illustrate the centrality of certain residents in the buildings and the distribution of conflicts persons in the center are those named most frequently by others in that building links in grey represent connections and links in red represent conflictual relationships with the named neighbor depending on the type of relationships residents identified from the coding grid these are persons they consulted when they needed information or services or wanted to attend building activities tables 3 and4 summarize the networks data for each building in the other two maps we removed the links representing conflictual relationships as well as the residents who did not attend chap and were not directly connected to someone who had attended these maps were intended to illustrate direct diffusion opportunities 25 between people in each building in the building 1 network configuration we could reach 59 of residents and in building 2 82 removing conflict links allowed us to identify the main actors of diffusion in each building table 1 network measures used for analysis measures definition proposed analysis or use indegree centrality sum of links received by an actor or number of times he is nominated by the members of the network divided by the total number of possible links a high percentage shows confidence and interest in this actor could help identify opinion leaders in each building total degree centrality sum of incoming and outgoing links of an actor divided by the total number of possible links a high percentage indicates that an actor is more likely to be in the flow of information and thus retain a central diffusion position group membership number of groups of which an actor is member this measure complemented the evaluation of an actors ability to diffuse informationbehavior social networks in building 1 the leader makes the difference in building 1 which had a relatively high attendance rate at chap sessions there were two clans a recent conflict between the leaders of these two clans had affected various activities including chap session attendance figure 1 shows that one leader had many red links one of which was with the other leader leader f0 did not attend any chap sessions because the other attended all sessions f6 was a clan leader with 232 indegree she attended all sessions which may have contributed to this buildings high attendance rate this leader position for f6 was confirmed after the conflict links were removed with a total degree of 284 for f6 and 017 for f0 in addition the indegree ranking indicated that four out of six members of clan 1 attended at least one session versus two out of six for clan 2 which illustrates the group influence of clan 1 on attendance the map of diffusion potential in the building 1 network configuration shows that the total degree remained high for leader f6 which means she remained a primary actor in diffusion and a key agent for the chap implementation social networks in building 2 the hidden bridge in building 2 which had a lower attendance rate the leaders had 327 indegree and did not attend any sessions again there were two main clans in this building the presence of conflicts indicated there were more conflicts around the central leaders than around the peripheral leaders the indegree ranking indicated that of the six residents from clan 1 five did not attend at all and one attended once in this network configuration we can see the total degree changes between the leaders and a chap participant who was not identified as central before conflict links were removed fm0 had 276 and f1 173 after conflict links were removed f1 rose to 195 and fm0 declined to 134 indicating that f1 was the most important person to promote program activities in this building this person was with m0 a primary actor of diffusion and a key agent for the chap implementation whom we should have involved in the program diffusion strategies thus f1 was a common relation to the two cited main leaders and represented a kind of bridge in this divided network proximity and distance strategies qualitative analysis showed that residents of both buildings adopted proximity and distance strategies in their relationships with neighbors to various degrees the first level of proximity strategies consisted of general polite behaviors theres this woman that i often chat with she likes to sit on one of the chairs in the indoor lobby downstairs whenever i see her there we wave to one another you could say that this is a kind of interaction yeah we greet each other and then maybe just say a few words nothing more most people appreciated greetings and respect for an acceptable noise level some were also willing to exchange services occasionally which put them in closer relationships with some neighbors especially those who were highly involved in the community andor members of the residents association and local leaders a greater level of proximity was also seen among those who had few 12 people with whom they regularly exchanged services and visits r sure sometimes ill just go there or sometimes we just help each other out in small ways for instance if i make a big batch of homemade soup i might bring some of it to neighbors who have done me a favor these are the kind of encounters i have q how about meeting for activities r no that hasnt happened proximity also took the form of shared activities and friendships well i know xy i see her pretty often especially when there are activities down below or whenever she walks her dog and then there are x and y who i would say are good friends they also demonstrated their connection by helping out in situations of illness or providing more substantial services during more serious illness rather than only helping in emergencies the highest level of proximity was to contribute to the community through volunteering or by serving on the residents association residents participated in different activities for a variety of reasons including socializing and forming new friendships however some did not need to participate in activities to rub shoulders with people some tended to become more involved because of others participation in the same activity yes i did go to the chap session once its the kind of thing i go to with x and his girlfriend i had asked them to come with me … because im not really all that comfortable going there alone yet once i get a better sense of whos there and how things are done ill probably go on my own but right now im still just checking it out respondents preferred to focus on the activity rather than on the majority of respondents also mentioned using distance strategies several reported that they only helped others in emergencies such as a power outage or a fall sometimes they charged for their services a widely used strategy was to avoid neighbors in common spaces sometimes they wanted to avoid a particular person with whom they had a conflict i try not to bump into her whenever possible for instance i avoid opening my front door when i know shes on the other side sometimes they adopted this behavior as a habit i go when i think no one is there but if i see someone i immediately turn around this strategy seemed to be used particularly to avoid conflicts or being judged im just afraid of making a bad impression on others because i worry about that a lot … so ive become really withdrawn as a result i cant stand conflict or engaging in gossip im just not the kind of person who wants to get close to neighbors gossip turns me off or even being caught in clans yes there can be tribalistic behavior here in fact thats the main reason why i decided to distance myself from people i had established relationships with reasons for conflict included noise divergent opinions personal attacks and gossip among others tensions also were created by personal attributes of certain neighbors such as negative behaviors or strong personalities sometimes due to medical conditions some conflicts were current while others had occurred in the past causing breakups and ending the mutual assistance that once existed such that some respondents were reluctant to form new relationships with neighbors these same reasons also explained the isolation of some residents many appreciated or were accustomed to solitude some also were visited by relatives who lived outside the building which influenced their withdrawal from neighbors and helped mitigate their loneliness however not all respondents appreciated solitude and some expressed distress regarding their relationships with neighbors maybe its because im not in a good head space right now … because you know i dont think im a bad person and i certainly dont mean anyone harm but i dont like how people treat me here … they remind me that im worthless or worse and so thats how i feel now worthless this portrait needs to be nuanced by the fact that it was not possible to classify respondents strictly into these two separate types of strategies the interviews showed a deeper ambiguity for example a resident might have helped a neighbor intensively during a certain period or been friends with them and afterwards avoided this person because the relationship had become timeconsuming or because a problem of trust or poor health had made the respondent unable to continue in some cases respondents used distance or proximity strategies or a mix of both in their daily life depending on their mood their health or the people they encountered on one hand i need to keep to myself and i need to live alone and on the other hand i dont want to be all alone all the time i do need to see people sometimes and then after i do i need to be alone again to get back to my peace and quiet reasons for attending or not attending chap sessions reasons for attending chap sessions were related to the programs objectives namely knowing their health status checking their bp following up with their doctor acquiring new knowledge through workshops and conferences and wanting to take care of themselves i go once in a while the last time i only went to attend the nutritionists talk on healthy eating i found it really interesting some attended the sessions for the programs benefits and because even if they were not looking for social interaction they met someone there with whom they were comfortable i go to those sessions to get my blood pressure checked theres only one or two people that i chat with because as i see it … most women show up in pairs theyre always in pairs theres one person i talk to regularly and we always have a good connection thats been my experience q is that really the extent of your interactions r i have very very few im telling you … im not comfortable with social interaction i think ive put a wall around myself some respondents had attended the chap sessions because a neighbor invited them for example respondent r1 who was generally isolated from the neighbors did come once when x told me about it and said she was going i said to her alright ill come with you however she added the only reason i dont go is because i dont want to see any of my neighbors while some respondents did not feel the need to attend chap sessions because they were already being followed by their doctor the main reasons mentioned for not participating were related to respondents relationships with their neighbors since i already have a family doctor i can consult with her over the phone whenever i need to i think maybe i just want to avoid being around certain groups in this building they also mentioned the sometimes charged atmosphere between residents during the chap sessions as a barrier to attendance i try to go but im not sure ill keep going even though going means that i can get my blood pressure taken q are you disappointed r yes because i want to listen to the talks i want to hear the experts health tips and what she has to say also respondents did not want neighbors to be aware of their health status when their blood pressure was being taken yeah well you know some of us may feel selfconscious about attending those sessions q in the sense that your neighbors might see you there r yes thats what i mean in general the chap was considered to be no different from any other activity in the building some respondents did not participate in any activities including chap because they generally preferred to avoid conflicts and vindictive behaviors personally i go often and ive noticed that its usually the same ones who tend to participate too for instance 90 of people who show up for bingo are regulars q from one of those two gangs have you seen there any of the women that you describe as meanspirited r i guess so to tell you the truth im not sure … i went only once to bingo and i kept to myself i kept my head down and especially gossip theres this 53 yearold woman who stopped coming to the sessions i told her i miss you i liked seeing you there she replied theres too much gossiping and i just cant deal with it i think shes right to say there are many people in this building who like to gossip finally another reason mentioned was the presence of cliques and clans there are tribalistic groups that have coalesced in this building they get together downstairs and they say slanderous things … its so draining i cant wait to get back up to my place when i hear them get started discussion the main objective of this study was to evaluate whether relationships and social structures among residents affected participation in the chap program many other studies have shown the importance of having a peer leader to successfully implement a communitybased program 13213051 mapping existing network dynamics and residents positions and links within the building is highly relevant to identify internal leaders who could support program implementation 121623 respondents were able to clearly identify leaders in the community from their perspective but using sna to map the network configuration showed that leaders can also have a negative influence on the community interestingly the peripheral leader in building 2s network was unaware of his position and did not know he could improve the programs implementation by attending sessions another interesting aspect of the relational dynamics in this building was that a person not identified as central had a combined membership in 20 groups within the network just behind the most central person who had 27 but with numerous conflicts we were also able to identify marginal individuals or groups who had not attended chap sessions but were connected to individuals who had such insight may be useful to adapt program implementation strategies accordingly 12 in a network with many cliques a person who is able to reach many others through memberships in numerous groups is highly valuable as an opinion leader 28 while our qualitative results identified the same distance strategies demonstrated in other studies 313344 our application of these findings to the barriers and reasons for not attending chap appears promising respondents tended to consider chap to be no different from any other activity held in the building despite the programs potential benefits for their health their conflictual relationships with leaders in their building andor other residents constituted the most important reason for their nonattendance our results complement those of studies on social participation defined as taking part in activities that allow interactions with other members of the community 3852 and demonstrate its close association with social support and networks 38 our aim was to identify promising strategies to increase the chap attendance rate from our analysis four recommendations emerged for future implementation first when setting up programs in environments where participants live side by side strong emphasis must be placed on confidentiality the chap program already had some measures in placetraining volunteers in confidentiality issues placing tables as far away from each other as possible respecting participants privacy when measuring waist circumference etcbut given the conflictual relationships among residents more should be done especially when measuring bp second respondents said in the interviews that they would go if they knew for sure that someone else they knew in the building was also planning to attend based on studies of other successful programs one promising strategy might be to raise awareness among participants of their role as potential change agents and to use community peer networks to recruit and reach as many members of the community as possible 1214282951 third as the majority of respondents reported having a trusted person in the building encouraging them to come in pairs could help to overcome barriers such as fear of rejection by an already formed group fourth in a context of conflict if a power dynamic is identified in a building intervening through the positive leader may be the most effective way to create beneficial change 2528 on the other hand in situations of conflict andor negative leaders intervening through bridging individuals might be more effective 18 this study presents two main limitations particularly in relation to changes that might occur in the network between the beginning and the end of the program implementation as well as changes potentially induced by the presence of researchers for a portion of that time a significant event such as conflict between leaders or the deathdeparture of a leader can considerably influence network dynamics and peoples participation in activities including chap nevertheless the advantage of conducting research in this type of microsociety setting is that we became aware of such events as they arose over the course of the study because respondents reported them however given high resident turnover changes in leadership in the buildings and the emergence of conflicts that affect relational dynamics in general it would be ideal if network data could be collected at several points over the four implementation phases needs assessment program design implementation and program sustainability 12 the programs potential for diffusion in the community can be estimated and longerterm implementation strategies can be considered 1250 also replicating the research in different buildings to establish a referential typology of relational dynamics could help counter these limitations related to changing relational dynamics conclusion the objective of this study was to generate a portrait of two buildings relational dynamics by examining cases with different rates of attendance to see whether relationships could explain these differences we used an sna methodology to understand each buildings relational dynamics and their influence on program participation the quantitative measures of social networks helped identify positive and negative leaders to inform and support the program implementation the qualitative results illustrated how not only conflictual relationships but also the proximity and distance strategies used by residents can influence participation in health promotion programs in social housing the analysis revealed the presence of clans and conflicts chaps amalgamation with other activities in the building and other individual and relational factors to explain the differences in participation it also helped identify wellknown and appreciated leaders which could inform future chap implementation planning to enhance attendance competing interests the authors declare that they have no competing interests

background the cardiovascular health awareness program chap is as a communitybased cardiovascular disease prevention program recently adapted to target older adults living in 14 social housing buildings in ontario 7 and quebec 7 social network analysis sna has been used successfully to assess and strengthen participation in health promotion programs we applied sna methods to investigate whether interpersonal relationships among residents within buildings influenced their participation in chap methods our aim was to examine relational dynamics in two social housing buildings in quebec with low and high chap attendance rates respectively we used sociometric questionnaires and network analysis for the quantitative phase of the study supplemented by a phase of qualitative interviews all residents of both buildings were eligible for the sociometric questionnaire respondents for the qualitative interviews were purposively selected to represent the different attendance situations following the principle of content saturation results in total 69 residents participated in the study 37 through sociometric questionnaires and 32 in qualitative interviews of the latter 10 attended almost all chap sessions 10 attended once and 12 attended none results of the quantitative analysis phase identified wellknown and appreciated local leaders in building 1 which had a high attendance rate 343 there was a main leader indegree or named by others frequency 232 who had attended all chap sessions in building 2 which had a low attendance rate 239 none of the leaders had attended chap sessions results of the qualitative analysis phase showed that residents who did not attend chap sessions or other activities in the building generally preferred to avoid conflicts vindictiveness and gossip and did not want to get involved in clans and politics within their buildingwe identified four potential strategies to increase attendance at chap sessions by residents of subsidized housing for older adults strengthen confidentiality for those attending the sessions use community peer networks to enhance recruitment pair attendees to increase the likelihood of participation and intervene through opinion leaders or bridging individuals

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introduction m any families have at least two children living in their household 1 however very little is known about how parents respond to more than one child in the home with regard to weight and weightrelated issues for example do parents adapt their feeding practices to accommodate siblings in the same household do parents talk about weight and weightrelated topics similarly with siblings and do parents provide similar levels of support for physical activity with siblings furthermore it is unknown if parents adapt their feeding practices conversations about weight and weightrelated topics or their support for physical activity depending on the weight status or sex of the siblings 2 such information has been critically missing in the field of childhood obesity and is relevant for designing effective familybased parenting obesity prevention interventions although it is widely recognized that parents play an important role in shaping child weight and weightrelated behaviors 2 3 4 5 6 7 8 9 10 11 previous research has been limited regarding how parents influence and differentially respond to two children within the same household with regard to parent feeding behaviors weightrelated conversations or support for physical activity 412 the few studies that have been conducted have primarily focused on parent feeding practices these studies have shown mixed findings for example some studies have found that parents used more restrictive feeding practices with children who were pickier than their siblings and applied more pressure to eat with children who enjoyed food less were slower to eat and were thinner than their siblings 1314 other research has shown no differences in maternal feeding practices between overweightobese and nonoverweightobese siblings 15 or that mothers used restrictive feeding practices with both of their children not contingent on siblings weight status 16 these inconsistent results may be due to different measures being used varying sample sizes or the variety of age ranges included in samples additionally these sibling studies have not examined differences by child sex or explored differential treatment between siblings on other potentially weightrelated issues such as parentadolescent weight conversations or parental support for physical activity finally to our knowledge there have been no studies exploring weightrelated parenting practices within samples of adolescent sibling dyads examining differences by sibling weight status and sex is important given previous research with one child showing parents restrict more often with overweightobese children and pressure more with nonoverweightobese children 2 17 18 19 20 and showing parents engage in more weightrelated conversations with overweightobese children and with boys 1121 additionally previous studies have shown significant associations between parent weightrelated conversations and food restriction with more adolescent disordered eating behaviors and higher weight status 11 21 22 23 24 thus even if unintentional differential treatment by sibling weight status or sex could lead to more adolescent overweightobesity or disordered eating over time in the sibling experiencing restriction or weightrelated conversations more research is needed to address these important unanswered questions regarding parental response to sibling dyads in the home environment and to address inconsistencies in previous study findings based on the limited research inconsistent findings from previous studies examining parenting practices with siblings and because it is common for children to have a sibling it is critical to understand whether parent feeding practices weightrelated conversations or support for physical activity with siblings in the home differ based on child weight status or sex the main exploratory research question being examined in the current study is do parents engage in different feeding practices weightrelated conversations or levels of support for physical activity with sibling dyads if they are discordant on weight status or of the opposite sex results from this exploratory study will provide an incremental next step in understanding the relationship between parenting practices with siblings in the home and may set the stage for future intervention research regarding how to intervene in parenting practices when there are siblings in the home methods study design and population data for this exploratory analysis were drawn from two coordinated populationbased studies 112526 eating and activity in teens 2010 was designed to examine dietary intake physical activity weight control behaviors weight status and factors associated with these outcomes in adolescents families and eating and activity in teens was designed to examine factors within the family and home environment of potential relevance to adolescents weight and weightrelated behaviors 2527 survey development for both eat 2010 and feat are described elsewhere 2527 drafts of the surveys were pretested by 56 adolescents and 35 parents from diverse backgrounds for clarity readability and relevance and reviewed by an interdisciplinary team of experts after revisions the survey was additionally pilot tested with a different sample of 129 middle school and high school students and 102 parents to examine the testretest reliability of measures over a oneto twoweek period all study procedures were approved by the university of minnesotas institutional review board human subjects committee and the participating school districts for eat 2010 surveys and anthropometric measures were completed by 2793 adolescents from 20 public middle schools and high schools in the minneapolisst paul metropolitan area of minnesota during the 20092010 academic year for project feat data were collected by surveying up to two parentscaregivers of the adolescents in eat 2010 by mail or phone interviews in total 2382 eat 2010 adolescent participants had at least one parent respond and there were two parent respondents for 1327 adolescents following data collection and database management for eat 2010 and feat it became clear that the eat 2010 dataset contained siblings it was not originally anticipated that a substantial number of siblings would enroll in eat 2010 it was not until parent data were collected for project feat that we were able to ascertain sibling status of eat 2010 adolescents thus a unique opportunity to investigate siblings arose and research questions for the current study were formulated the study population for the current analysis was restricted to siblings in the eat survey with the same primary parent in the feat survey without missing information and who lived with their parent 100 of the time triads were identified by matching the addresses of the primary parents of the adolescents in the eat 2010 survey the birthdate of the primary parent was table 1 measures of parent feeding practices parentadolescent weight and weightrelated conversations parent support for physical activity and control variables used in the analyses measure descriptionquestions parent feeding practices parent feeding practices including pressuretoeat and food restriction were measured using an adapted version of the cfq created specifically for adolescents 28 this adolescent version of the cfq has been used in other studies 17182829 parent pressure to eat pressuretoeat foodrelated parenting practices were measured using all four items from the pressuretoeat subscale of the cfq a subscale designed to measure the degree to which the parent encourages their child to eat more food examples of selfreport items include my child should always eat all the food on hisher plate and if my child says im not hungry i try to get himher to eat anyway individual items were measured using a fourpoint likert scale with each point on the scale represented by a word anchor an overall parental pressureto eat scale was created by averaging responses to each of these four questions to assign an overall pressure score ranging from 1 to 4 parent restriction restrictive foodrelated parenting practices were measured using six items from the eightitem restriction subscale of the cfq a subscale designed to measure a parents attempt to control a childs eating by restricting access to palatable foods two items from the subscale were dropped based on recommendations from a validation study conducted within a diverse adolescent population examples of the selfreport items include i have to be sure that my child does not eat too many high fat foods and if i did not guide or regulate my childs eating heshe would eat too many junk foods individual items were measured using a fourpoint likert scale with each point on the scale represented by a word anchor for the current analyses an overall parental restriction scale was created by averaging responses to each of these six questions to assign an overall restriction score ranging from 1 to 4 positive parentadolescent eating and physical activity conversations and negative parentadolescent weight conversations were assessed using two items that were modeled after items in the parental energy index 28 positive parentadolescent eating and physical activity conversations mothers and fathers were asked how often in the past year never or rarely a few times a year a few times a month a few times a week almost every day have you had a conversation with your child about healthy eating habits and have you had a conversation with your child about being physically active parent encouragement to diet an overall score was created by averaging responses between the two questions ranging from 1 to 5 negative parentadolescent weight conversations example items asked for both mothers and fathers include how often in the past year never or rarely a few times a year a few times a month a few times a week almost every day have you mentioned to your child that heshe weighs too much and have you mentioned to your child that heshe should exercise in order to lose weight or to keep from gaining weight an overall score was created by averaging responses between the four questions ranging from 1 to 5 parent support for physical activity frequency of physical activity with child helping child be physically active frequency of parents engaging in physical activity with their child was assessed with the following questions 29 in a typical week how many hours do you spend doing the following none less than ½ hour ½ 2 hours 2 ½ 4 hours 4 ½ 6 hours 6 hours being physically active with your child each category was recoded to the midpoint of the range for a possible numeric range of 065 hours of all six categories continued on page 90 childhood obesity april 2016 used to ensure the same parent was responding to the questionnaire for both adolescents sibling 1 participants were predominantly female asian american nonoverweight with a mean age of 144 years sibling 2 participants were 65 female 25 asian american 61 nonoverweight with a mean age of 147 years primary parents were predominantly female white finished college or more and had a mean age of 424 years all measures used in analyses including parent feeding practices weightrelated conversations support for physical activity and siblings weight status are listed in table 1 statistical analyses means and standard deviations of parental feeding practices weight conversations and support for physical activity were calculated for the full sample of sibling pairs additionally subgroup analyses identified sibling pairs that were discordant on weight status or sex and examined whether parental feeding practices weight conversations and support for physical activity differed between these groups adolescent weight status was determined by categorizing adolescent bmi percentile greater than 085 as overweight and those less than or equal to 085 as nonoverweight adolescent pairs with one sibling overweight and the other sibling nonoverweight were included in the weight discordant subgroup analysis paired ttests and 95 confidence intervals were used to compare differences in means of each parenting practice between adolescents and their siblings in the subgroup analyses for discordant weight status and discordant gender separately because of the small sample size only unadjusted results are presented results parent feeding practices results indicated limited evidence that parents use different feeding practices with siblings who are discordant on weight status or sex however parents reported using more food restriction feeding practices with overweightobese siblings compared to nonoverweight obese siblings but these observed differences were not statistically significant in addition there were no significant associations between parental use of pressure to eat feeding practices and adolescent discordant weight status additionally comparisons in feeding practices of parents of opposite sex siblings revealed nonsignificant differences measure descriptionquestions frequency of parents helping their child to be physically active was assessed by asking 29 in a typical week how many hours do you spend doing the following none less than ½ hour ½ 2 hours 2 ½ 4 hours 4 ½ 6 hours 6 hours helping your child to be physically active each category was recoded to the midpoint of the range for a possible numeric range of 065 hours of all six categories a final total score was used in analyses by adding the two items together for a total number of hours control variables sociodemographic characteristics adolescents and parents raceethnicity age and parents educational attainment were assessed by selfreport in adolescents and parents respectively raceethnicity was assessed with the item do you think of yourself as white black or african american hispanic or latino asian american hawaiian or pacific islander or american indian or native american and respondents were asked to check all that apply participants who checked white and another option were included in the other category those who checked two nonwhite options were categorized as mixedother race additionally those checking hawaiianpacific islander or american indiannative american were also categorized as mixedother race due to their small numbers in this dataset highest level of parent educational attainment was used as a proxy for socioeconomic status and was assessed using the following question what is the highest level of education you have completed response options included less than high school high schoolged vocational technical school associate degree bachelors degree graduate or professional degree 30 parent and adolescent age was calculated using selfreported birth date and survey completion date cfq child feeding questionnaire 90 berge et al parentadolescent weight and weightrelated conversations results indicated some evidence suggesting parents used more weight and weightrelated conversations with siblings who were discordant on weight status or sex specifically among discordant weight status siblings parents reported significantly higher levels of negative weight and weightrelated conversations with their adolescents who were overweightobese compared to adolescents who were nonoverweightobese in addition while not statistically significant parents tended to report more encouragement to diet conversations with overweightobese siblings compared to nonoverweightobese siblings comparisons in parentadolescent conversations about healthy eating within weight discordant sibling pairs and opposite sex siblings revealed nonsignificant differences comparisons in weightrelated conversations of parents of opposite sex siblings revealed nonsignificant differences parental support of adolescent physical activity results indicated no evidence of differences in parental support for adolescent physical activity by sibling discordant weight status or sex discussion in general we found limited evidence that parents use different parenting practices with adolescents of different weight status or sex however potentially important patterns emerged in the data including more negative parentadolescent weight and weightrelated conversations parental food restriction and encouragement to diet with overweight obese siblings compared to nonoverweightobese siblings while only one of these differences by sibling weight status reached statistical significance these patterns may warrant further discussion and are important issues to consider for future research these findings may lend some evidence to the hypothesis that parents respond differently to siblings based on their weight status when engaging in parentadolescent weightrelated conversations and using feeding practices while it is likely that the use of different foodrelated parenting practices with siblings of discordant weight status are a reflection of wellintentioned efforts by parents to help their adolescent achieve a healthy weight differential treatment by sibling weight status could lead to adolescent overweightobesity or disordered eating over time in the sibling experiencing restriction or weightrelated conversations this hypothesis aligns with prior literature showing that parents in general tend to engage in pressure parent encourages child to diet 18 16 12 04 19 19 00 parent support of adolescent physical activity frequency of physical activity with child helping child be physically active to eat practices with children who are nonoverweightobese and food restriction practices with children who are overweightobese and that using food restrictionpressure techniques can have unintended effects including more disordered eating behaviors and overweightobesity in adolescents 211 17 18 19 20 21 22 23 24 exploring these issues further is important because understanding whether parents use one universal feeding style with both siblings regardless of their weight status or whether they adapt their feeding practices in response to the siblings weight status will inform interventions that target feeding practices with parents with multiple children additionally there were notable patterns in the findings related to parentadolescent weight and weightrelated conversations for example parents reported significantly higher levels of negative weight and weightrelated conversations with overweightobese adolescents compared to nonoverweightobese siblings additionally parents reported more encouragement of overweightobese siblings to diet compared to nonoverweightobese siblings although the finding was not significant these differences are important to examine further because prior research has suggested that overweightobese adolescents who are encouraged to diet or who experience weightbased talk by their parents are at higher risk of excessive weight gain over time and the use of disordered eating behaviors 11 21 22 23 24 28 patterns in the findings for parental support for physical activity provide little support for the hypothesis that parents respond differently to adolescent siblings with regard to engaging in physical activity regardless of adolescent weight status or sex thus it may be the case that foodeatingrelated parenting practices may be more influenced by factors such as discordant child weight status or it may be that encouragement or support for physical activity may be seen more for health benefits than for weight concerns overall findings from the current study may be useful for guiding future research and familybased interventions specifically while parents with one overweightobese adolescent appeared to be more likely to engage in negative weightrelated conversations food restriction and encouragement to diet these behaviors may have counterintuitive outcomes based on previous literature 211 17 18 19 20 21 24 and parents may want to focus their parenting practices on householdlevel behavior and not direct restriction pressure to eat or weightrelated conversations at a particular child regardless of weight status however more research is needed in order to make recommendations to providers this study had several strengths first this data set included parent adolescent and sibling triads which is rare thus this study provides a first look at parenting practices with adolescent siblings in order to inform familybased interventions with parents with siblings second data used in the study were participantspecific weightrelated variables whereas previous studies have primarily used the mothers report of child weight and weightrelated variables there were also study limitations first and foremost the study sample was small it is important to consider the possibility that this small sample size limited our power to detect important differences in parenting practices that said it may also be true that there were no true differences to find further because of the small sample size we were unable to adjust our associations for possible confounding factors in addition because of the cross sectional nature of this study we do not know when examining parenting practices and adolescent weight status whether the parenting practices are a cause or consequence of adolescents weight status conclusions overall in this exploratory study we found limited evidence that parents use different parenting practices with adolescents of different weight status or sex however there was some suggestion of patterns including more negative parentadolescent weightrelated conversations parental food restriction and encouragement to diet with overweightobese siblings compared to nonoverweightobese siblings for future research it will be important to use larger samples of siblings to further examine differences in parent restricting and pressure to eat feeding practices parentadolescent conversations about weight and weightrelated behaviors and parent encouragement of dieting by sibling dyad concordantdiscordant weight status it is also important to examine consequences of parental differential treatment by sibling weight status for example parental differential treatment by sibling weight status may be associated with higher risk of overweightobesity for the adolescent sibling who is already overweightobese because this is one of the first studies including siblings in examining parenting practices and sibling weight status and the first with adolescents the findings set the stage for future research with a larger sample furthermore it would be important to examine differential parent feeding practices in younger children when parents are shaping childrens eating patterns on a more regular basis author disclosure statement drs berge and maclehose had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis none of the authors have financial disclosures to declare and none of the authors have conflicts of interest to declare

background it is unknown if parents with more than one adolescent child use similar or different parenting practices of relevance to weightrelated health with different children in particular it is unclear whether parenting practices differ based on whether siblings are discordant on weight status ie one is overweightobese one is nonoverweightobese or are different sexes methods data from two linked populationbased studies eating and activity in teens eat 2010 and families and eating and activity in teens feat were used in this exploratory crosssectional analysis participants included socioeconomically and raciallyethnically diverse parents n 57 93 females and adolescent siblings n 57 pairs 60 girls mean age 145 range 1118 students filled out surveys and had anthropometric measures taken in school parents filled out mailed surveys in their homes results overall results from this exploratory study showed limited evidence that parents use different parenting practices with adolescents of different weight status or sex however potentially important patterns emerged when exploring parenting practices and siblings weight status for example within sibling dyads with discordant weight status parents reported significantly more negative weightrelated conversations with overweightobese siblings compared to nonoverweightobese siblings p 005 although observed differences were not statistically significant parents also reported higher levels of food restriction p 005 and encouragement to diet p 007 with overweightobese siblings compared to nonoverweightobese siblings there were no significant differences in parenting practices by adolescent sex conclusions results generally suggest that parents use similar parenting practices with adolescent siblings however notable patterns emerged when examining parenting practices and siblings weight status that may be important to explore in future research

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open access injections and use of pills as other birth control methods genderbased violence especially amongst female students is a particular concern as some of them are dating older men evidence shows that they are unable to negotiate condom use because their male partners are older and tend to have many casual partners south africa has responded through numerous interventions including condom distribution programmes and hiv education there have also been a number of wellpublicised hiv awareness campaigns using a variety of media including khomanani love life soul city and soul buddy the 2012 national communication survey on hivaids evaluated these national campaigns and found that they were having a positive effect particularly on students aged 1524 years with an increase in condom usage hiv testing counselling and male circumcision however research interventions which included large trials have shown mixed results with regard to the reduction of risk behaviour students aged 1524 years in south africa continue to have poor health outcomes because of their highrisk behaviour there is an urgent need to find interventions that may prevent and reduce youth risk behaviour we thus developed implemented and evaluated a contextbased behavioural riskreduction intervention in umgungundlovu district municipality kwazulunatal province aimed at reducing risky sexual behaviour use of alcohol and other drugs and violence enacted by learners purpose of the research the purpose of this study was to assess the effects of a behavioural riskreduction intervention on sexual risk behaviours substance abuse and violencerelated behaviours of grade 10 learners assigned to receive a behavioural youth riskreduction intervention compared to those who did not receive such an intervention methods the study was conducted in 16 public coeducational high schools in umgungundlovu district municipality south africa from 2014 to 2015 this district comprises seven local municipalities six of which were selected the office of the premier of kwazulunatal requested to exclude msunduzi local municipality as it felt that the said municipality was already saturated with projects we invited high schools to participate in the behavioural riskreduction trial only public high schools were eligible because of the existence of the operation sukuma sakhe facilitators and we randomly selected 16 of the 45 high public schools in the district to ensure comparability of intervention and control groups schools were stratified and pairs of schools were randomly selected from the same stratum one randomly allocated to intervention and another to control sample size owing to financial constraints this study focused only on grade 10 learners the sample size of 2000 grade 10 students from 16 schools was calculated to detect a 19 reduction in the proportion of students engaging in risky behaviours between intervention and control groups we set a study power of 80 and a significance of 95 probability a design effect of 7 was included in the calculation to account for the randomised clustered design of the trial instrumentation a questionnaire based on the sayrbs comprising the following variables was used and piloted prior to being completed by the learners demographic profile violencerelated behaviours substance abuse sexualrelated behaviours circumcision hiv and aids a pilot study was conducted amongst grade 10 learners in schools which did not form part of the main study and 22 learners completed the questionnaires demographic profile these questions comprised age sex living arrangements and information about the head of the household to investigate the risk behaviour of participants the sayrbs was used the sayrbs is a schoolbased survey used to monitor priority health risk behaviours that contribute to the leading causes of death disability and social problems amongst youth violencerelated behaviours these were adapted from the sayrbs the measures of whether students carried a weapon and a gun were as follows during the past 30 days how many days did you carry a weapon such as a gun knife or club on school property and during the past 30 days on how many days did you carry a gun these were scored as 0 no days 1 12 days and 2 34 days substance abuse the measures of cigarette alcohol and marijuana use were limited to the past one month time frequency and quantity were measured questions included were as follows on how many days did you smoke a cigarette how many cigarettes did you smoke on an average per day how often in the past one month did you have at least one drink of alcohol how often in the past one month did you have five or more drinks of alcohol how many number of drinks did you have in a row and how many times did you smoke marijuana on average per day the questionnaire used the local term dagga instead of marijuana sexualrelated behaviours having highrisk sexual intercourse was measured by the following two items did you drink alcohol or use drugs before you had sexual intercourse the last time you were having sex and did you or your partner use a condom during sexual intercourse the last time the following questions were added at the followup after 4 months in order to investigate the effectiveness of the then current hiv testing campaign and circumcision for hiv and aids the questions were adapted from the sayrbs measures of hiv testing and perceptions and comprised the following have you ever been tested for hiv do you think you might be hivpositive when it comes to hiv do you feel you are circumcision having been circumcised was measured by the following item have you ever been circumcised hiv and aids the measures of hiv testing and perceptions comprised the following have you ever been tested for hiv do you think you might be hivpositive and when it comes to hiv do you feel you are procedures all 16 participating schools were allocated to the intervention and control groups using stratified random sampling general information sessions about the study were facilitated for the principals school governing bodies and all grade 10 students in all 16 high schools this process provided an opportunity for the recruitment of potential participants information sheets and informed consent forms were sent to parents or guardians of all grade 10 students and were collected before the actual enrolment process during enrolment all the learners who were willing to participate signed informed consent and assent forms this study was approved by the university of kwazulunatal ethics committee and the department of education gave permission to conduct the study in the school ethical issues such as confidentiality anonymity and voluntary participation were discussed with parents or guardians and students during the enrolment process all students in both arms of the intervention completed a baseline and followup survey 4 months after the intervention using a questionnaire that was completed in the classroom about five students did not participate because of the nonavailability of parental consents and there were no other refusals in this study intervention arm after each school completed enrolment and the baseline survey a behavioural riskreduction intervention was implemented if a school was in the intervention group two facilitators per school delivered sessions which took place during the life orientation periods the duration of the sessions lasted from 45 min to 1 h and comprised the following topics knowing yourself peer pressure decisionmaking healthy and unhealthy relationships contraceptives teenage pregnancy condom use hiv aids and sti prevention alcohol and drug abuse violence and genderbased violence child support grant human rights and responsibilities in sexual health the sessions were designed to include brainstorming group discussions roleplays reflections and demonstrations all the eight schools of intervention group agreed for two sessions per week and the intervention was implemented in all these schools within 2 months we assessed the process of implementation of the intervention by requesting that the facilitators record each session by giving students an attendance register to sign for each session control arm there was no intervention in the control schools they continued with their lo learning area which is a compulsory learning area for all learners attending public schools statistical analysis and evaluation we matched preand postquestionnaires by students identification the questionnaires were coded to ensure confidentiality we recorded question responses using the likert scale categorised into three groups no risk moderate risk and high risk at baseline the intervention effect was measured by the difference between learners responses on the pretest and posttest questions this difference was dichotomised into positive and negative behaviour a generalised estimating equation model was used to compare the groups this model adjusts for the possible correlation of students within schools and baseline characteristics such as age significance was set at p 005 for all the analyses we used stata 13 statistical software to analyse the data ethical consideration ethical approval to conduct the study was obtained from the university of kwazulunatals biomedical research ethics committee in south africa results and findings a total of 16 high schools and 1558 grade 10 learners participated in the trial with eight schools per group all were analysed at followup table 1 shows the characteristics of participants the ages of the learners ranged from 13 to 23 years the old age of some learners was a result of kwazulunatals policy not to exclude older learners from rural schools students from the intervention group were older than the control group male and female learners were equally represented more than onethird of learners were residing with their mothers and extended families whilst only 28 were living with both parents over half of the heads of the households had been to high school but surprisingly household heads in the control group were more likely to have posthigh school qualifications and be professionals table 2 shows the baseline prevalence of risk behaviour in intervention and control groups measures were confined to 30 days of the learners in the intervention group 115 carried a weapon and 61 carried a gun and in the control group 73 and 36 had carried a weapon and a gun respectively one third of the learners reported alcohol consumption with 13 in the intervention and 12 in the control groups reported having binge drinking of the learners in both groups 268 versus 220 reported smoking cigarettes and 126 versus 107 had smoked marijuana at least once in the past 1 month respectively a quarter of the sexually active learners 42 versus 34 reported drinking alcohol before having sex and 40 of the learners had not used a condom at their last sexual intercourse of the learners 60 in the intervention group and 51 in the control group reported testing for hiv in the past 1 month behavioural change there was a decrease of 11 between baseline and followup amongst the learners in the intervention group reporting carrying of a weapon during the previous 30 days compared to the 7 decrease in the control group although there was a decrease in the use of tobacco and alcohol in the intervention group this was not statistically significant the 10 decrease in the use of marijuana in the intervention group was similar to that in the control group similarly decrease in the open access use of alcohol before sex was similar to that of the control group condom use before sex increased substantially by 20 in the intervention compared to 17 in the control group but this was not statistically significant the odds of learners in the intervention group not carrying a weapon in the previous 30 days were one and a half times greater than that of those in the control group there was also a trend towards a reduction in carrying a gun there were no statistically significant differences between the groups for smoking alcohol consumption and binge drinking use of alcohol before sex decreased and use of condom at last sexual intercourse increased in both groups hiv andor aids and circumcision the prevalence of hiv testing by learners in the postsurvey was 530 for the intervention group and 433 for the control group although the results are not statistically significant we found that more learners in the intervention group compared to the control group reported having been newly tested for hiv after the intervention had been completed a similar finding was for the sexually active learners where 94 learners in the intervention group compared to 66 learners in the control group had tested for hiv but this was not statistically significant many of those learners who did not test for hiv did not perceive themselves to be at risk of hiv only 16 versus 19 of these learners perceived themselves to be at risk or somewhat at risk namely 21 in the intervention group versus 30 in the control group a number of learners perceived themselves not to be at risk but most learners of the intervention group and the control group were unsure whether they were at risk of contracting hiv circumcision to reduce hiv transmission the overall prevalence rate of medical male circumcision in the postsurvey in both groups was 65 amongst circumcised learners there was no significant difference between intervention and control groups perceptions as to their risk of being infected with hiv limitations the intervention programme did not have the desired effect on learners risk behaviours with the decrease in substance use and sexual risk behaviours occurring in both intervention and control groups although the intervention was intensive the 2month period may have been insufficient for the wide and complex range of topics covered a further limitation was that the learners questionnaire responses were selfreports of their behaviours the process evaluation indicated that no other interventions had taken place in the schools but media access by students was widespread and this was not monitored and may have influenced the study results although all grade 10 students were invited the proposed sample size of 2000 was not attained discussion since behavioural risk and school violence surveys were conducted in south african schools violence has been reported to be high our intervention appears to have reduced the number of days students carried weapons to their schools with the intervention group indicating a significant reduction in the number of learners carrying weapons to school compared to the control group there have been numerous interventions aiming at reducing the risk behaviours of young people but most of the studies on the existing interventions which focus on sexual risk behaviours such as sexuality education alcohol and drug abuse and genderbased violence showed mixed results in south africa interventions targeting violent behaviours such as physical fighting and carrying weapons amongst learners are limited in south africa the department of basic education has developed an antibullying policy to be implemented across public schools but it is not clear whether it is being implemented as bullying continues to be high amongst high school learners the other risk behaviours that were targeted by the study are similar to youth risk behaviours targeted by south african researchers and other countries however the context in south africa differs in that youth seeking their independence and wishing to enjoy themselves are often limited by their social circumstances south africa has one of the highest gini coefficients indicating societal inequality worth mentioning is the increase in hiv testing that was found in the present study overall a general decrease in risky behaviours in both intervention and control groups was observed the intervention was developed to take into account the context in which youth facilitators from the area were trained to implement the programme in the schools the envisaged strategy was that their being employed by the kwazulunatal premiers office would enable them to continue to work in the schools to reinforce the programme efforts to reduce students risk behaviours however in the year that this school programme was implemented the youth facilitator programme was discontinued for internal budgetary reasons the intervention programme although intensive was only for 8 weeks and lacked a followup component to reinforce the intervention messages we observed that selfregulation through a motivational continuum from extrinsic and intrinsic motivation in students is necessary the study afforded students an opportunity to reflect on and internalise their perceptions of their risk and the consequences of antisocial behaviours such as violence including their taking necessary measures towards prevention of hiv and sti infections teenage pregnancy and prevention of alcohol and drug abuse changing behaviour is complex and the health promotion messages need to be reinforced so that students are able to personalise these messages and reduce their risk behaviours amongst students condom use has increased from 14 to 60 over the past decades which although insufficient demonstrates that consistent messages could make inroads towards more healthpromoting behaviours education is compulsory in south africa and the life skills component of lo curriculum presented in all grades in public schools offers an opportunity for reinforcing key messages as students move up the grades data availability statement data sharing will be available on request competing interests the authors have declared that no conflicts of interest exist disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors

globally youth risk behaviour including risky sexual behaviour drug abuse and violence is a public health concern and south africa is no exception a range of behaviours place youth and in the context of this study south african youth at risk although numerous interventions have been conducted to mitigate risktaking young people continue to practise unsafe sex binge drink and use illicit drugs and are involved in violence the latest south african survey on youth risk behaviours reports that adolescents initiate alcohol use prior to the age of 13 years and that men were more likely than women to use alcohol engage in binge drinking to have driven or walked under the influence of liquor and engaged in physical fighting burton leoschut 2013ashisana et al 2015 furthermore in south africa although the human immunodeficiency virus hiv infection rate is decreasing youth are severely affected by hiv violence and unplanned teenage pregnancy district 2012 national department health 2012mkhwanazi 2010 it is also widely acknowledged that the high prevalence of hiv and other sexually transmitted infections and rate of teenage pregnancy are fuelled by highrisk behaviours harrison et al 2010a evidence shows that substance abuse has detrimental consequences for youth scottsheldon et al 2013yach et al 2015 the results of the south african national violence survey reported that of the 47 learners who smoked marijuana at school 31 reported witnessing learners who were high and 27 reported knowing learners who were drunk at school burton leoschut 2013a this is undesirable in a teaching and learning environment and particularly concerning as alcohol abuse has been associated with violent behaviour peltzer davids njuho 2011 the prevalence of violence in south african schools has been reported to be high schuld 2013 one in four learners reported knowing learners who brought weapons such as firearms knives and other sharp objects to schools burton leoschut 2013award et al 2012 these learners may carry weapons to initiate or threaten other students or for selfdefence the prevalence rates of students reported carrying weapons vary across the country burton leoschut 2013a learners from kwazulunatal province were aware of learners who had brought a weapon to school and 82 stated that they were threatened whilst at school burton leoschut 2013a another concern is the lack of contraceptive use bhana et al 2010catalano gavin markham 2010 in the third south african youth risk behaviour survey sayrb 2011 learners reported condom use 451 as the main method to prevent pregnancy this was followed by contraceptive background youth behaviour in south africa continues to be a public health concern primary prevention interventions remain a prerequisite for promotion of improved social and health outcomesthe aim of the study was to assess the impact of a behavioural youth risk reduction intervention among grade 10 learnersthe study was conducted in kwazulunatal high schools at umgungundlovu district municipality methods we conducted a cluster randomised controlled trial at 16 kwazulunatal high schools where learners completed a selfadministered questionnaire assessing youth risk behaviours schools were divided into two arms intervention and a control arms resultsthe intervention reduced learners reports of carrying of a weapon to school in the past 30 days but did not significantly reduce other assessed risk behaviours although the intervention appeared more likely to reduce learners risk behaviours when compared to the control group such as carrying weapons risky sexual behaviour and alcohol and drug abusethis study was unable to show statistical significance for these outcomes

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introduction the adverse health effects of tobacco smoking have been widely recognized as a global concern the world health organization has attributed around 5 million deaths per year to tobacco smoking a figure expected to rise to more than 8 million by 2030 given current trends in tobacco use at the same time the morbidity and mortality associated with tobacco use is shifting from developed to developing countries in which estimates suggest almost 70 of deaths will take place one of those countries is jordan which has a population of more than 6 million and is classified by the world bank as an uppermiddleincome country with severely scarce resources smoking in jordan is a serious problem that needs to be targeted urgently as it affects almost all segments of society including children in spite of the existing laws and control efforts in place including a total ban on smoking in public transport and government offices and newly introduced legislation to control smoking in restaurants surveys show that 4050 of adult men currently smoke while the prevalence of smoking among females is reported to range from only 5 to 15 these rates could be underreported as it is not usually considered socially acceptable for women to smoke smoking by women is an important area for further exploration given the maledominated nature of the society the global youth tobacco survey performed on 1315 yearold jordanian students in 2007 showed a fairly high prevalence of current smoking of 103 a recent study on a younger cohort in irbid jordan reported a prevalence of current smoking of 229 in boys and 87 in girls this is a high prevalence in a country where more than half of the population is under the age of 18 years studies have shown more than threequarters of students in jordan reported people smoking in their presence on at least one occasion in the previous 7 days another study reported that 657 of male smokers in jordan started their habit at school age before reaching 18 years old there appears to be very little research into smoking behaviour among young people aged 1618 years in jordan and this study is an attempt to fill the gap the aim of this study was to examine the correlates of smoking behaviour among secondaryschool students attending public or private schools in the eastern and western suburbs of amman the health belief model proposes that individuals perceptions of their susceptibility combined with their perception of the severity of a disease results in their assessment of the perceived threat of disease and this determines their motivation to change their behaviour the study therefore also identified the predictors of students knowledge and their perceptions of the severity of lung cancer and their susceptibility to it as a consequence of smoking methods participants and recruitment this paper is based on a quantitative study of secondaryschool students aged 1618 years in amman jordan stratified random sampling was used to select schools and to recruit eligible participants a total of 24 schools were selected randomly out of all 155 secondary schools from a list obtained from the ministry of education website the list was then verified with the moe and the directorates of education the student list was obtained from the selected schools and all eligible students were invited to participate with the prior permission of the school principal participants of the study equally represented the 3 variables sex school type and residential area samples were selected using 3 stages stage 1 was selection of area and schools stage 2 was selection of classes and stage 3 was selection of the study participants classes within preselected schools were chosen randomly and all students from the selected grade were surveyed students participated in the study voluntarily they were informed about the survey and written consent was obtained prior their completing the questionnaire the eastern and western parts of amman were chosen to represent low and high socioeconomic status areas respectively prior to commencing the survey approval from the moe in jordan was obtained for conducting the survey ethical clearance for the study was obtained from the university of sydney human research ethics committee instrument the instrument of the study was based on the lung cancer and smoking survey developed by the american cancer society and founded on the health belief model the original questionnaire was written in english and translated into arabic by a certified translator the translated instrument was verified by the first author 2 academics of the university of sydney and 2 health professionals in jordan who are bilingual and any differences were reconciled the questionnaire was pilot tested on 30 students to test the readability of the translated instrument and ease and clarity in answering the survey questions participants of the pilot study were not involved in the final study the survey collected data on participants background information their smoking behaviour family history of smoking knowledge of lung cancer perceptions knowledge of lung cancer was significantly higher among those who started smoking at a younger age compared with those started at an older age bivariate results show that students in western amman were more knowledgeable than their peers in eastern amman about the best way to diagnose lung cancer its symptoms and possible causes governmentschool students and those who lived in eastern amman were more knowledgeable about the prognosis and fatality of lung cancer compared with students in private school and those who lived in western amman female students scored higher than their male counterparts on knowledge of the symptoms of lung cancer and the possible relationship between smoking and weight loss they were also more knowledgeable about passive smoking and the possible negative effects of smoking ie lung cancer females also knew more of the effects of chemotherapy than males did students in western amman demonstrated significantly better knowledge than their counterparts in eastern amman concerning the effects of chemotherapy and radiotherapy the results also showed that knowledge of smokingrelated consequences was associated with duration of smoking as well as the age of commencing smoking of the seriousness of lung cancer and perceptions of their own susceptibility to lung cancer students were asked to state their daily allowance in order to measure their ability to access cigarettes participants knowledge of lung cancer was assessed by 14 statementtype questions testing their knowledge about lung cancer symptoms and detection and other related questions with response options of agree or disagree perceived susceptibility to and severity of lung cancer were assessed with statementtype questions rated on a 5point likerttype scale from strongly agree 1 to strongly disagree 5 perceived susceptibility was measured with 8 questions while perceived seriousness was assessed by 5 questions scores on each module of the statementtype questions were separately converted into a percentage score out of 100 and presented as mean and standard deviation scores whereby a lower mean indicated lower knowledge lower perception of susceptibility and lower perception of seriousness data analysis bivariate analysis including the chisquared mannwhitney u test ttest and analysis of variance and multivariate analysis including multiple linear regression analysis were conducted using spss version 17 the multiple linear regression analysis was performed to determine the significant predictors of perceived susceptibility of lung cancer once a significant association had been determined between predictors and criterion variables using bivariate analyses results demographic data the 648 participants were equally distributed by sex school type and location students from the western part of amman received a significantly higher daily allowance than their peers in the east of the capital a similar pattern was seen according to school type whereby students in public schools received a lower daily allowance compared with their counterparts in private schools smoking behaviour the data on participants smoking behaviour showed that 435 had smoked daily for 1 year at any point in time prior to or at the time of the survey of the ever smokers 635 were current smokers at the time of the survey the majority of smokers consumed 12 cigarettes daily with more than half obtaining their cigarettes primarily from shops followed by friends and family onequarter of students reported starting smoking at age ≤ 14 years the data on family smoking showed that the great majority of students had a smoker in the family primarily the father followed by a brother more than twothirds of these family members smoked on a daily basis knowledge about lung cancer the means score for knowledge about lung cancer was 463 range 71857 perceived susceptibility to lung cancer a small proportion of the surveyed students believed that their susceptibility to lung cancer was high while more than half of the students saw their susceptibility as low and the remainder were unsure the mean score for perceived susceptibility to lung cancer was 624 range 125100 a far higher percentage of the students in high ses western amman perceived themselves as having low susceptibility to lung cancer compared with their counterparts living in low ses eastern amman perceived susceptibility to lung cancer was assessed against participants smoking variables results from both ttest and anova show that current smokers those who smoked rarely and those who smoked 12 cigarettes per day perceived themselves to be more susceptible to acquiring lung cancer than those who consumed more cigarettes per day also students who depended on their family as the main supplier of cigarettes and those who bought their cigarettes by the pack perceived themselves to be more susceptible to lung cancer compared with students who depended on other sources including friends for cigarettes and those who purchased cigarettes singly the association between perceived susceptibility to lung cancer among other diseases and the sociodemographic variables of students is shown in table 3 sex and school location were significantly associated with perceived susceptibility to certain diseases females and students living in the eastern suburbs of amman believed themselves to be more susceptible to the listed diseases than their male counterparts and students living in western amman perceived seriousness of lung cancer the mean score for perceived seriousness of lung cancer was 618 range 200100 students in grade 10 mean score 651 perceived lung cancer to be more serious than did students in grades 11 mean score 602 and final year 12 mean score 601 in addition students in eastern amman mean score 631 perceived lung cancer to be more serious than did students in western amman multivariate analyses multiple linear regression analyses were carried out to predict perceived susceptibility to lung cancer in relation to demographic and other smokingrelated variables and perceived seriousness of the disease to determine which of the sociodemographic variables could significantly predict the outcome variable regression analysis using dummy variables was carried out the results showed that female students perceived themselves to be more susceptible to lung cancer than their male counterparts and students who perceived lung cancer to be more serious also perceived themselves to be more susceptible to the disease compared with their counterparts the model explained 117 of the variance in the perceived susceptibility to lung cancer discussion this survey showed a high prevalence of current smoking among the studied students at 276 we can locate very few studies that target this exact age group of jordanian youth in order to compare our findings this scarcity of studies was also reported by alzyoud et al who concluded that the prevalence of smoking waterpipes increased with age for example more of the 1516 years old schoolstudents smoked than their 1718yearold counterparts compared with our findings the gyts in 2001 and 2007 conducted crosssectional surveys on a younger age group and reported lower prevalences of current smoking of 108 and 198 respectively a recent study of 7th grade students in irbid jordan also reported a lower prevalence of current smoking compared with our study of 3 different studies performed on university students in jordan one revealed a similar prevalence rate of smoking to our sample the second showed a lower prevalence while the most recent study documented a much higher prevalence studies performed on comparable age groups in neighbouring countries within the eastern mediterranean region reported lower prevalence rates of current smokers 141 in the united arab emirates and 108 in riyadh saudi arabia in egypt the gyts revealed that 4 of 1315 year olds were current smokers in 2005 a considerably lower figure than the 198 reported in jordan by the same study in the latest gyts survey jordan ranked 4th from among 15 countries with regard to the prevalence of current smoking the number of cigarettes smoked is an important indicator of both addiction to and accessibility of tobacco products our results showed that the majority of smokers smoked 12 cigarettes daily while less than a quarter smoked more than 10 cigarettes per day as a comparison approximately 80 of students surveyed in malaysia smoked less than 3 cigarettes per day these differences in consumption may be explained by differences in ses students ability to purchase tobacco products and peer pressure despite laws that prohibit the sale of tobacco products to children under 18 years in jordan 650 of the current smokers surveyed found it easy to buy cigarettes in a shop or on the street by comparison only 406 students in riyadh region and 38 of malaysian students managed to buy their cigarettes from shops and depended instead on social sources the welldocumented strong correlation between adolescent smoking and family smoking habits was confirmed by our study results it was also confirmed in a qualitative study by the authors on the same age group of students our study suggest that students smoke not because of lack of knowledge about the risks of smoking but due to some misguided beliefs and attitudes such as the connection between smoking and weight loss to reduce anxiety and boredom and to enhance attention and concentration and due to factors such as the family environment and school location similar factors were identified by a recent study in irbid jordan with regard to sex differences female students had a better understanding of the symptoms of lung cancer and possible negative effects of smoking concerning lung cancer this finding of our study concurs with the findings of prescott et al in denmark the findings of the multiple regression analysis showed that the age of starting smoking was the only factor to predict knowledge of lung cancer this could be because those who started smoking at a younger age have been smoking for longer and have had more time to think about it and consider it a real threat a study of adolescents in the united states coincides with this findings suggesting that adolescents perceived less risk of adverse effects from smoking socalled light cigarettes however no study on teenagers age at initiation to smoking and their knowledge of possible impact of smoking in jordan was available to compare our results with our finding that females felt more susceptible to heart disease bronchitis and blood circulation diseases than did males is wellsupported by studies elsewhere some of which were on different age groups this in addition to cultural reasons might explain why smoking is less prevalent among female students than males in this part of the world interestingly students in eastern amman felt more susceptible to bronchitis lung cancer and stroke than their peers in western amman this result contradicts the majority of the published literature as it has been hypothesized that those from lower ses are more susceptible to becoming smokers because they usually have lower education and hence feel less vulnerable to acquiring dangerous diseases an explanation for our finding could be that those from western amman have the financial means to purchase cigarettes and thus continue smoking our findings also concur with a who report showing that poor or deprived categories of society smoke more than other groups in all regions of the world except in the emr where high income seems to be a factor in smoking it is important to acknowledge that the data reported in this study pertain to cigarette smoking only and do not include other types of smoking such as waterpipes a habit that is on the rise among young people especially females within the emr the results of this study cannot be generalized to all jordanian youth of the same age category the survey was restricted to 1618yearold students attending certain schools in the eastern and western suburbs of the capital of jordan only and does not necessarily reflect the smoking behaviour of other jordanian students conclusions the high prevalence of current smoking and past smoking among 1618yearold school students in jordan in conjunction with their high exposure to passive smoking in the home environment is alarming despite the existence of legislation to prevent it students access to tobacco references products from shops friends and family members appears to be uninhibited knowledge of lung cancer was higher among those who started smoking before the age of 12 years ie those who have been smoking for longer only onetenth of the surveyed students believed themselves to be highly susceptible to the disease more than half rated their susceptibility as low females and students living in low ses areas felt more susceptible to the disease than those from a higher ses background feeling more susceptible to lung cancer appeared to increase the seriousness with which the disease was perceived as a signing party to the who framework convention on tobacco control jordan is committed to certain legislation regulations and laws to enforce tobacco control among different components of society especially youth however it appears that smoking is prevalent among jordanian youth and that the dangers of smoking in particular the threat of lung cancer are not taken very seriously it also appears that attempts to curtail youth smoking have not been overly effective thus far the authors suggest that this study covers a gap in the literature about this particular age group a very important segment of the population of jordan our findings should provide valuable information to policymakers seeking to tackle the problem of youth smoking not only in jordan but elsewhere in the emr the findings of our study will contribute to a better understanding of those young peoples smoking behaviour and the way they perceive cigarette smoking and its possible consequences the findings of gender and ses differences in the perceived seriousness of and susceptibility to lung cancer point to areas that could be specifically targeted to increase awareness of the consequences of smoking further research should be conducted in other regions and other sectors of jordanian society in order to strengthen our understanding of young peoples smoking behaviour and their perception of certain risk behaviours in order to help policymakers enact effective policies to curb these dangerous behaviours competing interests none declared

smoking in jordan is a serious problem as it affects almost all segments of society including children this study aimed to evaluate the smoking behaviour of jordanian secondaryschool students aged 1618 years their awareness of the dangers of smoking and their perceived susceptibility to lung cancer of the stratified random sample of students from amman schools n 648 43 were ever smokers had smoked for 1 year and 276 were current smokers while 81 reported having a smoker in the family students in western amman higher socioeconomic status and those who started smoking at a younger age demonstrated better knowledge about smokingrelated consequences perceived susceptibility to lung cancer was significantly associated with sex perceived seriousness of lung cancer and school location students sex socioeconomic status and the family environment were important factors that influenced students smoking behaviour and risk perceptions and these findings have significant policy implications

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introduction domestic violence is a public health concern and human rights violation affecting more than one third of all women in global 1 domestic violence and intimate partner violence are frequently used interchangeably in the literature 2 it is estimated that one in three women disclose domestic violence during or after pregnancy but prevalence differs depending on the location 3 the prevalence has been estimated from 3 to 30 percent 4 reaching 15 to 71 in low to middleincome countries 5 in relation to the literature the prevalence of domestic violence may increase during pregnancy remains unchanged or decreases 6 despite the prominence of the dignity of the woman in the islamic there are different types of violence against women 7 the results of a review study conducted in iran with an assessment of 38 articles showed that the prevalence of domestic violence in iranian pregnant women varies from 193 to 945 8 domestic violence during pregnancy threatens maternal and fetal health and is a dangerous but preventable factor for many perinatal morbidity and mortality 9 these complications included isolation reduce maternal social networks inadequate pregnancy care inadequate pregnancy related weight gain vaginal bleeding spontaneous abortion preeclampsia sexually transmitted infections stress reduced quality of life dissatisfaction of pregnancy and drug and alcohol abuse other complications included stillbirth premature birth low birth weight newborn complications avoidance of breastfeeding delayed mother infant bonding maternal abusive behaviors toward their infants and children personality complications 10 11 12 13 14 15 16 women who experience domestic violence often use a variety of mental and behavioral strategies to inhibit or stop the violence 1718 actually in the face of increasing violence mothers often revealed increased activity in protecting themselves and their children abused pregnant women confront significant difficulties in keeping themselves and the unborn baby safe 19 pregnancy can create a common sense of isolation that may be enhanced by experiences of domestic violence and reduce maternal social networks 13 social support provides the chance to discuss stressful experiences receive support and reduced risk of suffering from domestic violence during pregnancy 20 21 22 coping is an essential strategy for managing domestic violence that includes efforts to manage a problem through the continuous change of intellectual and behavioral efforts 23 24 25 in domestic violence situations coping relates to resilience strategies that victims accomplish to minimize harms and handle the situation 26 the two main forms of coping strategies are problem focused and emotion focused coping 2527 the process of coping with domestic violence can be understood in relation to the social and cultural background capacity and access to supportive resources and the severity of the violence 24 the capability to inhibit and cope with violence is different for pregnant women compared to nonpregnant population 2829 and coping strategies are affected by adolescence and pregnancy 30 abused pregnant women may use resilience through problem focused coping adjusting their motherhood expand levels of their social support and seeking help 31 in spite of the increased risks of domestic violence during pregnancy many women use their experiences effectively such as resilience 32 as domestic violence during pregnancy and coping with it has a close association with the social regional and cultural context it is essential to collect the associated information in various social and geographical contexts 33 therefore conducting the research in a certain local context can be the most important factor in better clarification and move toward resolving the problem of domestic violence iranian islamic society is a patriarchal society that highlights mens authority over women in the family 34 35 36 wifes obedience to the husband tolerate husbands violence and keeping the family are womens duties and considered honorable 34 islam has highlighted the mothers were interviewed in mashhad in the north east of iran the results showed abused mothers used escape strategies and situation improvement strategies for managing domestic violence mostly abused mothers used emotion oriented strategies such as escape strategies for managing violence these strategies included of concealment passive dysfunctional behaviors and neutral behaviors some mothers with regard to individual decisionmaking and individual abilities tried to improve their situation by active selfregulation protecting family privacy and help seeking the results of these various strategies vary from reducing domestic violence to not changing the intensity of the violence or intensifying the perinatal domestic violence in conclusion inappropriate strategies against domestic violence could be threatening for fetal and maternal safety and appropriate strategies should be considered in perinatal education understanding the experience of managing domestic violence among abused pregnant women is essential to design evidence based domestic violence prevention strategies and programs issue of family integrity and deems divorce is a lawful but undesirable and discouraged act 36 women are defined by their roles as mothers or wives which expect them to sacrifice and put their husbands and childrens needs ahead of their own to keep their family from breaking up 35 in such circumstances abused pregnant women attempt to adopt various strategies to strengthen their marital relationship and prevent family breakup in order to achieve a deeper understanding about the strategies for managing domestic violence during pregnancy it is necessary to develop a qualitative study that reflects maternal behaviors and needs different qualitative studies on pregnant womens experiences with domestic violence were conducted in the world 1930 37 38 39 but no evidence exist to explain the experiences of iranian pregnant women with domestic violence and their strategies for managing domestic violence during pregnancy understanding the experience of domestic violence among these women is essential to design evidence based domestic violence prevention strategies and programs to the best of our knowledge this study would be the first one to explore iranian womens strategies for managing domestic violence during pregnancy methods design the conventional content analysis approach was used to design this qualitative study to get deeper insight into pregnant womens experiences of managing domestic violence 40 qualitative content analysis is a proper method to study cultural related contextual issue 41 in health science study 42 setting the current study was carried out from october 2019 to june 2021 in mashhad the capital of khorasan razavi province one of the most populous city in the north east of iran at first obstetrics and gynecology departments of teaching hospitals were used to select the participants the reason for this selection were high referral of pregnant women and effective management of these departments purposive sampling led to the selection of comprehensive health center prenatal clinic midwifery counseling center provincial welfare center forensic medicine center social emergency consultant voice center and other related organization as study setting data collection purposive sampling with a maximum variation such as age occupational status education number of marriages gestational age wanted or unwanted pregnancy and domestic violence screening score was used to select the participants data were collected through individual semi structured indepth interviews with 13 women who experienced perinatal domestic violence one husband and one daughter and 24 key informants comprising of health care professionals as well as the specialists in reproductive health social working forensic medicine psychology law sociology and media two focus group discussions with attendance of 20 abused mothers were conducted because of their resistance to be interviewed individually the participants profile is shown in tables 1 and2 inclusion criteria were maternal agreement for participation in the study their ability to communicate with the researcher endorsing perinatal domestic violence and ability to share their related experiences exclusion criterion was maternal physical and mental disease that prevent their participation in the study interviews were conducted by the first author with good experience of qualitative research and 23 years working experience in the field of reproductive health and midwifery the interviews were accomplished at a time and place that was appropriate to participants and were audio recorded the interviews continued until the data saturation data saturation was obtained following 37 interviews and 2 focus group discussions however to confirm data saturation two further interviews were carried out which revealed no new data in the field of different maternal strategies in managing domestic violence an interview guide with open ended questions was used to explore participants experiences as follows please describe your experience of violence during pregnancy or postpartum other questions followed the main question were how do you react when you are abused how does pregnancy influence the managing skills you used what are some of the ways you keep yourself and unborn baby safe and what is your advice for other pregnant abused women and service providers the interviews lasted between 30 and 120 min and each focus group took approximately 90 min data analysis conventional content analysis was used to explain the research question the data were analyzed concurrently with data collection based on the graneheim and lundman method by maxqda software 42 after each interview the first author listened to it several times to get an overall perception of the content and then transcribed the interview verbatim and read it several times to obtain a general understanding of the data the text of each interview was divided into meaning units as words sentences and paragraphs the meaning units were condensed and condensed meaning units were summarized and coded codes were compared based on the similarities and trustworthiness to confirm the rigor and the trustworthiness of the data guba and lincolns criteria including credibility confirmability dependability and transferability were applied 43 to maintain the credibility of the results the data analysis were reviewed and approved by the participants and three expert qualitative researchers to increase the credibility purposive sampling with maximum variation and appropriate size was used for dependability the correctness of data analysis was approved by three external skilled researchers in qualitative research in order to maintain confirmability some of the transcripts along with the codes and categories were provided to the main supervisor as well as three other faculty members outside the field of study and the process of analysis was confirmed to make transferability possible the research characteristics including the participants and the context of the study were described in detail therefore other researchers could be able to evaluate the transferability of the results results the abused mothers age were ranged between 19 and 41 years maternal educational levels ranged from illiterate to doctor of philosophy degrees domestic violence screening score ranged from 11 to 20 in present study 1568 codes 20 subcategories 6 categories and two main themes emerged from the data analysis through the data analysis escape strategies and situation improvement strategies were emerged as the main themes escape strategies was comprised of three categories including concealment passive dysfunctional behaviors and neutral passive behaviors situation improvement strategies was comprised of three categories including positively active selfregulation protecting family privacy and help seeking a more precise presentation of the results is given below quotations from the participants are included to better clarified womens strategies for managing domestic violence during pregnancy escape strategies abused mothers were constantly confronted with the harms and threats posed by violence and had to deal with these harms in different ways at first they tried to reduce the psychological stress of violence in various ways such as concealment passive dysfunctional behaviors and neutral behaviors without directly paying attention to husbands violence reduction concealment the special sociocultural conditions of iran and various contextual factors caused abused mothers to conceal violence concealment of violence abused mothers were initially at a crossroads in choosing to disclose domestic violence or conceal violence mostly abused iranian mothers concealed perinatal domestic violence despite the routine screening for domestic violence during prenatal care they hided violence from family friends the health care system and the legal community and in this manner they manage perinatal violence in their ways one participant stated in my opinion all pregnant mothers are abused in some way but they do not disclose it they dont tell this situation to anyone they hide violence passive dysfunctional behaviors abused mothers knew they were being harmed by violence but remained in a relationship due to maternal commitment and lack of support usually they used passive dysfunctional behaviors to decrease psychological complication emotional release abused mothers initially react to their husbands violence by crying getting angry and even laughing this quote reflects it abuse to husband and child some abused pregnant women try to get rid of psychological distress by sexual disobedience sexual ignorance and even extramarital relationships and thoughts of killing their husbands one participant stated i got very upset when my husband bothered me so i slept in another room and i did not allow him to have sex under the psychological stress of perinatal domestic violence a few mothers hit the fetus harassed and beat their children and even left them one participant declared when i was angry because of my husbands violent behavior i hit the baby in my stomach and empty myself in such a way helplessness and confusion pregnancy and postpartum create a sense of isolation for mother that magnified by experiences of domestic violence inefficient selftalk leave spirituality inattention to herself selfworthlessness selfforgetfulness and wish for death were maternal strategy for dealing with the emotional effect of perinatal domestic violence one participant explained i have not prayed for a long time previously nothing could stop me from praying but i stopped praying for a while now im very sad every time i did not pray i felt as if i lost something i lost my way recourse to divorce a few abused mothers decided to divorce as the final solution to get rid of their abusive husband when they could not find another way to reduce the violence one mother said if my husbands behavior had not changed and he continued to be violent i would have separated from him even with a child because my child would be under more pressure in this stressful life neutral behaviors the result of the present study indicated that neutral passive behavior such as placating strategies and diverting attention were of the common strategies used by abused mothers to minimize the recurrence and intensifying violence in their marital relationships placating strategies placating and conscious acceptance of violence were recommended by most of participants as one of the best ways of minimizing the recurrence of perinatal domestic violence placating such as silence tolerance patience obedience indifference waiver and violence normalization were of the best ways of keeping peace in the house the following quote reflects it a pregnant woman may face the worst insults disrespects and behaviors in her husbands house but she must be silent she should be quiet and calm in the house diverting attention diverting attention from the issue of violence forgetting and justification mechanism were maternal strategies for dealing with domestic violence the following statement confirm this despite violent behaviors of my husband i tried to calm down by diverting my attention i was involved with my baby in my womb this made me not to think about violence applying situation improvement strategies some mothers while believing in the necessity of covering up violence with regard to individual decisionmaking and individual abilities and in the shadow of high selfesteem and selfconfidence or disclosing violence and seeking support tried to improve their situation by active selfregulation protecting family privacy and help seeking active selfregulation maternal urge to protect the unborn baby and protect marital life were of the most important impetus to reduce domestic violence by selfactualization comprehensive selfcare skills promoting positive selfconcepts resilience and strengthening spirituality selfactualization some abused mothers used the maternal active strategies for dealing with domestic violence in order to be able to protect the privacy of the marital life without causing psychological harm these strategies included creating a good mood selfrelaxation return attention through enjoyable activities positive mental imagery and maintain authority skills and empowerment these quote reflects it every time my husband was beating me the baby in my womb was in a bad mood her movements were slowing down but i was entertaining myself every day as soon as my husband left the house i would do the housework and go for a walk with my children to calm down so that we would feel better comprehensive selfcare skills the abused mothers acquired comprehensive selfcare skills through physical selfcare emotional psychological selfcare social selfcare and spiritual selfcare the following statement approve this i was prioritizing for myself i made time for myself i even went to the park so that the baby in my womb could hear the sound of the babies in the park i controlled myself i calmed myself down promoting positive selfconcepts maintaining and promoting selfconfidence selfesteem and selfcontrol were the strategies that the abused mothers used to promote positive selfconcepts the following statement confirm this some pregnant women lost their selfconfidence during pregnancy they think that their husbands are no longer interested in them because their appearance has become ugly and they have become fat so their situation is getting worse day by day i never told my husband that i was ugly during my pregnancy and postpartum i always told i m very good and i have no problems resilience despite the increased risk of domestic violence during pregnancy many women effectively navigate their experiences and come to display adaptive outcomes such as resilience resilience included promote individual growth being purposeful internal control flexibility realistic look and thinking positive one participant stated i think a part of the husbands violence is because of economic issues i understand the pressure on my husband in life i think it is fair to tolerate verbal violence occasionally but not other types of physical sexual and emotional violence especially during pregnancy strengthening spirituality abused mothers endorsed strengthen spirituality as a form of adaptive coping strategy in dealing with perinatal domestic violence relying on god appealing to the imams and submitting to the divine destinies were the strategies which resulted in maintaining maternal peace and reducing her vulnerability and ultimately increasing maternal ability to protect the privacy of the marital life this quote reflects it no one can help me only god can help me only god can create an opening in my life and improve my situation only imam reza can help me protecting family privacy the result of the present study showed that protecting family privacy by a purposeful effort to correct spouse behavior supportive efforts and maintain maternal commitment were the active maternal problem solving strategy for dealing with domestic violence constructive purposeful efforts in the initial exposure to violence some mothers tried to control violence by a purposeful effort to correct husbands behavior such as turn disputes into positive negotiation building trust create intimacy promote his information maintain his authority meet his sexual needs encourage him for psychological counseling and trying to change his destructive behavior the following statements indicate it i tried to maintain my husbands authority and i did not do anything without his information when the fetal movement was reduced i endured a lot of anxiety from morning to night but i didnt want to go to the hospital without my husbands information to control the fetal heart rate supportive efforts some mothers supported their husbands in economic and emotional status although supportive efforts did not reduce the husbands violence it could improve the mothers psychological states and it affected the mothers sense of satisfaction with her ability and empowerment one educated mother stated i was teaching at university before i got pregnant i had some savings i paid for my prenatal care and screening tests because i felt my husband was resisting paying for them i was so happy to be able to pay for my prenatal care maintaining maternal commitment maternal commitment such as efforts to maintain fetal health trying to keep the children calm and priority the comfort of the fetus and children to maternal liberation from violence made mother to stay in an abusive relationship and didnt think about separation in fact mothers sacrificed themselves and put their childrens needs ahead of their own to keep their family from breaking up one mother explained when you become a mother the feeling of motherhood makes you look at life differently you are responsible for maintaining the health of your child and the most important thing is to be patient and tolerant preserving marriage some abused mothers tried to save their marital life despite their husbands violence because of their interest in cohabitation and their husbands satisfactory commitment one participant stated although my husband sometimes abuses me but my marital life is good i think my life is better than my sisters and my moms i love my husband my husband is a man who has been standing on his own feet since he was 15 years old i m very satisfied with my life i do not want to lose my life avoiding social judgments avoiding social isolation and preventing the stigma of divorce the stigma of remarriage preventing the lack of financial support after divorce and the lack of a supportive family prompted the abused mother to try to protect the privacy of the marital life one participant described i was born and raised in a small town if a woman divorces society and her family look at her with pity and her life will destroy these are the things that make a mother stay under violent circumstances and try to save her common life help seeking the result of the study revealed that some abused mothers finally tried to generate solutions by disclosure violence and gain formal and informal support disclosure of violence some abused mothers finally disclosed domestic violence following the failure of previous strategies and the intensification of violence maternal empowerment and familiarity with individual rights the ability of the health care system to identify violence the presence of supportive families and support systems and the intensification of violence have been factors that facilitated the disclosure of violence the following statements confirm this men should know that they have no right to abuse pregnant women now i have come to forensics i want to make it clear to my husband that he has no right to beat a pregnant woman looking for network support domestic violence reduced maternal social network and the result of the present study demonstrated the importance of formal and informal support and seek help from these support systems in facilitating dealing with domestic violence formal support was included health system psychological counseling use of welfare services forensic medical center social worker relief committee the police and justice informal support was included friends and family abused mothers formed a friendly alliance and asked help from formal and informal support systems the following statements confirm this abused mothers should be informed about support systems what services can they receive from the health centers where can they go for psychological counseling discussion this is the first qualitative study in iran which identified maternal strategies for managing perinatal domestic violence according to the results maternal strategies used for managing perinatal domestic violence included escape strategies and situation improvement strategies in the shadow of maternal commitment to preserve marriage and child health mostly abused pregnant women in the early stage of confronting with violence used emotion oriented strategies such as escape strategies for managing violence gradually the recurrence and intensifying of violence caused applying situation improvement strategies these results are similar to lazarus and folkman conceptualization in which emotion focused coping was used to reduce distress associated with problems such as violence and problem focused coping was used to manage the problems 44 despite the routine screening for domestic violence during prenatal care the majority of abused iranian mothers concealed perinatal domestic violence they hided violence from family friends the health care system and the legal system several factors were important in concealing violence such as inadequate information on violence maintaining social reputation protecting the unborn child facing multiple fears social judgments lack of family support and poor performance of health care and judicial systems this result is consistent with damra et al 45 study similar to a study by kaye et al 30 findings from this study showed abused young mothers adopted retaliation and fighting back as an emotion oriented strategy which usually had no effect on reducing violence but sometimes intensified husbands violence similarly few abused mothers harmed themselves to cope with the psychological stress and presented additional health concerns which is aligned with previous study conducted by bhandari et al 19 similar to a research by zakar et al 46 findings from this study revealed that some abused mothers did not submit demands of their husband ignored them and used husband abusive behavior such as sexual disobedience to get rid of their psychological distress these strategies had no effect on reducing violence and sometimes cause more violent behavior of husbands domestic violence usually causes maternal social and physical withdrawal to decrease their emotional distress this result is aligned with the previous study 30 consistent with a study conducted by bhandari et al 47 findings from the present study indicated that some abused mothers used placating strategies and diverting attention to minimizing the recurrence of perinatal domestic violence and keeping peace in the their house some abused mothers used active selfregulation such as selfactualization comprehensive selfcare skills resilience and strengthening spirituality they could control their distress by these effective strategies these results indicate the importance of educating mothers about the cycle of domestic violence the warning signs to look for in marriage and how to develop safety after termination of a violent marital life that is consistent with another study 48 selfcare is recognized mindful activities and taken by women families and societies to promote the health status 49 some abused pregnant women displayed resilience and actively responding to their husbands harassment behavior for dealing with domestic violence resilience cause maternal wellbeing after violence the result is similar to the study conducted by levesque et al 31 that victimized pregnant women may display resilience consistent with the study conducted by zakar et al 46 participants in the current study used strengthening spirituality as a form of emotion oriented strategies these strategies made abused mother calm in dealing with domestic violence some mothers used family protection strategies and stayed in a marital abusive relationship maternal commitment and protection of the fetus were the important motivation for dealing with perinatal domestic violence this result is in contrast to bhandari et al 47 study abused mothers in the face of intensifying violence increased activity in protecting themselves and their children which is similar to the result of previous study conducted by gillum et al 18 pregnant and postpartum women used safety planning resisting placating and formal and informal support networks to deal with violence in their lives this result is align with bhandari et al 47 study social support was associated with reduced risk of perinatal domestic violence since this kind of formal support could provide the opportunity for abused mothers to discuss about their vulnerable experiences and receive support in the context of perinatal domestic violence this result is consistent with the previous studies 20 21 22 family support could help abused mothers to reduce violence and promoting maternal and fetal health similarly family support could help mothers decide to leave the abused marital relationship which is consistent with previous studies 2550 women who received psychosocial counselling showed a reduction in the frequency and severity of domestic violence and this included both physical and emotional abuse psychology counseling could be an effective approach to reduce the recurrence of violence in pregnant women exposed to domestic violence the basics of counseling was empowerment and increasing selfcondense through this way abused mothers found that they are able to find appropriate solutions to solve domestic violence through their empowerment and positive negotiations with their husbands the results were similar to the previous studies 5152 the result of the present study recommended that life skills training classes should be considered for abused pregnant women in health centers to reduce the prevalence of prenatal domestic violence which was similar to the study conducted by taghizadeh et al 53 in line with the study conducted by zakar et al 46 bhandari et al 47 and kaye et al 30 some abused mothers used problem solving strategies such as gaining formal and informal network support and asked help from these support systems which could facilitate dealing with violence the results of this study increase understanding of iranian pregnant womens strategies for managing perinatal domestic violence which could enable support systems to encourage abused mothers to use more effective strategies and seeking help to reduce domestic violence these include strengthening formal and informal support systems and facilitating access for abused pregnant and postpartum women to formal and informal services particularly the effective health care system according to the different cultural values of iranian society further research is needed to explore facilitators and barriers of disclosing domestic violence during pregnancy similarly further research is also needed to design effective interventions for women who report domestic violence during and after pregnancy strength and limitation this is the first study performed in iran to explore iranian womens strategies for managing domestic violence during pregnancy similarly data collection through interviewing with specialists from various disciplines diversity of participants and multiple perspectives of domestic violence during pregnancy and postpartum were the strengths of this study patriarchal cultural context of iran and the difficulty to obtain responses from the abused mothers considering the taboo of violence were important limitations of this study information regarding domestic violence during pregnancy is considered an individual family issue and should not be discussed with strangers even though they are health care providers that may in turn lead to under reporting of domestic violence during pregnancy by the participants practical implications despite the methodological limitations of the study our findings will be useful to health care providers program managers and policy makers in addition to women and human rights activists they can be used in the development of specialized training and materials for building providers capacities to deal more effectively with cases of domestic violence during pregnancy and postpartum and it is also fundamental to collaborate with other professionals in order to develop shared healthcare pathways conclusion the high prevalence and the negative consequences of domestic violence against pregnant women provide a golden opportunity for performing interventions pregnancy and protection of unborn child could affect maternal strategies for dealing with domestic violence the results of the various strategies that the mother used to reduce perinatal domestic violence vary from reducing domestic violence to not changing the intensity of the violence or intensifying the perinatal domestic violence it is noteworthy that adopting inappropriate strategies against domestic violence could be threatening for fetal and maternal life and appropriate strategies should be considered and emphasized in maternal education understanding the experience of domestic violence among these women is essential to design evidence based domestic violence prevention strategies and programs • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from authors contributions mab rb kmn rlr and mmb designed the study mab was involved in data collection mab and rb finalized verbatim for the results mab rb kmn and rlr contributed in data analysis and interpretation mab wrote the draft of manuscript while rb kmn rlr did an extensive review of the manuscript all authors read and approved the final manuscript competing interests the authors declare that no potential conflict of interest with respect to the research authorship and publication of this article exists

background domestic violence during pregnancy is a severe public health problem abused pregnant women are confronted with the threats posed by domestic violence pregnancy and protection of the unborn child could affect maternal strategies for managing violence the purpose of this study was to explore iranian womens strategies for managing domestic violence during pregnancy methods this qualitative study was conducted in october 2019 to june 2021 in mashhad iran data were collected through individual semi structured interviews with 13 women who experienced perinatal domestic violence two relatives and 24 related specialists as well as two focus group discussions with attendance of 20 abused mothers until the data saturation was achieved data were analyzed by the conventional content analysis approach of graneheim and lundmanthe main themes escape strategies and situation improvement strategies were emerged as the result of data analysis escape strategies was comprised of three categories including concealment passive dysfunctional behaviors and neutral behaviors to control maternal emotional distress situation improvement strategies was comprised of three categories including active selfregulation protecting family privacy and help seeking to control violenceunderstanding the experience of managing domestic violence among pregnant women is essential to design evidence based violence prevention programs which enable supportive healthcare and social systems to encourage abused mothers to use more effective strategies and seeking help to overcome domestic violence

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introduction in germany children with an immigrant background still have to face disadvantages regarding variables that are health related such as psychopathological problems or obesity their educational success and the probability for them to live in highrisk environments is higher leuzingerbohleber et al 2011autorengruppe bildungsberichterstattung 2020 bundesministerium für arbeit und soziales bmas 2021 sachverständigenrat deutscher stiftungen für integration und migration svr 2021 however it is not the migration background per se that poses the risk of these children being disadvantaged but rather factors associated with the migration of the parents psychological factors in the context of different phases of the migration process and socioeconomic factors which create a difficult development environment for these children particularly disadvantaged are children of mothers who have just recently migrated to germany because the mothers themselves are in an emotionally insecure situation they have to find their way in a new environment without experienced caregiverssuch as their parents and siblingsavailable especially in the vulnerable time after the birth of a child they often feel isolated and alone and the risks of social withdrawal loneliness and depression are significant these stresses and strains on the mothers can have a negative effect on the emotional quality of the early motherchild relationship and the security of attachment and thus bring additional disadvantages to the children which assigns them to a special risk group of the immigrant population this shapes the developmental context for the children and can have negative consequences for their development a child who unconsciously perceives that its mother feels strange in the new country and is very homesick could get into a loyalty conflict in which integration into the country of immigration is experienced as a betrayal of the mothers home country as a result it can be quite ambivalent for a child to adopt a bicultural identity and to learn the language of the new country and its development can be further impaired if it gets stuck in these ambivalences if parents have been unable to process their migration experiences sufficiently the stressful effects of migration can be transmitted to the next generation as kogan described the grieving process that is necessary for a mature processing of the migration experience can be impaired by feelings of guilt toward those who remained in the country of origin as well as previous traumatic experiences before or during the migration especially for refugee families it is important to reduce the likelihood of the parental trauma being transmitted on to the next generation furthermore many are confronted with other stressful factors after their immigration a lack of early integration can be associated with a possible disruption of attachment development in the course of migration and young motherhood as the results of the frankfurt prevention study showed in germany there are a number of projects that promote the social integration of children with an immigrant background the majority is aimed at older children or adults as the focus is on learning the german language and the wellbeing of small children is not explicitly taken into account although in recent years more emphasis has been put on early child development and parenting skills this makes sense because children do not start with their active language acquisition before their second year of life and during the first years of life learning their mothers tongue is most important as is known language development is based on earlier embodied experiences and preverbal relationships stern showed in his studies on the developmental stages of the self that the verbal self in the second year of life is based on earlier developmental stages empirical research results also suggest such an approach infants growing up in an emotionally secure and positive environment learn languages more easily show less aggression are more creative and show a better affective cognitive and socioemotional development it can therefore be assumed that approaches based on early relationships in the immediate living environment could improve the integration of children with a migration background in infancy and toddlerhood all these results and assumptions led to the development of the first steps intervention a psychoanalytically oriented prevention program for immigrant families who mostly have a low socioeconomic status and are difficulttoreach1 they generally use counseling services less frequently than many german families the intervention was offered from birth of the child until them entering kindergarten as described before its focus is on the specific challenges and needs of families with an immigrant background seeking to optimize the early developmental environment of children at risk of growing up disadvantaged due to their parents acute migration the project has been inspired by the psychoanalytically oriented first steps program by meurs et al in belgium which started in 2000 and has already been evaluated their results indicate that children with an immigrant background and children with and without an immigrant background affected by poverty show developmental delays in different domains already during the first 3 years of life in addition meurs et al showed that their program helped to prevent early developmental delays in immigrant children especially if they were affected by poverty and that in the long term the program had positive effects on the school success of the children compared to a matched control group of children with an immigrant background furthermore to our knowledge no other psychoanalytically oriented early prevention for immigrant children exists so far emotional availability originally introduced by mahler et al is a construct describing an individuals emotional responsiveness and attunement to anothers needs and goals it refers to the ability of a dyad to establish an emotionally healthy connection including a wide range of emotions positive as well as negative bornstein et al define ea as the open eager collaborative reciprocal communication that can occur between a mother and infant under optimal conditions regardless of their culture place of residence or socioeconomic status ea as described by biringen is characterized by a dyadic perspective rather than a unidirectional reaction of the caregiver to the childs signals which means that both mother and child contribute to the overall quality of the interaction the emotional availability scales assess ea as a multidimensional construct consisting of four dimensions focusing on the caregiver and two dimensions focusing on the child sensitivity refers to adult qualities regarding the ability to be warm and emotionally connected with the child closest connected to the classic concept by ainsworth et al it comprises a positive authentic and genuine affect as well as the congruence of verbal and nonverbal channels of expression structuring refers to the extent to which the adult serves as a mentor guiding the childs activities and providing a holding framework nonintrusiveness describes the absence of overdirective or overstimulating behavior unrequested interferences or overprotection of the caregiver nonhostility refers to the absence of hostile reactions of the caregiver hidden or obvious in deed or word responsiveness of the child refers to the emotional as well as the social responsiveness of the child to the caregiver it comprises both the affective and the behavioral quality of the childs reaction thus its eagerness interest and pleasure to a parental invitation to interact this scale reflects the concept that most closely approximates the current attachment view of a securely or insecurely attached child and relates to the childs ability to explore independently of and respond affectively positive to the caregiver childs involvement of the caregiver is about its ability to attend to interactions with its caregiver to engage him or her and to invite the himher into a playful exchange overall the eas were applied in more than 22 countries showing adequate validity and reliability in each of them see review by biringen et al positive associations of ea with attachment security have been reported for different samples from europe northamerica japan and israel furthermore studies reported positive associations with the childs capacity for emotion regulation sleepwakeregulation or the social and language development see review by biringen et al parental knowledge about childrearing in italy the united states and argentina and mothers psychosocial functioning in a mexican group of immigrants in the united states in addition several studies have shown that samples at high risk of developmental problems due to various psychological or mental problems have a comparatively lower ea for an overview see biringen et al see also rickmeyer et al only very few studies though compared the crosscultural level of ea among immigrants from different parts of the world but living in the same country or ea patterns in different countries to date the abovementioned study by bornstein et al investigating n 220 dyads from the united states argentina and italy is the only published study of crosscountry comparisons using the eas in this study the scores in structuring and sensitivity of italian mothers were higher than the ones of mothers from the united states and argentina in a study by derscheid and derscheid et al with subcultural comparisons in the united states no significant differences in ea were found between african american caucasian and hispanic motherchild dyads several prevention or intervention studies using the eas exist indicating that they are sensitive to change this was reported in two studies on adopted children one on internationally adopted children compared to nonadopted ones in the united states by garvin et al and one by van den dries et al on children adopted mostly from china but also some other countries by families in the netherlands in the study by garvin et al parental ea predicted postinstitutionalized childrens improvement of social adjustment over time van den dries et al found children whose adoptive mothers were more sensitive to show less indiscriminate friendliness and former foster care children to improve to a higher extent than former institutionalized children regarding their responsiveness after adoptive placement furthermore studies using an ea intervention training showed an enhancement of ea this was the case also for adopted children in an ea parent intervention but not in a control group and for both children and teachers in an ea child care intervention also compared to a control group in a recent study with a brief parenting intervention with only one session for middle class motherchild dyads from 0 to 3 years only the child dimensions showed significant improvement in an attachmentbased intervention study with multicultural pregnant adolescents in australia the intervention group scored significantly higher than the comparison group in two subscales in a free play situation and additionally in maternal sensitivity in a free play plus separationreunion setting both in the nurse family partnership study on lowincome mothers and their infants as well as in a study using parenting child interaction therapy on families at risk for child abuse parental sensitivity improved significantly more in the intervention compared to a control group recently a parenting child interaction therapy with toddlers showed amongst other things positive effects at a communitybased australian child behavior treatment clinic regarding all ea scales for two different time points posttreatment compared to a waiting group salomonsson and sandells showed in a randomized controlled trial comparing two groups of motherinfant dyads in sweden amongst other things that maternal sensitivity improved significantly more in the motherinfant psychoanalytic treatment plus chcc compared to only child health centre care they showed in an additional study including qualitative characteristics of mothers and babies that maternal sensitivity improved significantly more for an ideal type of babies they created and called affected by disturbance in the mip than in the chcc condition in a longitudinal perspective in a four wave study of a subsample of a community based sample in canada of motherchild dyads without an intervention ea among the mothers turned out to be stable whereas child ea significantly increased during infancy and the toddler years into preschool to our knowledge the eas have not been used yet in order to evaluate the effects of a psychoanalytically oriented intervention for immigrant background and meurs et al did not apply the eas or another attachment related instrument in their study thus our study is a pilot study in this respect regarding variables influencing or interacting with parental and child ea at one time point or predicting it across time there is some evidence that maternal education maternal perceived social support age of the mother age of the child and child gender may play an important role for child gender the reported results are inconsistent some reporting no differences while others indicate higher ea scores for mothers in interaction with daughters than with sons as mattegagné et al sum up child gender is generally associated with differing emotional reactions of the parents for maternal education as an indicator of ses there has also been found a relation to maternal ea but as mattegagné et al point out mostly not in a longitudinal perspective ses in general seems to influence both parenting behavior implicit parenting motives or health socioemotional and cognitive development of children furthermore access to social support seems to play an important role for maternal ea during infancy both at one point of measurement and in a longitudinal perspective with higher levels of social support predicting higher levels of maternal sensitivity and structuring mattegagné et al found the same for the level of maternal education however when social support was controlled this relation disappeared and additionally they found a prediction of lower levels of maternal hostility by level of maternal education in addition the age of a child is supposed to influence the complexity of mutual exchanges and the age of the mother is considered to influence maternal characteristics considering the reported results on the eas sensitivity to change due to an intervention as well as on stability especially of the parental dimensions over time without an intervention the scales seemed to be a suitable instrument for our study in order to investigate a potential change in the emotional relationship between the participating mothers and their children due to our program still in sum the findings on variables predicting parental and child ea across time are inconsistent and further research is needed aims and hypotheses the project first steps aimed at evaluating the implementation as well as the shortand longterm effectiveness of psychoanalytically oriented professionally supported early parenting intervention a compared to the outcomes of intervention b led by paraprofessionals in a rct design amongst others it was expected that at time of measurement t2 the children in intervention a show a significantly greater improvement in the quality of ea measured by the emotional availability scales in interaction with their mothers compared to the children in intervention b in relation to a baseline measurement when the children were approximately 511 months old this is the topic of this substudy since longitudinal studies suggest stable parental ea over time without an intervention during infancy and the toddler years it is expected that if effects are found they will mostly be attributable to intervention a or b respectively for children it is more of an open question whether intervention or developmental effects will be predominant since mattegagné et al found a change in both of the ea child dimensions over time attributable to natural developmental processes the current study aimed a examining the following questions 1 do the motherchild dyads in intervention a show a significantly higher increase of eas scores post treatment compared to the motherchild dyads who received intervention b 2 are these intervention effects only found on the maternal dimensions of the eas or also on the child dimensions materials and methods the intervention intervention a first steps as described before in more detail the mothers2 were supported by psychoanalytically trained female project staff who were mostly mothers with an immigrant background themselves mainly in moderated weekly motherchild groups conducted by two project staff members and if necessary in individual contacts the mothers and children were ideally supported from the time of birth until the children entered kindergarten the training of staff included a curriculum psychoanalytic supervision with child and adolescent psychotherapists and a regular reflection on group dynamics and topics with the coordinator of the practical implementation3 the manualized curriculum is based on empirical and psychoanalytic developmental psychology and was developed by the frankfurt coordinator claudia burkhardtmußmann its conceptualization is based on other already evaluated psychoanalytically oriented parenting programs especially on the first steps project in belgium conducted by meurs et al see meurs andjullian as described by lebigervogel et al the practice staff was trained to develop a psychoanalytic mind set and to assume a holding and containing function during group sessions and in contact with each woman4 this also helped them to gain a deeper understanding of the situation of mothers in the vulnerable phase of their early motherhood as well as the needs of the children and enabled them to serve as role models and a secure base the focus thus was on the individual needs of mothers and children questions and concerns of families about the development of their child as well as questions in connection with the immigration of the families in this way the project staff supported parenting skills and coping with difficulties related to recent immigration in a typical psychoanalytic approach the topics of the group meetings were not fixed rather themes which were brought up by the participants during the meetings were discussed our approach as well as the belgian one can best be described as relationshipbased development counseling intervention b in intervention b the motherchild groups took place with the same frequency and duration group leaders were two female paraprofessionals also mainly mothers all with an immigrant background they were encouraged to pass on their experiences to the mothers and to invite for exchange as a kind of helping people help themselves but were only instructed and informed about the study very basically including the frequency and duration of the weekly group meetings the aimed duration of the intervention until children enter kindergarten and the research instruments otherwise they were free to lead their groups according to their views and experiences as immigrants and mothers they received no contentrelated support and apart from contact to the research team regarding organizational questions and collecting data had no contact with the project implementation design of the study the longitudinal study was carried out in a rct design with two different recruitment strategies as described above in frankfurtmain integration courses of three collaborating institutions served as clusters and were randomized because women from the same integration course could not be referred to different intervention offerings in berlin at a maternity unit of a large hospital the vivantes clinic neukölln first generation immigrant mothers also with little knowledge of the german language were informed about the study as soon as possible when visiting the clinic in order to carry out a single randomization when they agreed to participate the participants were all blinded to their group assignment that is if they were participating in intervention a or in intervention b as described in more detail before as described before the sample size calculation and power analysis is based on α 005 at a power of 080 at least small effect sizes were expected leading to a number of n 72 participating motherchild dyads ideally selected per treatment participants all participants who agreed to be videotaped at both times of measurement were included in this substudy thus a subsample of motherchild dyads from 37 different countries who had recently moved to germany was included in this study5 informed written consent was obtained from all of the participating mothers the three largest groups were the following n 34 of the mothers had subsaharan origin mostly coming from ghana ethiopia or eritrea as well as from kenya nigeria somalia and sudan n 19 women originally came from north africa mainly from morocco and algeria as well as from egypt and n 18 mothers were from turkey the majority of the women reported to be muslims followed by christians the age of the mothers at the first time of measurement varied between 1846 and 4405 years average age of the mothers was almost identical in both groups mean level of school years was 1110 years 214 of the women reported no graduation 786 reported having graduated either in their country of origin in germany or in both countries 169 did not specify their level of education of those reporting a graduation mostly in their country of origin but some also in germany 123 reported a minimal level of school education 114 reported lower secondary education 537 had alevelshighschooldiploma of those having a graduation 343 reported a college degree and 356 reported to have a different kind of vocational qualification but only 59 had already worked in the profession they had been qualified in in germany concerning family status 161 of the women reported to be a single parent or to be widowed divorced or separated altogether 22 the majority of the women were married or lived together with their partner without being married together 78 the age of the children at the first time of measurement varied between 193 and 2803 months they were 45 female and 55 male children study procedures and instruments assessments in order to assess the main outcome of this study the emotional availability scales were applied as noted above the eas consist of six dimensions each dimension can be scored on a dimensional scale with values from 1 to 7 in a direct global score a higher score indicating a higher ea independent raters blind rated videos from a freeplay motherchild interaction where the instruction to the mothers was to interact with their child as usual other studies reported partly good partly excellent contextual retest and interrater reliabilities which seems to hold independently from setting after being trained and certified by the developer of the eas zeynep biringen all four raters in the present study were blinded to the motherchild dyads intervention group for the global ratings they achieved an interrater reliability of icc 09410 which indicates excellent agreement observation length was scheduled 30 minutes stemming from findings showing reliability increasing with observation length the following potential confounding variables were tested due to their relevance indicated by previous studies either descriptively or inferential statistically age of the child sex of the child age of the mother depressive symptoms overall strains of the family using a mannwhitney utest family resourcessocial support level of education of the mothers in years partnership depressive symptoms and strains of the mothers were included due to their associations with a healthy emotional exchange with their child depressive symptoms of the mothers were assessed at baseline with the german version of the center for epidemiological studiesdepression scale a widely used standardized selfreport screening instrument with good psychometric criteria the overall strains of the family were also assessed at baseline with help of the heidelberg stress scale a standardized screening instrument that allows to estimate familys stresses and resources and shows satisfying psychometric criteria due to the fact that not all of the mothers agreed to be videotaped or to attrition over the course of the intervention the comparability of the two groups a and b at baseline was not taken for granted even though the rct design was pursued as described thus both groups were compared regarding all relevant sociodemographic variables at baseline in almost all of these variables no significant baseline difference between the groups a and b were found using a ttest a mannwhitneyutest when assumptions for parametric testing were violated or for nominal variables a chi square test only in overall strains of the family assessed with the hbsl significant differences using the mannwhitneyutest were found and it correlated with posttreatment maternal sensitivity leading to its inclusion in later analysis level of maternal education was also included as a covariate for maternal sensitivity due to its potential but especially in a longitudinal perspective still unclear influence especially on this dimension in previous studies depression scores assessed with the ads were low on average and scattering in both groups thus this measure was not included in later analysis additionally ads scores were below the clinical cutoff score of 22 in both groups which suggests a nonclinical sample statistical analyses since the design of this study is an analysis of variance design with repeated measures the methods used for evaluation were analysis of variance and analysis of covariance models the betweensubjects factor is the intervention group and the withinsubject factor is the time of measurement thus the initial value in each of the 6 dimensions of the eas compared to the value in the eas dimensions after the intervention spss version 230 was used for all statistical analyses additionally to anovas with each of the eas dimensions the described characteristics were added as covariates to the models since both anova and ancova are relatively robust against violations of assumption of normality and of homoscedasticity despite the violation of normal distribution in the included variables and homoscedasticity in some of them the anova design was still pursued results table 2 shows the mean values of the six different ea dimensions preand posttreatment testing the relationship between them at baseline and post treatment revealed a significant correlation between all of them with each other r 048 p 000 child responsiveness r 049 p 000 child involvement r 039 p 000 all correlations were highly significant with nonparametric tests too however the anovas with repeated measures for each of the eas dimensions revealed no significant main effects and no interaction effects for the parental dimensions only for maternal sensitivity the interaction effect was found to be almost significant with a small effect size f 349 p 0064 η 2 003 for the child dimensions significant effects of time of measurement were found for both child responsiveness f 501 p 0027 η 2 004 indicating a small effect size as well as highly significant effects for child involvement of the parent f 4552 p 0001 η 2 028 for the latter with a large effect size but again no interaction effects with the intervention group factor were found these findings hint to developmental effects in children in both child dimensions no other main effects and interactions were significant in the anova models the significant and highly significant main effects for the child dimensions were in line with significant simple main effects which were found when looking separately at intervention a and b for child responsiveness this was the case only for the intervention group a f 599 p 0016 η 2 005 due to an increase of the mean value in this group from baseline to post treatment for child involvement highly significant simple main effects were found for group a f 3258 p 0001 η 2 022 and for group b f 17337 p 0001 η 2 013 again due to an increase of the mean values post treatment but for this dimension in both groups additionally for nonhostility simple main effects showed for the comparison group b f 424 p 0042 η 2 004 due to a decrease of the mean value in this group from baseline to t2 in the intervention a condition among the potential confounding variables tested inferential statistically in ancovas controlling for overall strains of the family assessed with the hbsl f 619 p 0014 η 2 005 and mothers duration of school education f 585 p 0017 η 2 005 both led to a highly significant and for the latter to a significant interaction effect both with a small effect size of intervention group and time of measurement for maternal sensitivity in the expected direction controlling for both variables in one ancova led to a highly significant interaction effect of intervention group and time of measurement for maternal sensitivity f 798 p 0006 η 2 008 with a medium effect size again in the expected direction thus mothers in intervention a showed a significant increase of sensitivity post treatment compared to the mothers who received intervention b who showed a slight decrease no other significant interaction effects between the factors time of measurement and intervention group were found including all other possible confounding variables for all other scales discussion to our knowledge this study is one of the first ones using observations of motherchild dyads from different cultural origins to shed light on variation of ea in the context of a preventive support for recently immigrated families as far as we know only one other study looking into eas scores in an immigrant population in europe exists so far however in the study by van ee et al no program was evaluated and as already mentioned in the belgian program no attachmentrelated outcome was assessed our study aimed at comparing the effects of two different interventions on the relationship quality of children with an immigrant background in germany to their recently immigrated mothers measured by the eas therefore the effectiveness of first steps compared to an intervention with paraprofessional group leaders was evaluated in a prospective randomized comparison group design anticipated was that the promotion of the earliest parentchild interactions and parenting skills in the professional psychoanalytically oriented intervention would have a greater positive impact on the quality of the parentchild relationship than the intervention of paraprofessionals with an immigrant background as described comparable intervention doses were offered in the course of the three years of intervention to ensure that effects would be caused by the type and not just by different amounts of intervention our hypothesis therefore was that all parental ea outcomes in the first steps group would be superior different from what was expected repeated avonas revealed no significant group differences for all four parental eas dimensions for the child dimensions the effect of time of measurement was highly significant which can be interpreted as mostly natural developmental effects a result which is in line with the findings of mattegagné et al in a longitudinal study during infancy and the toddler years still on the level of simple main effects for each intervention group only in the first steps groups child responsiveness significantly improved in addition when controlling for confounding variables a highly significant medium sized interaction effect of time of measurement and group was found for maternal sensitivity with an increase of the mean value in the first steps condition as hypothesized and a slight decrease in the comparison group consistent with the findings of other studies controlling for overall strains of the family as an indicator of social support and for maternal education as an indicator of ses in this regard was found to be of additional explanatory value thus to control for both of these confounding variables was found to be useful in detecting significant effects in favor of the first steps condition this allows for the tentative conclusion that despite the nonsignificant results for the remaining eas dimensions maternal sensitivity as well as child responsiveness were influenced more positively by a participation in the first steps intervention it could be hypothesized that a participation in the psychoanalytically oriented professional intervention increased the mothers sensitivity toward their childs signals and the childs emotional response to her the systematic group differences indicate that the broader more individual and professional first steps intervention explicitly focusing on the individual needs of the participating families is more suitable to support the quality of the motherchild relationship amongst immigrant motherchild dyads than usual care this is in line with the results of meurs et al regarding the efficacy of their intervention on early developmental delays in immigrant children and their school success it is an important question why first steps participation yielded effects on maternal sensitivity and child responsiveness but not on the other ea dimensions however this result it is in line with the results of salomonsson and sandells study on a psychoanalytic plus vs only a communitybased intervention a ceiling effect might be an explanation for the absence of differential outcomes for maternal nonhostility as salomonsson and sandells point out still the simple main effect due to a decrease of nonhostility for the comparison group b allows for the tentative conclusion that participation in the first steps intervention may additionally have prevented mothers from becoming more hostile in interaction with their children when they grow older nevertheless the described effects might not be broader due to the fact that the intervention b could at least to some extent also offer continuity and a holding experience while offering group sessions and thus could support immigrant mothers and their children in this vulnerable phase of early parenthood too as described the burdens on families in the context of migration can be particularly high in the period after the birth of a child moro 2014 see also lebigervogel et al support in everyday life for the young parents by experienced and trustworthy caregivers such as close relatives like grandparents and friends is oftensince they are far awaynot possible early parenthood among immigrants therefore easily leads to a situation that is overwhelming for them accompanied by the risk of depressive withdrawal and social isolation all these factors as well as the described disadvantages immigrant children still have to face in western societies stress the importance of preventive approaches with a welcoming culture as was implemented and pursued in the first steps intervention as early as possible in the lives of these vulnerable children limitations and implications for future research the generalizability of the present results is limited to immigrant mothers of the first generation in germany several other limitations should be noted first no fathers were included in the present study limiting its results to only one parent of the included children as biringen pointed out ea is a relational construct and each dyad has its own pattern and history of ea thus including the fathers might have in some cases led to different conclusions however we decided not to include fathers in the group meetings since this would possibly have created quite a different atmosphere which would have made it a lot more difficult to open up especially for women with cultural backgrounds where gender segregation is a common phenomenon like in many muslim societies this could easily have been the case taking into account that more than half of the participating women reported to have a muslim religion another limitation is the representativeness of the reported findings because this study only included a subsample which consists of those mothers who completed the 3 years intervention and not the whole original sample however no significant differences in baseline characteristics were found between the participants who dropped out and the ones who finished the intervention additionally both the insecure and sometimes fast changing living conditions many immigrants have to face as well as the long duration of 3 years contributed to the fluctuation of the participants in addition it is important to take into account that natural developmental effects in the ea child dimensions which are of course tremendous in the first years of life seem to be predominant leading to only slight variations due to interventions which are designed over such a long time period another limitation is that due to the naturalistic design and associated practical reasons the age range of the children is quite large both at baseline and post treatment which is problematic regarding the interpretation of the results however since there are no significant differences regarding the age ranges in both groups at both times of measurement this limitation is of minor relevance furthermore the comparability between the two institutional settings in the two cities as well as the different randomization strategies should be taken into consideration regarding the generalizability of the reported findings however due to this design advantages and disadvantages of a setting in two different institutional contexts in two different german major cities with a large percentage of families with an immigrant background could be explored providing important implication for future projects see fritzemeyer et al for a detailed comparison of the two different locations an important methodological issue is the validation of the methods used as described before in at least 22 countries all over the world the eas have been applied with validity and reliability in each of them see review by biringen et al however as pointed out comparisons from a crosscultural perspective in order to investigate possible crosscultural differences in ea levels were only made in very few studies by now the same applies for instruments assessing possible covariates and concurring predictors like depression since its expression might vary in different cultures too this tackles a commonly discussed problemthe adaptation of instruments validated in a specific sample to a new language and a different cultural group where crosscultural validity of the applied research instruments is not guaranteed an important subject for future studies factors like social desirability gratefulness or phenomena of overcompensation in the first time after a migration might have also played a role here however it should be noted that the often times unstable life circumstances of the families and lacking german skills made it particularly difficult to recruit the participating families to assess data and to conduct a longitudinal study with this sample implications for future research are to further shed light on which of the specific components of our program are especially useful to support immigrant families furthermore it would be interesting to investigate with a larger sample differential effects of the intervention for different groups of immigrant families eg those with a refugee background or women who immigrated through family migration the findings recommend controlling for the overall strains of the family and mothers duration of school education in future studies it could be particularly promising to investigate how mothers traumatization influences the effects of the psychoanalytically based intervention on ea because studies indicate that traumatized mothers show lower ea scores for example in the study by van ee et al in the netherlands a positive relationship between maternal posttraumatic stress symptoms and unstructuring hostile or insensitive but not intrusive maternal behavior was found in a sample of asylum seekers and refugees additionally infants of mothers who were traumatized showed lower levels of involvement and responsiveness individual development and adaptive education of children at risk which is supported by the landesoffensive zur entwicklung wissenschaftlichökonomischer exzellenz of the state of hessen germany it was additionally funded by the bundesamt für migration und flüchtlinge by the state of hessen regierungspräsidium darmstadt the hertie foundation the international psychoanalytical association the bundesministerium für familie senioren frauen und jugend aktion mensch the world childhood foundation the metzlerfoundation the ursula ströher foundation the crespo foundation the rotary club berlin and a private donator data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the studies involving human participants were reviewed and approved by the ethic review the commission of the federal chamber of psychotherapists of the state of hessen germany has approved the final study protocol and the final version of the written informed consent form written consent was obtained from each participating family the trial has been carried out in keeping with local legal and regulatory requirements written informed consent to participate in this study was provided by the participants legal guardiannext of kin funding first steps was carried out by the sigmundfreudinstitut and the annafreudinstitut in the center for research on conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher copyright © 2022 lebigervogel rickmeyer leuzingerbohleber and meurs 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

background in many western countries like germany the social integration of children with an immigrant background has become an urgent social tasks the probability of them living in highrisk environments and being disadvantaged regarding health and educationrelated variables is still relatively higher yet promoting language acquisition is not the only relevant factor for their social integration but also the support of earlier developmental processes associated with adequate early parenting in their first months of life the emotional availability scales eas measure the quality of caregiverchildinteractions as an indicator of the quality of their relationship and thus of such early parenting focusing on mutual and emotional aspects of their interaction method this pilot study examined in a randomized controlled trial the effects of the prevention project first steps regarding the hypothesis that the emotional availability ea improved to a greater extent in difficulttoreach immigrant motherchild dyads in a psychoanalytically oriented early intervention a first steps compared to a usual care intervention b offered by paraprofessionals with an immigrant background a sample of n 118 immigrant women in germany from 37 different countries and their children was compared with regard to the parental eadimensions sensitivity structuring nonintrusiveness and nonhostility and the child dimensions responsiveness to and involvement of the caregiver in the prepost rct designdifferent from what was expected repeated anovas revealed no significant prepost group differences for the parental dimensions for the child dimensions the effect of time of measurement was highly significant which can be interpreted as mostly natural developmental effects still on the level of simple main effects for each intervention only in the first steps groups child responsiveness significantly improved when controlled for confounding variables a significant interaction effect for maternal sensitivity in favor of the first steps

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background a key component of the marketisation of higher education has been rising tuition fees and the notion that university students are customers or consumers of education despite opposition to neoliberalism in the sector the increasing reliance on metrics to drive policy and practices is indisputable to the extent that it has been described as metric fetishizisation and datafication of he a significant contributor of the shift towards capturing and quantifying educational parameters has been the acquisition reporting and usage of the views of undergraduate students surveying university student ratings of their educational experiences befits the contested ideology of them as consumers evaluating the service or educational product that they have experienced there are benefits for universities being associated with desirable metric outcomes particularly the enhancement of national and international reputations as a consequence of favourable publicly available information in the uk this effect is galvanised by the incorporation of metrics into governmental evaluations of institutional quality and publicly available thirdparty schema such as league tables and good university guides hazelkorn highlights the heightened influence of metrics worldwide being driven by their inclusion in league tables the practice intensifies competition between institutions in a reputation race and may lead to contestable datadriven decisionmaking by senior managers thiel provides evidence of deleterious impacts of the effects on the academic community of management practices resulting from responses to survey outcomes drawing on notions of power and governmentality there is significant evidence of negative effects of metricisation in many organisational sectors baird and elliott articulate the problem with performance metrics underlying issues with performativity whereby academic staff try to improve metrics without believing in their utility spence builds on this by highlighting the narrow focus that educational metrics provide and how this leads to the illusion that universities are managing and controlling something more effectively but doing so produces consequences that run counter to the spirit of the overall exercise on the other hand there is evidence that university surveys have played a role in enhancing experiences through empowerment of university students and their student unions as institutions respond to published outcomes it has also been argued that selfreported educational survey metrics can act as proxy measures of the success of the pedagogical approaches used and there is a wellestablished assertion that tertiary level learners can make valid judgements of the quality of their educational experiences however there are complex interacting factors that influence survey participants and many counter views this emphasises the need for research into the nature of information about university courses that should be used to inform prospective students about their quality and potential value in those countries that they are used selfreported surveys can augment a culture of he institutions focusing and responding to overly simplistic quantified ratings there is a particular emphasis in the literature of evidence and viewpoints from the uk and australia for tertiarylevel education as their national survey instruments derived from a common ancestor these countries were early adopters of large scale selfresponding surveys of he student views we refer to adisa et al and hazelkorn for wider insights into the proliferation and worldwide use of this type of survey instrument often being linked to notions of satisfaction with university experiences satisfaction remains a contested term and surveys of student views normally provide a highly constrained and a highly simplified view of the complex notion of satisfaction despite the limitations purported measures of satisfaction are widely reported in research literature government outputs and general media in contrast the reporting of dissatisfaction and disagreement is much less prevalent in narratives about higher education metric outputs when there is an option of neutrality in survey instruments levels of disagreement do not simply represent an inverse of agreement meriting separate explorations of all three outcomes it seems a particularly valuable opportunity to explore disagreement metrics in an era of vociferous debate about value for money for university students and a need to avoid disappointment and complaints from he participants there is a long history of evidence that satisfaction and dissatisfaction represent different dimensions providing different information about views rather than merely being simple opposites of each other explorations of customer dissatisfaction are widespread most commonly in research literature for marketing and businessrelated disciplines however this is now highly developed in other sectors including a range of sophisticated measures of service quality in he such as the adaptations of servqual personal expectations are known to play key roles in governing subsequent dissatisfaction with the lived reality and subsequently complaint behaviours for example notions of unfulfilled expectations that lead to customer complaints include defective products poor service quality and unfulfilled promises dissatisfaction with products and services is generally the precursor to complaints and can result in the loss of consumer demand through negative brand association in the current study of the uks national student survey we necessarily use a widely applied and simple interpretation of the notions of student satisfaction and dissatisfaction derived directly from the metric responses to the survey item that enquired overall i am satisfied with the course participant satisfaction is therefore represented by metric outcomes of likert responses 4 and 5 and dissatisfaction by 1 and 2 to this survey item this simplistic metricsdriven approach is established in literature that explores the uks survey instrument the neutral response the midvalue of 3 is interpreted as neither satisfied nor dissatisfied in a broader sense we follow the ethos of oliver who interpreted student satisfaction as the favourability of a students subjective evaluation of the various outcomes and experiences associated with education our reliance on metrics means that we make no attempt to develop theoretical frameworks around notions of satisfaction further context about these concepts is provided by douglas et al and khan and hemsleybrown there is substantial literature that identifies complex and interacting factors that shape university student satisfaction varying in the level of influence academics can manage them examples include graduate employment campus and social life attainment personality traits and lecturer attitudes and behaviours it is argued that delivery of experiences that heighten student satisfaction requires employees of a university to adhere to the principles of quality customer service the socalled service encounters as students engage with university systems can lead to moments of truth as experienced by customers and these form an important part of their overall impression of the whole service perceptions of such experiences are largely driven by interactions between people however other aspects may significantly influence perceptions of general service quality senses of belonging in the educational journey and loyalty to the course or institution can further modify holistic perceptions of the wider student experience and influence student survey ratings the contentious studentascustomer perspective is a wellknown viewpoint that modifies narratives of the student experience in complex ways lala and priluck contrast uk student experiences with general customer service frameworks highlighting how comparatively simple it is to switch between commercial service providers compared to the complexity of leaving a uk university course in he systems such as those of the uk university students are subject to high switching costs not just financially but also due to the disruption of the educational process difficulty in finding and applying to a new course and emotional challenges of leaving one place and adapting to new physical and social spaces this complexity may make students more inclined to complain than to exit and this discontent is captured at least in part by survey comments and metrics student decisionmaking varies across the world as a consequence of the influences of many interrelated educational cultural and societal factors such as student expectations course experiences and ultimate learner outcomes drivers of universitylevel student dissatisfaction have been unearthed through qualitative explorations of student views for example douglas et al used critical incident analysis to elucidate the drivers of satisfaction and dissatisfaction using questionnaires and handwritten narratives in douglas et al this body of work provides valuable evidence of the importance of themes of communication and attentiveness as key contributors to satisfying and dissatisfying aspects of undergraduate student experiences these themes have been related to metric predictors of student satisfaction and there is consensus that very few survey items strongly predict the overall satisfaction metric in the uks national student survey instrument these relate to ratings of courses running smoothly perceived effectiveness of teaching and to a lesser extent the support they receive there remains minimal research connecting the accompanying text comments to the output metrics langan et al found that a higher proportion of negative text comments about aspects of course organisation and teaching was associated with lower overall satisfaction these were also the aspects of the student experience commented upon most in the participant text responses there remains a paucity of evidence that dissatisfaction disagreement metrics are explicitly made available in he worldwide although the notion may be raised in local reporting dissatisfaction metrics are reported in other areas such as medicine architecture digital resource use as well as broader consumer views we focus on the uks national student survey that was launched in 2005 the selfresponding instrument was introduced as a development of the australian course experience questionnaire and intended to provide publicly available data to inform prospective students about where to study before being used for quality assurance and quality enhancement purposes for more information about its history refer to richardson et al andkandiko howson andmatos the original instrument harvested views from over two and a half million university student participants and reported mostly steady yearonyear increases in its metric outputs during its lifetime from 20056 to 201617 this was despite indications of levelling off of some dimensions such as teaching before the instrument was modified the rise in metric outcomes was widely interpreted as the product of changes implemented by uk institutions as a consequence of responding to student views after 10 years of usage the nss instrument underwent a review the original core set of questions was later modified and relaunched in the 201718 academic cycle providing 12 years of data from the original instrument the new survey instrument included additional dimensions and reworded items but retained much of the original uk national survey instrument reported on here which comprised the six dimensions teaching assessment and feedback academic support organisation and management learning resources and personal development much of the original survey wording remained unchanged in the new version including the holistic rating of overall satisfaction overall i am satisfied with my course this single item is often considered to be a survey dimension on its own it is now indisputable that the uks national survey instrument has had significant impacts on the uks he sector emanating from reporting of student satisfaction and agreement metrics which are incorporated into a governmentallevel teaching excellence framework or tef there remains dynamism and debate about the use of nss metrics including the halving of their contribution to the tef the uk he ecosystem is viewed as susceptible to tensions associated with metrics and we suggest that international audiences can benefit from our dissection of the lifetime of a national survey instrument as means to unveil metric drivers associated with student satisfaction and dissatisfaction the current study provides new insights into national student surveys by reporting longitudinal patterns of disagreement and neutral metrics in contrast to discourses dominated by narratives about student success and satisfaction machine learning is used to rank the importance of predictors of student dissatisfaction metric outcomes are methods the quantitative approach used follows langan and harris who explored levels of student agreement across institutions in the uk nss the survey is administered by an independent agency to acquire information about the views of undergraduate students in their third year of study the output metrics are intended to inform the choices of stakeholders such as potential future students acting as a surrogate measure of the quality of the courses participants provide ratings of agreement for positively worded statements about university experiences for consistency with previous research we refer to survey items using the notation q eg q1 for survey item 1 for each item there is the option of neutrality therefore expression of disagreement is not necessarily an inverse of agreement only the final core survey item in the uk survey enquires directly about respondent satisfaction with their course the term satisfaction in this context is also commonly used in the wider literature to refer to other survey dimensions as well such as students being considered to be satisfied with teaching in reference to items in the teaching dimension strictly this usage is not representative of the wording of these survey items which are ratings of the experience and not an explicit expression of respondent satisfaction here we use terminology such as agreement and disagreement with the positively worded survey item statements the terms satisfaction and dissatisfaction are used in reference to the outcomes of the survey item enquiring about overall satisfaction with the course the current study utilises the full lifetime of the original uk survey instrument to provide a longitudinal view of the metric outcomes drawing on 12 years of returns to explore consistency and patterns over time the revised instrument in 2017 was very similar in general terms but added new survey dimensions including learning opportunities learning communities and the student voice the core components of the original survey instrument were retained often with identical or very similar wording 1 3 500 respondents during each year for analysis and used raw data for all student typologies this resulted in a set of 154 institutions and 2741654 returns across the 12 years random forest analysis was used to interrogate the dataset to rank individual survey items q1q21 in their association with classification of overall dissatisfaction neutrality or satisfaction for survey item q22 this approach is widely used in classification analysis where the task is to identify associations between a set of predictor variables and a categorical dependent variable in general terms random forest analysis is a powerful supervised machine learning algorithm that creates multiple decision trees creating a forest of outcomes each slightly different we used the metric survey items to classify the outcomes of the overall satisfaction question to create the different trees the analysis samples subsets of the overall dataset selecting a subset of variables and cases the outcomes were aggregated for an overall ranking of which survey items best predicted the satisfied dissatisfied or neutral responses for our analysis we selected five predictors per tree and 500 trees using a selection of 70 of rows for each tree the relative importance of each predictor in the model structure was assessed as an equally weighted mean percentage of increase in mean squared error and its gini score ranking survey items in order of their importance in predicting dissatisfaction we qualitatively compared the importance of different variables in predicting each of the overall satisfaction class finally a simple university ranking table was created based on overall satisfaction and compared it to an alternative ranking based on dissatisfaction to facilitate examination of differences between these approaches all analyses were conducted using the statistical package findings trends of survey dimensions longitudinal trends of agreement disagreement and neutrality are shown in fig 1 highlighting the gains in ratings of 4 and 5 responses over the original surveys lifetime over time students became more satisfied and less dissatisfied together with a diminishing proportion of neutrals generally there were very few upper outliers within the agreement metrics and also there were few lower outliers with disagreement metrics however outliers representing institutions in the extremes of the datasets indicate that certain dimensions particularly those of organisation management and learning resources had examples of extreme levels of underor overperformance in the sector there were only minimal levels of disagreement at the start of the survey for dimensions such as teaching and personal development thus yearonyear changes were relatively minor and levels remained around 5 of the sample population most dimensions were relatively stable in their minimal levels of disagreement by the end of the survey instruments lifetime arguably with the exceptions of assessment and feedback and learning resources that still appeared to be declining in contrast there were clear declines in the levels of neutrality across all dimensions and at comparatively similar magnitudes the variation between the survey dimensions in the reductions of neutrality and disagreement that ultimately drove the increases in agreement is summarised in table 1 in terms of absolute values reductions in neutral responses to bolster agreement rather than this being a consequence of reductions in disagreement were most pronounced for the dimensions of personal development and teaching increases in metric outcomes of the other dimensions were more balanced in terms of the relative contributions to agreement of reduced levels of neutrality and disagreement this was with the exception of assessment which exhibited the highest level of enhancement overall and in this case the gains were drawn mostly from reductions in levels of disagreement fig 1 predictors of dissatisfaction and neutrality the predictors of dissatisfaction and neutrality were identified by calculating the amounts of variation explained by survey items explanation of variation was dominated by the organisation and management item the course is well organised and running smoothly tougher with items enquiring about perceptions of teaching notably q1 staff are good at explaining things and q4 the course is intellectually stimulating ratings of courses running smoothly were also the strongest predictor of neutrality and to a greater degree than with agreement and disagreement metrics the teaching dimension was most strongly associated with dissatisfaction together with low ratings of the support item q11 and the personal development item q21 in the latter case the perceived lack of confidence expressed in q21 was more dissatisfying when rated low rather than its presence being perceived as satisfying all other items made minimal contributions to the variation overall satisfaction and are considered to be little more than noise in the model illustrative league table based on dissatisfaction the survey instrument was not designed for comparing institutions wholesale or for its outputs being incorporated into calculations of simplistic league tables there is a very strong quantitative rationale that institutional output metrics from the nss should not be used for calculations that lead to rankings there is greater variation within institutions than between them and a lack of statistical differences between institutional outcomes other than at the extremes of the dataset however as simpson articulates well surveys beget rankings and survey ratings are routinely incorporated into third party ranked good university guides that have significant influence the uks teaching excellence framework uses metrics from some of the nss instruments as part of the calculation to simplistically rank institutions as bronze silver or gold therefore as much as the authors agree that league tables and rankings can be misleading we feel justified in providing a table of ranked institutions for illustrative purposes only this hypothetical exercise is for research purposes and should be viewed only as a way to demonstrate change that results from shifting emphasis to metrics of disagreement table 2 highlights ranking differentials of a selection of institutions after switching emphasis from measures of satisfaction to dissatisfaction change in rankings overall represents a zerobalance calculation so the winners and losers are balanced out in terms of net positional changes in the extremes there was minimal change in ranking of the very highest and lowest ranking institutions based on satisfaction when a lack of dissatisfaction became the premise however below these stable extreme groupings institutions began to show marked changes particularly midranked grouping which contained the institution that would have most benefited for the whole dataset institution aaaa this extremity climbed 47 places in the league table once the refocus was positioned on a lack of dissatisfaction the third ranked institution originally dropped seven places to 10th which shows significant changes occurred in the highest ranked institutions the greatest drop in ranking was an institution that would have dropped from a ranking of 22nd based on satisfaction to a ranking of 55th if an absence of dissatisfied participants was the focus discussion this longitudinal exploration of a national student survey has demonstrated several outcomes for the first time firstly the determinants of dissatisfaction and neutrality metrics were to a large degree both stable over time and mimicked that of student satisfaction secondly the widely publicised yearonyear increases in student satisfaction metrics have been driven by complex reductions in neutrality and disagreement from across different survey dimensions finally an illustrative league table developed from the longitudinal dataset has illustrated how a notional shift to the usage of dissatisfaction metrics would have impacted significantly on relative rankings of many uk universities table 2 an illustrative table to show institutional rankings based on percentages of both overall satisfaction and overall dissatisfaction based on 12 years of outcomes from the original survey instrument for illustrative purposes a selection of the 20 highest and lowest ranking institutions together with a middle grouping is shown overall dissatisfaction outcomes are shown alongside their relative change in rankings providing a relative difference that would result if the emphasis was moved away from the notion of satisfaction disagreement rankings 120 disagreement rankings 6685 predictors of dissatisfaction there was a clear set of metric predictors of overall dissatisfaction that are similar but not identical to those known to underpin overall satisfaction metrics for the entire lifespan of the original instrument variation in q22 was dominated by items enquiring about perceptions of the course running smoothly and aspects of the taught experience the trend was apparent for all three of the broad metric outcomes satisfaction dissatisfaction and neutrality and the overarching influence of perceptions of course organisation is supported by explorations of respondent free text comments aspects of teaching and course organisation have been highlighted as influential in other types of student survey notably the uks hepi student academic experience surveys consider wider aspects of the he experience several recent hepi reports reported experiences of teaching as most influential of student attitudes about perceptions of value for money these surveys also provide evidence that factors not measured in the nss such as teaching contact hours the likelihood of getting a wellpaid graduate job and personal wellbeing have greater impacts on the quality of the student experience than course organisation this approach exposes limitations of relying on single survey instruments such as the nss for decisionmaking despite being the largest in the uk in terms of participation rates and most influential we acknowledge several key constraints on our interpretations including that survey instruments such as the nss are highly constrained in the comprehensiveness of the information that they can harvest about the student experience and bespoke to the he ecosystem they are exploring in addition the current study provides a highlevel synthesis and there may be more subtle granular effects such as differences between subjects or participant demographics in addition we explored longterm data from the original uk survey instrument and this instrument has now been modified satterthwaite and roudsari explored the uks updated nss instrument and found that together with the perceived value of teaching quality a new category of learning opportunities was of significant importance parapadakis used related artificial intelligence approaches to explore nss metrics from computer science courses and agreed generally with our predictors whilst also highlighting differences in predictive factors between institutional typologies and institutional rankings the validity of using simple metrics to explore notions of satisfaction is of course disputable but they provide insights into university students and are relatable to other forms of research douglas et al revealed perspectives of notions of student satisfiers and dissatisfiers using critical incident analyses questionnaires and handwritten narratives that are relatable with the outcomes of the current study they positioned the student experience as a serviceproduct bundle that consists of elements such as physical or facilitating goods explicit sensual services and implicit psychological services the most impactful themes identified in douglas et al were around the themes of teaching ability of staff and subsequently in douglas et al the themes of communication and attentiveness to student needs were of highest importance many of the other aspects of the student experience were perceived as largely neutral in the interpretation relating to the noise of many items in our models predicting satisfaction we suggest that the key determinants in douglas works can be linked to the main nss dimensions identified as predictors in the current study notably teaching quality student support and to a lesser extent course management adopting this terminology in the current study the most influential item pertaining to perceptions that students courses are running well was the only example of an item being more of a satisfier when it was perceived as happening than a dissatisfier conversely the teaching experience seems to have been more of a dissatisfier when perceived as poor quality than a satisfier when perceived as high quality the nuanced outcome of some factors being more dissatisfying than satisfying was also the case for items enquiring about advice and support being able to contact staff and confidence in problemsolving douglas et al suggest institutions should focus on satisfiers as a means to improve the service for their primary customers whereas our outcomes suggest both dissatisfaction and satisfaction could be considered together as they represent different groups of participants with different viewpoints and needs drivers of metric gains in satisfaction the wellpublicised national increases in student satisfaction in the uk during the lifetime of the original survey instrument were driven by reductions in levels of both neutrality and disagreement we suggest that this scenario is preferable to one where the increase in satisfaction was drawn from neutral changing to express agreement with unchanged levels of disagreementdissatisfaction since the inception of the national survey there has been a mantra in ukhe of moving from threes to fours this has been in reference to the surveys likert scale of 1 to 5 where 4 is the threshold to be considered an agreeable response thus there was a possibility of reduction in neutrality but not dissatisfaction potential ceilings to levels of satisfaction were identified by langan and harris and the inverse in the current study is floors that are apparent in some dimensions based on disagreement dissatisfaction the flattening of outcomes occurs towards the end of the original survey instruments lifetime suggests a potential difficulty to reach population was prevailing before the survey instrument was reviewed and modified this situation prompts questions of how to further reduce the levels of disagreement and whether institutions will focus on this group if disagreement metrics are not reported directly the notion of a resilient dissatisfied group raises a possibility that student dissatisfaction may qualify as a wicked problem that will not be entirely solved a scenario that has been suggested for other he challenges this research flags a need to explore the new survey instrument when it has been administered for sufficient time to explore longitudinal trends there are already documented perturbations of the uks student views including drops in metric outcomes of the updated nss instrument and other nationallevel survey outcomes during the global coronavirus pandemic captured that remain under scrutiny use of disagreement metrics we suggest that there is need for debate about the public visibility of disagreement metrics if agreement metrics are to continue to be utilised and reported publicly disagreement and dissatisfaction provide a wider view of student survey outcomes and potentially could enhance datadriven decisionmaking it is acknowledged that there are risks associated with emphasising dissatisfaction including fuelling discourse about students as displeased customers at least in some contexts of their university experiences this approach could exacerbate known issues with neoliberalism in the sector such as the impacts of surveys on staff mental health and this in the context that students may not be fully aware of what is in their best interests dissatisfaction metrics could unfairly highlight the views of few individuals if they are the focus be seen out of context and disproportionally impact staff mental health meaning that studentcustomer satisfaction is not a worthy aim for colleges and universities the use of tabulation of rankings that we have provided is purely a mechanism to demonstrate how disagreement metrics could influence the uk he sector outcomes simply ranking them to show change if dissatisfaction metrics were available we suggest that it is extremely likely in the uk that some thirdparty providers would rank institutions in similar fashion to the use of agreement metrics we do not support compounding these metrics into rankings and acknowledge that the disagreement metrics represent only a small proportion of respondent views in the nss it is arguable that despite being a small proportion of the sample population these are important voices to be recognised representing several hundreds of thousands of nonsatisfied individuals over the surveys lifetime the hypothetical exercise showed how there would be noticeable changes in ranked outcomes and the most likely to be affected were institutions in the squeezed middle and not those in the extremes of the dataset there is also consideration that the competition for improved league table positions means that institutions need to change viewsexperiences of neutral and dissatisfied individuals in what seems like a hardtoreach group potentially creating the wicked problem of tackling student satisfaction as there may be for student withdrawal the current study prompts the question as to whether disagreementdissatisfaction metrics should accompany metrics of agreementsatisfaction consumer ratings that are negative are highly influential even if they represent a tiny proportion of the response population such as looking at the most negative reviews of products outliers in the current study show that some institutions have a significant number of students who expressed nonsatisfaction with their courses it is debatable whether universities should place more value on the majority vote of satisfaction or the lesspalatable minority who are dissatisfied in one sense we suggest that it is useful for stakeholders to have more information and greater context as long as they are contextualised in terms of the sample population they represent on the other hand authors such as thiel and sabri provide strong views that student surveys can have impactful negative impacts notably on academic staff tensions between the processes of marketisation of he financial drivers access for greater numbers diversity of students and the satisfaction of all stakeholders are beyond the limits of the evidence base of the current study we do however provide evidence of the changes in nonsatisfied participants for the lifespan of a national survey instrument and suggest the outcome need context for meaningful interpretation we also acknowledge that practices such as thirdparty rankings are an unsubstantiated reality of modern some he cultures arguably avoidance of reporting and utilising dissatisfaction metrics could be viewed in the same light as when he practitioners make difficult decisions in the design of higher learning programmes that enhance learning gains but are not popular with students there remains a need to clarify the effects at a more granular scale in terms of separating analyses of the ratings of disagreement and agreement amongst other outcomes this would highlight drivers of extreme dissatisfaction it has been suggested that the anchors definitely agree and mostly agree are less of an issue and can be combined for reporting as a measure of satisfaction whereas definitely disagree and mostly disagree are distinct and should not be combined as a measure of dissatisfaction this suggests more research is required to determine how dissatisfaction is usefully reported if it is agreed to be beneficial as a notional concept in the support of providing this type of information it is obvious that some prospective students may wish to know the levels of dissatisfaction for particular courses views of displeased customers in general are highly valued for example the negative impact of 1star reviews has been shown to be greater than the positive impact of 5star reviews the availability of dissatisfaction data would provide a more comprehensive representation of student views than the focus on agreement in terms of league table rankings even with a wholesale move to disagreement from agreement heis in the extremes of the rankings would likely see very little difference in this notional change the highestranking institutions had little potential for change due to the low proportion of neutrality and disagreement despite potential headspace for improvement in levels of agreement the very lowestperforming institutions in this context were significantly lower than counterparts that sat only slightly higher in the rankings and would thus need substantial change to enhance rankings it is important to stress again that although the survey outcomes are not designed for rankings they are most impactful when third parties do this we suggest it is necessary to frame the point in this manner as a means to emphasise the potential of a change of ethos there is a hypothetical argument that students that have made the decision to express disagreement would be more difficult to influence unduly than their neutral counterparts as a means to enhance the surveys outcomes there is evidence that institutions have used techniques to inflate the survey outcomes albeit much of this is in mainstream media these include signals to students to consider what do you have to lose by returning high metrics whereas poor nss outcomes may impact the reputation of their home institution and consequently negatively affect their own life chances there are many opportunities and means to overtly or covertly influence respondents to be more positive there also remains a possibility that campbells law is in effect namely that the more any quantitative social indicator is used for social decisionmaking the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor conclusions this study has confirmed that a narrow range of aspects of the student experience captured by a national level survey drove dissatisfaction metrics the most influential items were related to course management and teaching quality a finding that is consistent with predictors of satisfaction metrics most items were more dissatisfying when perceived as poor or absent than satisfying when effective or present this was apart from the most influential factor of a course running smoothly which was more of a satisfier when considered to have occurred diminishing levels of reported neutrality and disagreement that drive agreement metric enhancements were dependant on the survey dimension led to the increasing levels of positive responses nationally outliers show that some institutions are under and overperforming in the uk sector in terms of levels of dissatisfaction representing many students who have invested in the experience it is acknowledged that our findings are derived from the original uk nss survey instrument and we cannot account for more recent turbulence in the outcomes of the new survey instrument or impacts on outcomes of the new survey dimensions we suggest that it is worth the risk here of perpetrating neoliberal ideologies by providing our anonymised table of institutional disagreement rankings however this is just to raise the question and generate debate about whether the negative voices that emanate from a small proportion of the survey outcomes should be captured and considered alongside agreement metrics data extraction and analysis nationally available data for 12 years of the uk nss were extracted from 2005 to 2016 for all subjects and institutions we selected only institutions with more than publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

this study explores dissatisfaction and neutrality metrics from 12 years of a nationallevel undergraduate student survey the notion of dissatisfaction is much less prevalent in the narratives surrounding student survey outcomes and the underpinning metrics are seldom considered this is despite an increasingly vociferous debate about value for money of higher education and the positioning of students as consumers in a marketised sector we used machine learning methods to explore over 27 million national survey outcomes from 154 institutions to describe yearonyear stability in the survey items that best predicted dissatisfaction and neutrality together with their similarity to known metric predictors of satisfaction the widely publicised annual increases in student satisfaction are shown to be the result of complex reductions in the proportions of disagreement and neutrality across different survey dimensions due to the widespread use of survey metrics in university league tables we create an anonymised illustrative table to demonstrate how uk institutional rankings would have differed if dissatisfaction metrics had been the preferred focus for reporting we conclude by debating the tensions of balancing the provision of valuable information about dissatisfaction with perpetuating negative impacts that derive from this important subset of the survey population

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introduction among young adults sexual activity is an important aspect of their lives many young people have their first sexual experiences with other individuals when they go to university in subsaharan africa the prevalence of individuals having sexual intercourse for the first time at college and university ranges between 222 to 526 12 this is attributed to the university environment having minimal elder supervision which offers an opportunity for young people who are transitioning from restrictive adolescence to free and independent adulthood where they can test their limits of newfound freedom through sexual experimentation 2 such sexual exploration involves engagement in risky sexual behaviours including having unprotected vaginal oral or anal intercourse multiple sexual partners inconsistent contraceptive use and sexual intercourse under the influence of alcohol 23 these risky acts are conventionally known to predispose youths to sexually transmitted diseases and unwanted pregnancies 24 teenage pregnancies have reduced in most developed highincome regions but the rates are still high in lowand middleincome countries 56 approximately twothirds of the daily new estimated 6000 new hiv infections globally in 2013 were in subsaharan africa and those were disproportionately found among young women aged 1524 years 7 this attribution may be because of the high prevalence of rsb among university students in the region ranging from 26 in uganda to 639 in botswana 2 8 9 10 11 factors that have been associated with rsb among university students include the use of potentially addictive psychoactive substances watching pornographic content poverty having first sexual intercourse before 18 years being male having multiple concurrent sexual partners peer pressure living alone lack of parental control low family connectedness poor academic performance and being a student from urban settings 11 12 13 14 15 16 in addition previous studies in africa have found significant gender differences where risky sexual practices are higher among males than females 11 however females have been reported to have more detrimental consequences including unwanted pregnancies sexually transmitted infections and complications such as ectopic pregnancies cervical cancer chronic pelvic pain spontaneous abortion contracting hivaids and secondary infertility 17 substance use history has consistently been associated with rsb in uganda 91418 however the relationship between substance use and rsb is complex and influenced by social physiological and individual personality traits 14 for example rsb is associated with the impairment in decisionmaking and reduction in cognitive capacity that causes intoxicated individuals to focus on the cues that are most salient in the environment and reduction in the intention to use condoms 19 20 21 in uganda research has shown that most university students are sexually active start having sex before joining university have multiple sexual partners at university rarely use condoms and engage in sex under the influence of potentially addictive substances especially alcohol 914 rsb has been found to be higher among students with lower levels of knowledge about risks involved in premarital and unprotected sex studying at mixedsex secondary schools and having one or both parents alive 9 consistently male gender has been associated with higher rsb especially those having unprotected sex and those who get engaged in sex under the influence of alcohol 14 in addition university students affected with depression and anxiety have also been reported to engage in greater rsb 18 despite the previous literature few factors influencing sexual behaviours have been explored in uganda earlier studies have reported an association between different types of childhood mistreatment and adulthood rsb 2223 in a crosssectional survey among polish university students rsb was associated with physical abuse emotional abuse and neglect sexual abuse and household dysfunction 23 in the same study individuals who were sexually abused were six times more likely to have had more than three sexual partners whereas those who witnessed domestic violence were twice more likely to initiate sexual activity below the age of 16 years 22 in a retrospective cohort study examining adverse childhood events among adult females in the united states each category of childhood adversity reported was associated with an increased risk for rsb and individuals reporting their exposure to at least one ace reported more rsbs 23 experiencing at least four types of aces was significantly associated with early sexual initiation and having larger numbers of sexual partners 22 among individuals who experienced childhood maltreatment rsbs appear to attempt to achieve intimate interpersonal relationships and may underestimate the risks they take to achieve intimacy 23 based on previous literature the association between aces and rsb may be due to the victims desperate attempt to initiate an intimate interpersonal connection having grown up in families andor environments where they could not gain any intimate connections such individuals may significantly underestimate the risk they are taking to gain intimate connections later on in life through activities like rsbs 2324 studies in africa investigating the determinants of rsbs among young adults report that single parenting guardian parenting and low parental educational level were associated with increased risk for rsb 1325 other studies in highincome countries have found that family structure and culture influence sexual behaviour in later life where dysfunctional families and unstable family environments were associated with first having sexual intercourse at an early age 2627 in a rakai community cohort study in uganda adolescent girls who headed their households or lived with stepfathers grandparents siblings or other relatives had a significantly higher prevalence of having sexual intercourse at 16 years or below 28 therefore the family structure appears to be an important correlate of young peoples sexual behaviour however a study in iran reported no relationship between rsb and family structurerelated variables such as the number of children in the family birth order and family size 29 the present study further explores the relationship between rsb and family structurerelated variables among ugandan university students the family structure influence is part of an interlinked system described in kotchicks ecological model of determinants of sexual behaviours namely the family system the selfindividual system and extrafamilial system 30 rsbs have complex determinant mechanisms that range from sociodemographics childhood adversities and family environment which directly influence the risks attached to these sexual behaviours among a young literate population however in lowincome settings like uganda there is still a lack of evidence of the influence of exposure to aces and the family environment on the rsbs among university students therefore these factors were explored in the present study the objectives of the study were to determine the prevalence of sexual activity among university students and average risky sexual behaviour based on the sexual risk survey determine the different forms of rsbs utilizing the srs examine gender differences in rsbs and explore the association between rsbs and sociodemographics use of psychoactive substances family environment and aces methods study design area and participants the present pilot study was a crosssectional online survey conducted among students of mbarara university of science and technology a public university in southwestern uganda data were collected from april 3 to may 23 2021 using google forms the survey link was shared on online platforms like whatsapp groups and personal student emails to students in the universitys six faculties and its two institutions must had over 4269 undergraduate students enrolled in the academic year 20192020 and all were eligible to participate in the study a total of 316 students participated in the study the data were collected during the second year of the covid19 pandemic when students had just started returning to inperson teaching and most of the restrictions concerning covid19 prevention such as spatial distancing had been relaxed the participants were enrolled using a snowball convenience sampling technique where students who were approached could forward the survey link to other students in the university to avoid physical contact and to include as many eligible students as possible snowball convenience sampling was employed to enable efficient recruitment of university students during the covid19 pandemic as has been employed in previous studies conducted inside or outside uganda 31 32 33 34 data collection the online survey link was circulated on the different faculty and student social media platforms like endtoend encrypted whatsapp groups and students personal emails the survey tool was designed to only allow a single response from each student participant potential participants received a message requesting them to participate and to share the survey link with their fellow students at must the survey was in english questions were pretested among the students before the commencement of the study to ensure that they were all well understood study measures the online survey tool included a participant information page which provided participants with information to understand the intentions of the study and an informed consent page which all participants completed before responding and participating in the study as there were no mandatory questions to respond to participants were free to leave questions unanswered if they were not comfortable andor sure with the response however all participants responded to the questions except one question about the number of sexual partners in addition the survey included a sociodemographic questionnaire family environment questions the adverse childhood experiencesinternational questionnaire and the sexual risk survey given that participants responded to the tool items at their time of convenience participants were advised to use a calendar of the past six months to accurately remember their past sexual experiences and to minimize memory recall bias 231 sociodemographic information sociodemographic data collected included relevant personal information regarding basic participant characteristics participants age gender marital status and the region of the country of origin recent substance use history a single question with a binary response was used to assess recent substance use history those with a yes response selected the substances used family environment family environment data collected included information on the family type the number of family members the number of children primary care provider birth position in the family parents highest level of education having a family member with mental illness or who abuses drugssubstance or with a criminal record and whether a parent died before 18 years of age sexual risk survey the 23item srs 3 was used to assess sexual risk behaviour among college students over a period of six months prior to the study it comprises five subscales of risky sexual behaviours sexual risktaking with uncommitted partners risky sex acts impulsive sexual behaviours intent to engage in risky sexual behaviours and risky anal sex acts 35 for details see s1 table raw response frequencies were recorded and converted into ordinal categories which assign weights to the level of sexual risktaking ranging from 0 to 4 employing a method used by the scale developers 35 this approach addresses the skewness of frequency data commonly used in sexual risk assessment studies the total sexual risk score is calculated as a sum of all raw items responses with total scores ranging from 0 to 92 higher scores indicate higher sexual risk riskiness the srs has shown very good psychometric properties 3 although the cronbach alpha was 069 in the present study however the cronbach alphas for the five subscales were good to excellent risktaking with uncommitted partners risky sex acts impulsive sexual behaviours intent to engage in risky sexual behaviours and risky anal sex acts adverse childhood experiencesinternational questionnaire the 29item aceiq 36 was used to assess 13 childhood adversities items are responded to on a binary scale consequently total scores range from 0 to 13 where a higher score indicates greater childhood adversity in previous subsaharan african studies the aceiq has demonstrated good psychometric properties among adolescents and young adults 37 38 39 the cronbach alpha of the aceqi in the present study was 082 ethical considerations the present study received formal ethical approval from mbarara university of science and technology research ethics committee participants were informed about the sensitive nature of the questions on the srs and the aceiq due to the potential of some questions to give rise to distressing and negative emotions consequently participants did not have to respond to such questions and were free to end the survey at any point with absolutely no penalty whatsoever data confidentiality and anonymity were emphasized participation was voluntary and participants provided informed consent the survey included a detailed consent form that informed the participants about the study the risks and the benefits all participants were adults who provided their written informed consent to participate in the study these were automatically granted entry to the study survey a link to the departmental psychiatry team was provided within the survey and participants could access the link for help and support if they needed it statistical analysis data were imported into stata version15 statistical software where data were cleaned and analysed descriptive statistics are presented in percentages frequencies medians ranges and interquartile ranges the total score on the srs and its subscales were analysed as continuous variables gender differences in sexual risktaking and behaviours were assessed by wilcoxon ranksum and chisquare tests the gaussian assumption was used to test for normality of continuous data and was confirmed with shapirowilkss test and histograms hierarchical poisson regression was used to determine the predictors of rsbs and four models were generated all statistics were calculated at a 95 level of confidence and 5 statistical error results participants characteristics 311 sociodemographics a total of 316 students participated in this study the age ranged from 18 years to 44 years with over half aged between 1822 years the median age was 22 years close to threequarters were males and almost all were single substance use approximately onesixth of the sample reported a recent history of psychoactive substance use the majority had a history of drinking alcohol family characteristics regarding the family environment approximately half of the participants resided in nuclear families with approximately fourfifths having parents as their primary care providers it was also found that just over onesixth reported living with a family member with mental illness and about onethird lived with a family member with substance use disorder adverse childhood experiences the mean score on the aceiq was 65 all participants reported exposure to at least one ace with the majority of participants reporting experiencing four or more childhood adversities moreover all participants reported having been physically abused and just below onethird reported having been sexually abused approximately onefifth reported having had a household member sent to prison andor a family member who was mentally ill risky sexual behaviours over half of the student sample reported that they had engaged in sexual intercourse with onefifth reporting having had more than one sexual partner the mean score of the total srs was 134 the riskiest types of sexual behaviours reported by students were having sex with uncommitted partners and the least risky types of sexual behaviour reported were anal sexual behaviours the mean average scores for the other risky sexual behaviours were 181 for risky sex acts 487 for impulsive sexual behaviours and 109 for intent to engage in risky sexual behaviours 321 gender differences in risky sexual behaviour generally males had higher median srs scores across all subscales and had wider interquartile ranges than females the median total srs score for males was over two times higher than that for females among all subscales males had a higher score on the intent to engage in risky sexual behaviours subscale than females there was a statistically significant difference between the age at which individuals first had sexual intercourse and gender with more females first having intercourse at the extreme of the age groups than males which predicted approximately 13 of the variance in rsb all the sociodemographic variables exhibited a significant relationship with the srs score the explained variance in rsb increased to approximately 18 in the second model after adding the substance use variable the addition of family environment factors into the third model increased the variance in rsb to 28 in the final model adverse childhood experiences were added and the variance in rsb increased by approximately 5 all the models were significant and the final model accounted for 3333 variance in predicting rsb among the sociodemographic variables the following factors increased rsb score male gender being separateddivorced and being a thirdyear university student while being single coming from a region other than the central region and being a fifthyear university student increased the rsb score history of the use of psychoactive substances increased the rsb score in the final model for family environmentrelated factors being raised in a nuclear family the type of primary care provider family history of mental illness family member having a criminal record father having a primary level of highest education and mother having a secondary level of highest education increased the rsb score among university students however being raised in a grandparent and stepparent type of family grandparent being the primary care provider not being the firstborn child in the family and mother has a primary level of education resulted in a significantly reduced rsb score among university students almost all aces were statistically significantly associated with rsb scores except for having a family member treated violently the majority of the aces increased the rsb score except incarceration of a household member and community violence there was no collinearity among the variables included in the final model predictive models of risky sexual behaviour severity discussion the present study investigated the prevalence of sexual activity among university students and risky sexual behaviours were assessed as a continuous variable using the sexual risk survey the study is the first to be conducted in uganda that used a populationspecific standardized assessment tool to study risky sexual behaviours among university students additionally the study analysed the different forms of rsbs utilizing the srs gender differences in rsbs and association between rsbs and sociodemographics use of psychoactive substances family environment and adverse childhood experiences the few previous studies conducted among ugandan university students have only assessed rsbs such as the age at which sexual intercourse first took place having multiple sexual partners and inconsistent condom use 914 which is very narrow compared to the present study the mean score of the total srs of 134 was lower than that found among the us studies using the same tool 1619 reported by wang et al 40 147 reported by turchik et al 35 and 163 reported by hahn simons and simons 41 this lower score may be because uganda is an hiv epidemic region and its university students especially females may take fewer risks due to fear of contracting hiv 42 in addition the 23item srs has not been validated for use among ugandan university students some questions may not have been completely understood by all students resulting in lower scores for example some words may not be familiar to those completing the survey and require individuals to use a guide or glossary to understand them 3 the present study found that over half of university students reported having sexual intercourse at the time of the study which was higher than that reported among university students in ethiopia ranging between 269 and 389 134344 in a secondary analysis of global schoolbased student health surveys of five subsaharan counties the overall prevalence of ever having had sexual intercourse was 435 45 which is slightly lower than that in the present study moreover in another study 885 of young adults attending higher learning institutions in mbeya were sexually active 46 which is higher than that reported in most subsaharan countries the variations in the prevalence rates may be due to differences in participant characteristics and more importantly the cultural variations and social norms regarding sexual activity in african countries 47 in addition there may be differences in collegebased sexual risk education and information provision to students which could also be a reason for such variations 47 most studies conducted among university and college students have found that males are more engaged in risky sexual behaviours than females 404849 in the present study males had higher rsbs than females and being male statistically significantly increased rsb score however such findings may be due to sexual double standards as well as social desirability biases for example a study among private college students in mekelle city reported that males were four times more likely to have multiple sexual partners than females 43 additionally in a systematic review of the epidemiology of sexual behaviours among ethiopian college and university students males were 235 times more likely to engage in rsbs compared to females 11 this may be due to cultural influences where it is socially acceptable for men to take charge in sexual relationships and increase the likelihood of having multiple sexual partners similarly it may be due to premarital sexual permissiveness attitudes which are more common among males than females 50 the present study also found that anal sex was not frequently reported among the student sample surveyed anal intercourse is not socially acceptable in uganda and other parts of africa perhaps explaining the low rates reported in the study 51 52 53 in qualitative studies exploring perceptions of heterosexual penileanal intercourse among women in three subsaharan african countries participants described this socially stigmatized act as disgusting embarrassing sinful and shameful 5152 they also added that this type of sexual activity is against cultural and religious morals and that such acts may be practiced only by sex workers drug addicts and porn stars across the three countries participants asserted that anal sex was only practiced by perverse messedup insane or mentally ill people 51 therefore negativism and stigmatization of anal sexual practices do not appear to be practiced very often andor individuals do not report it even if they engage in such practices the present study generated four statistically significant models to predict risky sexual behaviours in the past six months based on students sociodemographic factors substance use history in the past six months family environment and adverse childhood experiences all models were statistically significant and indicated the importance of these factors in explaining rsbs among university students they only explained 33 of the variance this suggests that other factors play a bigger role in rsbs among university students however the findings in the present study are similar to those reported in many other studies in african countries such as botswana ethiopia and nigeria 115455 however due to the exploratory nature of the present study the models generated arguably have limited comparison with other prior african studies substance use history was associated with an increase in rsbs in the present study a finding that has consistently been reported in other ugandan studies 91418 use of potentially addictive psychoactive substances has been associated with impulsivity impaired decisionmaking reduction in cognitive capacity and causes people to focus on the cues that are most salient in the environment and reduction in the intention to use condoms especially following alcohol drinking 19 20 21 the relationship between psychoactive substance use and rsb is complex and influenced by social physiological and individual personality traits 14 therefore the use of psychoactive substances should be managed holistically to avoid its complications such as rsbs due to ruralurban migration and increased cost of living ugandas families are becoming nuclear 56 however these were associated with an increase in rsb in the present study a finding similar to previous research which reported less frequent condom use and early onset of sexual life among children brought up in nuclear families 5758 this finding was attributed to students from nuclear families not respecting traditions such as sharing family dinnerswhere most important discussions are started in families 57 the aspect of sharing and respecting traditions is still present in the grandparent family type where traditions are still followed which may explain its association with reducing rsb in the present study surprisingly growing up in stepfamilies was also associated with reducing rsb a finding contradictory to previous studies 59 this may be due to a fear of these students getting involved in rsb due to fear of getting pregnant and producing children who may unfortunately end up as stepchildren due to fear of relationship stabilitysince some grow up in a family where a relationship failed and they ended up as stepchildren students whose parents or grandparents are not their university tuition fees sponsors go through many hardships to obtain tuition fees since it is culturally believed that only grandparents and parents usually provide unconditional support without the expectation of being paid back and may easily offer money to students for their daily expenses while at university many students not sponsored by their grandparents or parents may get involved in rsbs either to acquire extra money or cope with their stress 60 similar to other studies 1327 the highest level of education of the parents was associated with higher rsb scores among university students in the present study however students having mothers with a primary level of education were associated with lower rsb scores mothers who have a minimal level of education may be very scared about their children at university being exposed to risky behaviours and may provide better advice compared to those with a secondary level of education who missed going to university who may want their children to enjoy university and may advise them to have fun fathers with a primary level of education may feel intimidated by their children who are at university and may fail to advise them against getting involved in rsbs not being the firstborn child in the family was significantly associated with reduced rsb scores among university students this could be due to them getting advice from elder siblings or learning from the complications faced by elder siblings due to involvement in rsb more familyrelated factors such as the family history of mental illness and a family member having a criminal record were significantly associated with higher rsb scores the pair has been associated with aces and many classify them as a form of ace which has consistently been associated with rsb in adulthood 2361 researchers have suggested that aces significant association with rsb is due to victims desperately attempting to initiate and maintain an intimate interpersonal connection 23 since they grow up in families andor an environment that was unable to protect them andor have intimate connections it may significantly make them underestimate the risk they are taking to achieve intimate connections or protection and may end up involved in rsb 2324 because of these possible associations between aces and rsbs the majority of the aces were significantly associated with higher rsb scores including emotional abuse contact sexual abuse alcohol andor drug abuse in the household someone being chronically depressed mentally ill institutionalized or suicidal in the family emotional neglect physical neglect bullying and collective violence however incarceration of a household member and community violence were significantly associated with a lower rsb score in the case of incarceration of a household member if the member was abusive then the child could have felt protectedan aspect associated with lower involvement in rsb 2324 for the case of community violence more research is needed to understand this paradoxical result interestingly all participants in the present study had experienced physical abuse before the age of 18 years this may be attributed to the parental style commonly used in uganda that involves physically punishing children to discipline them 6263 a comparative study with students who have not experienced a similar parenting style involving corporal punishment would enable a better understanding of the relationship between childhood physical abuse and rsb limitations and future research the present study had some limitations that should be considered when interpreting the findings reported here due to its crosssectional nature the study is not able to draw causal inferences future research should therefore use longitudinal designs to delineate the causality between the variables studied here in addition the study did not capture all sexualrelated factors such as sexrelated alcohol consumption and condom use therefore future studies should incorporate these and other factors that help determine the factors that contribute to rsb the srs arguably provided a comprehensive assessment of participants sexual activity but future research could expand on the five scale domains and examine other types of rsb not included another limitation was that the present study had a large minority of participants who had never engaged in sex at all which means the factors underlying rsbs were from a smaller subsample of all participants however schuster et al reported that among virgins there is still a likelihood of involvement in genitallybased sexual practices including fellatio and cunnilingus which increase the likelihood of transmission of stis including hivaids 64 further research is needed among virgins to establish the types of rsb they may engage in even if they are not having sexual intercourse the present study only comprised students from one ugandan university which may not be representative of other ugandan university students therefore future research using more representative samples of ugandan university students is needed to replicate and confirm the findings in the present study it should also be noted that since the study used snowball sampling to recruit students it cannot be guaranteed that all responses were university students from the same university therefore future research on the student population needs to implement methods that can confirm the student status of participants because the present study examined a very sensitive topic the responses are likely to have had social desirability biases and the retrospective nature of the study may have included recall biases therefore future research is needed to qualitatively assess the lived experiences and factors that facilitate or inhibit risky sexual behaviours among university students to develop specific interventions to reduce unplanned pregnancies stis and the spread of hivaids it should also be noted that the cronbachs alpha on the srs was relatively low and the instrument has not been previously validated among ugandan university students or similar cultural populations and some of the questions may not have been culturally appropriate consequently future studies should validate the tool for university students in subsaharan africa moreover in the present study substance use severity and specific types of illicit psychoactive substance use were not assessed in detail and only one item in the study related to substance use given that substance use appeared to be an important correlate with sexual behaviour future studies should look at this variable in more depth to include the range of substances used as well as the severity of substance use disorders when considering all the study variables the sample size was modest this could have affected the robustness of the final model therefore future studies should involve larger samples to investigate more rigorously the relationships between the studied variables and rsbs finally the results concerning rsb reported in the present study may not be a true reflection of the students behaviours since the previous 12 months they were not at university due to the covid19 pandemic and its associated restrictions also the high level of depression and its associated symptoms such as lack of motivation anhedonia hypersomnia among students during the first months of the pandemic 33 may have resulted in fewer students being involved in rsbs therefore replication of this study in a nonpandemic period is needed to ascertain whether any of the present studys findings were affected by pandemicrelated factors conclusion as with many previous studies the present study demonstrated that most ugandan undergraduate university students had engaged in sexual activity and that riskier sexual practices were more likely among males than females sociodemographic factors history of substance use family environment and adverse childhood experiences appear to have a role in risky sexual behaviours among ugandan university students although the present studys findings are preliminary they can be used as a basis for other researchers to explore these and other factors associated with risky sexual behaviour among university students identifying the factors in rsbs will ultimately help develop interventions to reduce such behaviour so that students can be protected from unwanted pregnancies stis and hivaids based on such findings awarenessbuilding programs among students in lmics could be developed focusing on safe sexual practices and where to seek help if someone is already engaging in rsbs such programs should be implemented based on evidencebased health promotion theories such as the theory of planned behaviour and the health belief model 65 66 67 the data underlying the results presented in the study are available from 18485417 supporting information s1 table sexual risk survey items and converting raw scores to ordinal categories

university students are known to have risky sexual behaviours rsbs the severity of the rsb is influenced by many factors including the family environment exposure to adverse childhood events aces and the use of addictive substances however there is limited information about the influence of aces and the family environment of these students in lowand mediumincome countries lmics therefore a pilot study was conducted among university students from a lmic ugandathe present study comprised a crosssectional online survey among ugandan students at a public university n 316 75 male 522 aged between 1822 years the survey included questions relating to sociodemographic information family environmental information the sexual risk survey srs and the adverse childhood experiencesinternational questionnaire aceiq over half 538 reported having had sexual intercourse males reported over two times higher mean total srs score compared to females χ 2 406 p 0044 approximately

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introduction on the 11th march 2020 the world health organisation declared the coronavirus disease 2019 outbreak as a pandemic the situation is evolving rapidly with global case counts currently just over 122 million and deaths rates over 27 million worldwide on march 22nd 2021 whilst ongoing clinical trials and investigations aim to further our knowledge about the virus its origin and how it affects humans countries all over the globe have implemented mandatory social distancing measures in an attempt to suppress and control the spread of the virus these strategies include lockdowns stayathome orders curfews nonessential business closures bans on mass gatherings school and university closures travel restrictions and bans remote working and quarantine of exposed peopletravellers studies exploring the psychological implications of previous epidemics and pandemics have found social distancing measures to be particularly detrimental to psychological health with symptoms such as posttraumatic stress exacerbated by infection fears longer quarantine duration frustration boredom inadequate supplies inadequate information and financial loss similar findings have been identified in the covid19 pandemic such as an association between negative changes in health behaviours and increased psychological distress as well as increased psychological morbidity in those who identified as being at risk of contracting the virus there is an emerging evidence base that focuses on exploring the psychological implications of the covid19 pandemic on athletes in response to the suggestion that athletes experience additional mental health risk factors compared to the nonathletic population athletes have expressed substantial grief and frustration in response to this enforced period of isolation disruption to normal training routines and competition cancellation these preliminary findings suggest that some pandemic mitigation strategies such as lockdowns could be having an adverse effect on the mental health and wellbeing of athletes according to the world health organisation mental health is defined as a state of wellbeing in which the individual realises his or her own abilities can cope with the normal stresses of life can work productively and fruitfully and is able to make a contribution to his or her community whilst mental health is a major resource for athletes in relation to their performance and development in sport high rates of psychological distress and disturbance are reported among athletes which may impair performance and wellbeing according to the international olympic committee consensus statement on mental health research suggests that the prevalence of mental health symptoms and disorders in male elite athletes in team sports varies from 5 for burnout and alcohol abuse to nearly 45 for anxiety and depression in female athletes mental health disorders range from 10 to 25 for depression and eating disorders in particular there is also evidence to suggest that occurrence of such mental health disorders amongst elite athletes are associated with higher incidence of severe injuries surgeries recent adverse life events a higher level of career dissatisfaction and a lower level of social support considering the increasing number of mental health problems being reported in the athletic population the challenges that the pandemic presents to them and recent research identifying the adverse effect of social distancing measures on mental health athletes could be considered an atrisk group during the current covid19 pandemic indeed this is reflected in recent findings that show the covid19 lockdown period significantly affected athletes physical and mental health specifically physical deconditioning worsening nutrition uncertainty on return to sport and disruptions to social interaction training and sleep patterns were associated with increased depression anxiety and stress symptoms furthermore in a recent study exploring adversity and resilience in athletes during covid19 athletes reported tangible losses with regards to their sport support networks and athletic identity and a sense of incongruence as a result of the dissonance between the usual structured goal directed environment they were accustomed to and the relatively aimless lockdown scenario presented by covid19 the incongruence experienced due to the lack of agency during the pandemic resulted in psychological distress ruminations negative emotions and loss of motivation whilst the authors acknowledged the role resilience is playing in mobilising coping methods to protect athletes from these adversities it could not be inferred that the athletes had positively adapted to the stressors as they are still living in a pandemic although the overwhelming evidence suggests that athletes have experienced negative physical and psychological effects of the covid19 pandemic şenışık et al reported that the mental health status of athletes was better than nonathletes attributing this difference to the potential protective effects of physical activity that were still experienced during their pause in sport participation whilst the literature reviewed has furthered our understanding of the impact of social distancing measures on athlete mental health the current research will utilise the concept of wellbeing as a framework for examining athletes experiences giles et al argued that whilst athletes are by definition sport performers first and foremost they are people whose physical mental and social health is reflected through their wellbeing and illbeing a consideration of athletes holistic health is fundamental to their identity as performers and people and their participation in sport can contribute to or detract from their wellbeing it is argued that the exploration of wellbeing in relation to athletes experiences of social distancing will provide a broader framework for investigation than mental health alone indeed recent recommendations from a consensus statement on improving the mental health of highperformance athletes identified various propositions to inspire researchers and support elite sport organisations to investigate and enhance mental health in athletes of particular relevance to the current study was their recommendation to better define mental health in sport as being more than the absence of mental illness separate from performance contextualised and acknowledging the full range of human emotions that are experienced throughout sport psychology literature researchers have found the construct of wellbeing to be both multifaceted and complex lundqvist argues that wellbeing is treated as an unspecific variable inconsistently defined and assessed using a variety of theoretically questionable indicators for the purpose of this research the concept of wellbeing will be based on a review of existing measures of wellbeing in sport performers by giles et al who recommends an integrated measure of wellbeing that includes emotional mental social and physical components of wellbeing according to stambulova et al covid19 can be interpreted as a career transition barrier that interferes with athlete development and career progression in the recent update of the international society of sport psychology position stand on athletes career development and transitions career excellence is defined as an athletes ability to sustain a healthy successful and longlasting career in sport and life and not as a destination to reach but more a journey to or process of striving for it in which athletes might need support if we consider covid19 as a career development barrier from a holistic developmental perspective it suggests substantial changes to athletes athletic development psychological health psychosocial aspects academicvocational responsibilities financial concerns and changing legal developments indeed gupta and mccarthy suggested that if social isolation is conceptualised as an abrupt diversion in an athletes career it could trigger dissociations from their athletic identity and negatively impact wellbeing athletes often have a strong sense of identity that is derived from their participation in sport and when this sporting platform is removed through injury or retirement they lose access to vital resources and support networks which can result in threats to their wellbeing preliminary findings suggest that the covid19 pandemic and lockdowns have presented athletes with a similar experience to that of forced retirement and recommendations to support athletes using career transition andor chronic injury psychological rehabilitation research as an intervention has been advocated the current pandemic has presented sport and exercise psychologist consultants with challenges and opportunities with how best to support athletes sport performance and wellbeing a recent editorial by schinke et al reviewed the challenges encountered by athletes such as social isolation career disruption qualification process uncertainty and unconventional and limited access to training facilities and training partners underpinning these issues was the need to help maintain the health and wellbeing of athletes in their pursuit of performance excellence during this extraordinary time schinke et al further reflected on their collective work with aspiring olympic athletes across asia europe and north america and suggested strategies to support athletes that encouraged openness to express their feelings and facilitate problem solving identification of gaps in their development and the setting of new goals mascret reported that confinement during the covid19 pandemic encouraged athletes to modify their achievement goals selfapproach goals and selfavoidance goals specifically they identified that selfapproach goals decreased and selfavoidance goals increased suggesting that during confinement athletes were more focused on avoiding performance decrements than enhancing it in order to support athletes during this continuing global health crisis further research is needed to investigate how social distancing measures are affecting athlete wellbeing given that isolation periods are detrimental to wellbeing and that elite athletes are at greater risk of mental health disorders together the impact of the covid19 social distancing measures on elite athletes could be profound it is vital that exploratory work which seeks to understand the lived experiences of athletes is conducted to contribute to a limited but growing evidence base in order to provide a foundation for future intervention studies to support athlete wellbeing and to help inform sport and exercise psychologists recommendationspractice research question this study aimed to explore the perceived impact of the covid19 social distancing measures on athlete wellbeing specifically the authors sought to investigate the emotional mental social and physical components of wellbeing that may have been affected by the lockdown measures materials and methods theoretical underpinning according to mayan qualitative studies should have methodological coherence which this study achieved by ensuring congruence between epistemological and ontological positions theoretical perspective and the research question this study adopts a realist ontological viewpoint which acknowledges there is an objective reality of the material world and also takes a critical realist epistemological perspective accepting multiple accounts of any phenomenon as described in maxwell critical realists thus retain an ontological realism while accepting a form of epistemological constructivism and relativism by taking this stance this research was able to explore how athletes perceived the impact of social distancing measures in the covid19 pandemic on their wellbeing this qualitative research collected data through combining the participant driven photo elicitation method with unstructured interviews and was analysed using thematic analysis conceptual coherence between theoretical and conceptual underpinnings of the research and the type of thematic analysis carried out is one of several proposed indicators of thematic analysis research quality in line with our aforementioned theoretical perspectives a reflexive approach to thematic analysis was taken acknowledging and embracing researcher subjectivity as an analytic resource the choice to carry out an inductive thematic analysis was informed by the understanding that the analysis remains grounded in the data furthermore this form of analysis ultimately respects the participants unique experiences of the covid19 pandemic and thus follows on from our previously stated ontological and epistemological position to further ensure that the themes developed from the data are true to the participants overt understanding of their experiences we employed semantic coding and did not aim to interpret any hidden or underlying meanings photo elicitation method the rise in accessibility and advancement of visual technology and communication through social networking sites and smartphones means that a wealth of contemporary phenomena and experiences are captured visually the photo elicitation method uses photographs within an interview setting in order to prompt emotional connections to memories and evoke more meaningful accounts bates et al describe the following three variations to the photo elicitation method participantdriven participants choose to take any photo they feel is relevant to the phenomenon under exploration participantdriven the researcher shares a set of questions with the participants and asks them to take photos that align with those researcher driven the researcher provides the photos for the interview to stimulate discussion only the photo elicitation method has previously been implemented to explore elite runners disordered eating to capture the experience of ironman competitors and in a similar vein creative collages using images has also been used to understand young athletes future career aspirations the current study utilised the participantdriven format as it was considered most appropriate to address the exploratory nature of the research question by encouraging the production of participantdriven photographs the researcher can attempt to understand the experiences of the participants rather than imposing their own framework or preconceived ideas on the topic the purpose of the images therefore is to create a dialogue and to introduce new dimensions that had not been considered by the researcher and in this respect is easily facilitated by the accompanying unstructured interviews recruitment as employed in previous qualitative work around athletes experiences purposeful sampling was utilised to recruit athletes residing in countries enforcing strict lockdown measures which prevented them from leaving their house to train and compete in their sport participants were recruited through the researchers network in elite sport and sustained through snowball sampling however none of the participants were known to the researchers so there was no potential for coercion contact was made to prospective participants through ethically approved invitations via email or through private messaging on public social media sites such as twitter the exclusion criteria were displayed in study invitations participants were unable to participate if they were under the age of 18 had any existing clinical mental health problems had contracted covid19 were recreational athletes or resided in countries who did not have to adhere to lockdown measures a heterogeneous sample of athletes were recruited to ensure that the research captured a wide range of athletes experiences from team and individual sports procedure upon recruitment participants were informed of the study aims and procedure and then provided their consent to participate participants were instructed to take any number of photographs they felt represented their experience of the covid19 pandemic as an athlete using any available technology they were informed that the photos should not contain any people or easily identifiable places and reminded that they were a conduit to aid discussions and would not be part of the data analysis only the associated narratives would serve as the data set participants were contacted again 2 weeks later to organise an online interview and to submit via email any photographs they wished to discuss in the interview all interviews took place between april and may 2020 and were conducted virtually via microsoft teams due to the geographical spread of participants across the globe and lockdown regulations in place at the time of data collection this virtual platform also provided a secure encrypted connection to ensure confidentiality the online interviews were held in private rooms and the participants were informed that if they felt any discomfort discussing their experiences they could terminate it without any questions asked each interview was audio recorded and lasted between 45 and 60 min in accordance with the participant driven photo elicitation method there were no predetermined interview questions the researcher began each interview asking please could you talk through these photos and explain why you chose them to discuss today and asked follow up questions when appropriate in this sense the photos selected and discussed by the participant framed the interview process leaving the control and power of the interview process as much as possible with the participant to protect anonymity participants were assigned pseudonyms and any identifying information was redacted from transcripts and interview data were stored in a password protected computer participants were debriefed following the interviews and given an information document that signposted to support resources in the event that any of the discussions had prompted any adverse psychological or emotional reactions data analysis due to the exploratory nature of this novel research reflexive inductive thematic analysis was used to analyse the data and the analysis process was informed by braun and clarke six phases of analysis in order to achieve data familiarity the researcher first transcribed interviews verbatim using nvivo software and engaged in repeated reading of transcripts and relistening to the data helping to move the analysis beyond a focus on the most obvious meanings in the second stage of the analysis all data relevant to the research question were coded this process identified the first patterns in the data by grouping similar data segments at the semantic level similar codes were then clustered together to create a visual map of key patterns in the data these existed in a hierarchical structure containing overarching themes themes and subthemes the themes were reviewed to ensure they fitted with the coded data and the overall data set and that they each had a clear organising concept at this stage the second author reviewed the themes to ensure they were substantially supported by data extracts and contributed to answering the research question the final themes and subthemes were then clearly defined and summarised to provide conceptual clarity and a road map for the final report methodological rigor in alignment with the aforementioned conceptual underpinnings of the research the authors engaged in careful design thinking to conduct reflexive thematic analysis research with methodological integrity and to ensure the validity of findings for example the lead author engaged in regular journaling reflecting on the process to ensure an indepth engagement with the data resulting in a meaningful analysis as recommended by braun and clarke furthermore the lead author carried out the initial coding process which was reviewed by the second author this process was repeated at the initial theme development stage as per braun and clarke recommendations for best practise in reflexive thematic analysis credibility was ensured by giving participants the opportunity to check transcripts for accuracy and to engage in a process of member reflections with the lead researcher to explore any gaps in the results and to share any similarities in the interpretations of the findings the analysis was also discussed and cross analysed at various stages by the lead researchers professional doctorate supervisory team to ensure worthy contribution to the topic and meaningful coherence as such we feel that this research is timely and that the findings contribute unique insights regarding athlete wellbeing throughout the covid19 pandemic afforded by our use of the photo elicitation method that is seldom used in sport and exercise literature finally the analytic write up contains data excerpts and analytical commentary to provide strong evidence of patterning across the data which we hope resonates with other members of the elite sporting community also affected by covid19 mitigation strategies ethics statement ethical approval for this study was obtained from the research ethics committee school of social sciences humanities and law at the university of teesside results following the participant driven photo elicitation method participants provided the researcher with photographs they had taken which documented their experience as an athlete living in lockdown due to the global covid19 pandemic though the images were important to elicit discussion they were not part of the analysis reflexive inductive thematic analysis was applied to the participants discussions of the images and identified three main themes which highlight their experiences of lockdown as athletes these were threats to wellbeing adapting routines and maintaining motivation and reflecting on participation in competitive elite sport theme 1 threats to wellbeing this theme is defined by athletes discussions that focused on how the lockdown and social distancing measures negatively affected their wellbeing athletes talked about how existing worries were exacerbated by lockdown including maintaining a balanced diet body image mental health and injury recovery and how limited training opportunities and reduced access to outdoor space threatened their wellbeing subtheme 1 lockdown impedes basic athlete needs following the initial shock of the covid19 crisis and its ramifications for participation in sport the continued lockdown period posed a threat to wellbeing for those athletes who were already coping with some form of adversity in their lives pertinent to the pandemic amelia spoke of the stress she experienced when she could not buy the food she needed to maintain her physique because of the panic buying in supermarkets so not being able to access my usual food in lockdown was really stressful at first in my head i was thinking oh my goodness if i dont have 120grams of protein today i am going to lose all my gains but if i took a step back and thought logically i knew i was not going to lose two years worth of muscle in the space of a week because i couldnt get my hands on the food i needed but at the time i thought my whole world had come crashing down first they cancel my competitions and now i cant maintain my nutrition or physique because i cant eat the food i need to eat i just cant cope with this jess also expressed physique concerns as she described noticing physical changes to her body due to the lack of training which translated into poorer mental wellbeing the selfie she took in the bathroom mirror illustrated how her preexisting body image struggles had been amplified during the lockdown in terms of the other things like my hair and my skin and even my nails theyre not growing the same way i just dont feel that nice and thats when i started getting down which is a bit concerning i have tried not to look in the mirror to be honest i just try not to overthink it i havent been on the scales because i just actually pointblank refuse at this point i know its the physical activity the lack of it makes me feel disgusting but yeah its horrible im just managing it i really just try not to think about it ive always struggled with kind of weight and i always knew that this period i said to myself this is gonna be hard youre going to gain some weight as soon as the restrictions are lifted im really motivated to get rid of it already for many participation in sport and exercise was used as a way to destress and to channel both physical and mental energy in a positive activity this is exemplified by rachel who shared a photograph of her empty training diary and described how competing in sport had been a way of managing her attention deficit hyperactivity disorder and maintaining her wellbeing prior to lockdown i always needed the physical stimulus of sport but didnt know why it wasnt until after the diagnosis of adhd and then only last year when i was doing some work with my counsellor and i said i feel guilty about training because i havent started working and i have to collect my son and my days are really short she said have you thought that maybe you need it in order to function and that was a massive light bulb moment for me i didnt realise she was right she was spot on i need my sport to manage my mental health referring to a photograph of him participating in rehabilitation training at home charlie described how the psychological implications of injury recovery were more difficult to cope with during lockdown charlie described how not being able to see friends family or his teammates exacerbated feelings of social isolation during the lockdown its been tough having an injury in lockdown usually i would use this time off to spend time with friends and family which i dont usually get time to do but with lockdown you cant sat at home being isolated trying to find ways to connect with people but its not the same as face to face and i have found that difficult being injured can be quite isolating you are away from the rest of the squad you dont get those social interactions at the club that you really enjoy and you feel like you are away from the group and so you go and see family and friends and to not be able to do that is pretty tough rob also echoed this idea that being isolated from fellow athletes throughout lockdown posed a threat to wellbeing as he described relying on team training as an opportunity to offer and receive social support which he and his family miss as a family we miss the social interaction my wife has a strong bond with a lot of the women in the training group and we all miss that as much as we miss the running itself we are a bunch of good friends who support each other through difficult times we can talk to each other on the phone but it is that actual physical interaction with a person that we miss overall the athletes discussed how existing stressors were exacerbated by the pandemic restrictions which they seemed to have negatively affected their wellbeing subtheme 2 lockdown stunts athletic development this subtheme contributes to the overarching theme as many of the athletes shared how the lockdown had stunted their athletic development which they felt negatively affected their wellbeing in response to their reduced access to training facilities the athletes made attempts to adapt equipment they had at home amelia shared a series of photographs of the weightlifting equipment she and her dad had built together during lockdown she described how her reduced financial income paired with price increases on home training equipment encouraged her to build her own training kit at home with her dad according to amelia this had a positive effect on their fatherdaughter relationship and her wellbeing that photo is of a drill on a bench so being on furlough i couldnt afford to buy any decent kit so my dad built me a squat rack we built that together so it was a bonding thing so i could work out i just couldnt afford anything it felt like everywhere shot up their prices when lockdown happened so the only way around it was to build it myself my dad has been so supportive of me and hes always pushed my athletic side and thrown money at all the sports i played as a kid but nothing ever really stuck so hes seen my passion for body building and ive made it me and hes been so supportive and anything he could do to help he was happy too lets build the equipment you cant buy and make weights if we have too he told me which was really nice some athletes turned to social media to share their home training efforts in order to feel connected with others in their sport for example sarah shared images of herself training at home on instagram with fellow gymnasts which helped her feel part of the gymnastics community despite the lockdown restrictions as you can see in the photo of me doing a handstand on a wheelie bin i have been posting lots on instagram which helps you feel like you are in the world that i am in the gymnastics environment so it does sort of help it keeps me motivated as i can see that everyone else is training at home and my friends call me and we are there for each other although sarah found some solace in sharing her training online other athletes found such updates to be damaging to their wellbeing triggering downward social comparisons of body image and their own ability to cope with lockdown jess and olivia described feeling pressured to be proactive and accomplish goals during the lockdown period which had a negative impact on their wellbeing so some girls on my team are skinnier than me or better than me and i have never gone i wish i was like that it has never impacted me because ive always had that self confidence that i am who i am and to an extent i really do like who i am and im happy with how i am and what im doing and my achievements but now for some reason it has hit me like should i be doing that why am i not doing that how can i do that or why are people not including me in that ive been noticing the most intricate things and im thinking to myself youre never normally like this you shouldnt even be focusing on it all over social media there is this thing that we need to use this time to get motivated and be so much better when we come out of the other side but for some people they need a break to slow down and relax for a while because all this bettering yourself might not be what you need right now and i think a lot of people are being pressured to think that they have to get better to use this time productively and they beat themselves up if they dont it is a really big thing right now they shouldnt feel pressured to come out of the other side so much better than when they came in by immersing themselves in their respective virtual sporting communities the athletes not only compared their adaptation to lockdown life with other athletes online but they also noticed inequalities with regards to access to equipment ben expressed feeling disadvantaged due to his lack of home training equipment a lot of people are putting stuff on social media who have managed to get access to equipment and you wonder well if theyve got that then what advantage have they got over me similarly olivia described feelings of animosity towards fellow athletes who could access more equipment than her but also felt uplifted and inspired by some of the stories shared but theres definitely been jealousy on social media with people who have access to more than i do at the moment but it is also really cool to see people in similar situations who are fighting through this and are coming together to get through this underpinning the above conversations regarding athletic development during lockdown there was a clear common effort amongst the athletes to find alternative ways of training at home although this did not always alleviate feelings of social isolation sarah a young gymnast captured her experience of loneliness when training at home in an image of a sunset training from home not only heightened feelings of loneliness but also blurred the boundaries between athletes multiple identities which rachel found difficult to manage i need to have my places that i go too to do stuff like the gym is where i train and eat i go to uni to be quiet and have space and my son and dog cant come i need to have those places to function but i dont have those places and now my life isnt functioning rachel went on to explain how training from home was particularly challenging but she was determined to make it work as her wellbeing depended on it this is a photo of my makeshift home gym so yesterday i had the first training session in it i built it last week it was ready to go but there was so much other stuff in there and i thought ugh i cant i had to move the fridge freezer to get the plates on the bar theres a lawn mower so i cant get into the cage i have to move it its really dusty in there so the first time i thought argh this isnt working so the first lift when i had to breath in and brace i got a mouthful of dust and wasps flying around my head and the dog was under my feet i thought this is dangerous i cant do this i think i just did ten squats and then i thought i cant do this i cant use this gym i cant lift safely and i cant get into the space into my head that i needed to with all that shit in there despite the differences in lockdown restrictions between countries many athletes acknowledged the instrumental role that spending time outside had on their wellbeing luke reflected on a photograph of him doing circuit training in his small garden and discussed how the lockdown restrictions limited his opportunity to exercise outside for which he relies on for a natural biochemical mood boost we are all athletes and love being outside doing something that engages the endorphins so to not be able to get the blood flowing and those positive vibes has been hard similarly amelia described how her daily walks by the canal were an uplifting experience helping to relieve the pressure of living in close quarters with her family during lockdown so that is a photo of my caterpillar boots throughout lockdown every morning i would stick them on and take myself out for an hour or two hours and go walking up by the canal i am lucky where i live there are lots of beautiful places round here to walk it was my meditation those boots have done some mileage over the last year during the lockdown my dad was also furloughed from his job so we were stuck in the house together we are very close but like any family you rub against each other eventually so my walking was my time it was my time to get out of the house and call my friends or stick my headphones in and listen to music or a podcast it was my time to myself which i didnt have in the house for some athletes like rob the importance of access to outdoor space became even more apparent as he reflected on his friends efforts to train with limited indoor space friends who stay in an apartment block have had to get permission from everyone in their apartment block to run up the flights of steps we are so fortunate with the size of our garden and the treadmill their level of frustration is a lot higher than ours they just want to be able to get out on a road and be less restricted in this subtheme athletes discussed how the lockdown stunted their athletic development as a result of the lack of access to training equipment social support and limited space which negatively impacted their wellbeing various strategies were utilised as coping methods to facilitate their athletic development and to protect their wellbeing such as building their own equipment connecting with teammates through social media and participating in exercise outside where possible to boost mood and maintain healthy wellbeing theme 2 adapting routines and maintaining motivation in this theme the athletes mobilised coping resources such as adapting their routines and changing their motivational focus to manage the diminishing psychological wellbeing they experienced due to their lack of agency during the lockdown they reflected on how before the pandemic their lives were structured and goal driven but the lockdown scenario had created an aimless existence which threatened their wellbeing subtheme 1 replacing old routines with new ones a key aspect which some athletes felt they lost in lockdown was their training routine which for many provided a structure to their day for rachel the lack of routine had deleterious implications for multiple aspects of her wellbeing she discussed this as she shared a photograph of a bottle of gin and a kitchen cupboard filled with junk food i had nothing to do literally nothing to get up for and i lost momentum i went to bed later and later every night and then got up later every day and within a week and half i couldnt sleep i was staying up late watching netflix and then going to bed late having crazy dreams probably because of the alcohol but also because everything was just weird then waking up really late and the whole day i felt like i was on the back foot nothing was getting done it was one long thing of sleeping and staying up late and not getting much done at all my routine went out the window and i felt awful now i have one it feels better similar to rachel ben also shared the challenges of having so much spare time and how adapting his routine had helped ease the boredom and frustration it was quite hard to adapt in the first couple of weeks and get into a routine and now i have that routine of i wake up and do a little circuit or something in the morning and then do some uni work and then go out training in the evening and now i have that routine it gives me a good structure and gets me through the days it is quite good to have that routine or you sit around doing nothing all day some athletes involved their family members in their new routines which had a positive impact on their wellbeing for example sarah spoke of how she had coped with the decreased feedback from her gymnastic coaches during the lockdown by becoming more autonomous with regards to her training and her parents taking on coaching roles in this picture my mum and sister are holding onto the bar we normally hang our washing on it but its not that strong and i have been working on it to improve my grip i have grown a lot because i used to rely on my coach to help me do stuff but now they are no longer there i have to motivate myself and do it all by myself so i think i am more independent my parents have learnt a lot in the process as i have had to teach them how to spot i am so used to my coach knowing what to do so i had to teach them my family has been my biggest support during lockdown however it was not only about setting new athletic routines that was protective for wellbeing the inclusion of new non sport related hobbies were equally effective at maintaining wellbeing olivia described how taking up photography helped pass the time but also acted as an outlet for expressing her feelings during lockdown during the lockdown and having all this free time i have gotten into photography right so i have been playing with the camera and me peeking through the fence in that photo i was trying to get the same feeling as being isolated from other people and that was the best thing i could do being isolated from the outside not being able to leave and not being able to have the freedom of choice and that sort of stuff luke took a photograph of his playstation console to explain how his new routine involved playing online video games with his teammates during the lockdown he felt this helped him to stay socially connected with fellow cricketers and also filled some of the competitive void he was missing from playing sport so call of duty i am a very competitive person and i like to do things that involve competition and so obviously being locked up there are not many ways that we can find to do some competitive things so having some online gaming has been entertaining and kept me busy and its been nice because ive been playing with a lot of other friends which is pretty cool there are a lot of international cricketers that play so theres a lot of banter and stuff on the game which is quite cool for others like charlie the simple act of setting small achievable nonsport related goal each day was a useful strategy to protect his wellbeing i sent you a photo of a big hedge i trimmed that was a whole days work it wasnt something i wanted to do it just had to be done it is about setting goals and that was my goal for the day being a sportsman you are so used to having goals you have games at the weekend and that is your goal all week so doing things like that has helped me see that it is not just another day its the hedge day or the grass day or painting and it has been really important its really helped me overall this subtheme encapsulates how athletes replaced their usual strict training routines with new activities that enabled social connection and emotional expression helping to support their wellbeing during the pandemic subtheme 2 motivation for training in lockdown whilst many athletes adapted to the lockdown by creating new routines many of the athletes discussed the challenges of motivating themselves to train for their sport during lockdown as they were unable to access training equipment and they were uncertain when competitions would resume i didnt know why to train in quarantine i had no big events coming up i thought why should i train its been quite lonely and my motivation has been quite low it has been in peaks and troughs sometimes i am really motivated and have really good days and some days i do nothing at all keeping my motivation has been harder than anything else just keeping my goals in mind despite the situation that is going on adjusting goals from ego orientated to task orientated in light of the competition postponements and cancellations helped maintain their motivation to train despite the lack of agency in their sport my training diary is a good way of keeping track of what i am doing and that helps motivate me normally my sessions would be 2x200m and id know exactly what times i need to hit but now i dont really know what a good time is to run across a football pitch in or from one lamp post to the next none of these things mean anything to me at the moment it is all relevant to just me in addition to changing their motivational focus to one of selfimprovement in their sport hannah described how she was exercising to maintain her wellbeing as you can see from this photo of our pool its not very big but i swim in the morning it is my favourite part of the day even though it is quite cold it is not difficult it is not like training to keep fit it is really fun every time i get out of the pool i feel refreshed it is a good start to my day it lifts my mood it seems that some athletes relied upon external motivations from family members to continue to train during this period of uncertainty in their athletic career i just try to get by week by week and motivate myself by oh look my dad is running today i should run as well so my family plays a big role in motivating me with the four of us in our family running if the kids arent motivated my wife will motivate them to get on the treadmill or do a couple of laps around the garden the community within the family is very motivational annika chose a photograph of her family running around the garden to illustrate how they had motivated each other through exercising as a group we are doing a park run every saturday we have done four since lockdown and everyone must participate we are running around our house we have a big area where we can run we are not allowed outside of our house my son follows his time and he and his older brother compare their times the rest of us we are just enjoying it whilst some relied upon the people they lived with during lockdown for motivation ben was enjoying competing online against other runners in his local town by setting up routes to race on through the smartphone application strava which he shared a photograph of on strava you can map your run and the whole athletics community can get involved and you can do segments to find out what other people have run and you can get a crown for running the fastest time on that segment there is a segment that runs from lamp post 77 to 82 in my town which used to belong to my brother in whatever time he did he was the champion of that segment so i went out and did my run to try and get it and i did so its quite a good way to keep that competitive element of athletics by trying to race and become the fastest on different areas of road that are dotted around my town although you cant race against anyone in close proximity in this subtheme the athletes described relying upon family and friends to motivate and encourage them to train for their sport during lockdown perhaps in replacement of teammates and coaches others however were motivated not by the pursuit of athletic development but to protect their wellbeing during the lockdown such as exercising outdoors to boost mood theme 3 reflecting on participation in competitive elite sport towards the end of the first lockdown period the athletes began to reflect on their athletic career it seems the time spent away from competitive sport encouraged them to consider its place in their lives some engaged in a costbenefit analysis of their participation with regards to the impact it had on their wellbeing dave began to reflect on the financial strain associated with competitive sport and questioned if the current pressure he felt to recover from his injury was outweighed by the rewards of a gold medal i had planned to do the provincial biathle champs and the nationals i probably wont go overseas as it is expensive and i now question its value it has all been cancelled now and i have broken my elbow it may never be straight again i have a lot of pressure to get this arm straight but the other side of this thing is why am i competing is winning and getting a gold medal what it is really cut out to be reflecting on a photograph of his professional rugby kit charlie also commented on his changing view of the importance of competing but now its like bloody hell we were really onto a good thing here and could have gone into the top league and had an amazing time but thats disappeared as well and the longer it has gone on you realise that its only one year one season and seasons come and go and ive done 13 of them or something and as much as winning and being at the top is great it doesnt mean anything really not when you really think about it its just a moment in the sun isnt it for some participants lockdown restrictions gave them time to reflect on how damaging participation in elite sport could be to their mental and physical wellbeing being rather thankful for the time out when looking at a photograph of his race number rob shared his experiences of debilitating performance anxiety whilst competing and the relief he felt that this years competitions had been cancelled due to the pandemic i honestly think it is a good thing not to be competing on race day my emotions are a combination of nerves and excitement i usually have to go to the bathroom 34 times on the morning of an event my stomach works overtime it is nothing to do with my diet i have tried every variant of breakfast and lunch and dinner nothing helps it is just my nerves i have a toilet roll in my back pocket i put exceptionally high expectations on myself i think that there has been more benefit to not racing from the psychological point of view less stress on me like rob luke also seemed to appreciate the time out provided by the pandemic describing how before the lockdown he had continued to play hurt despite his injury and that the lockdown had allowed him to take the time he needed to recover from his surgery and mentally prepare for his return to play but this came at a good time for me as i actually tore my groin and my abdominal wall in january but was still competing i had an operation at the end of january so its been quite nice as i was actually supposed to come back to play but it has given me a longer recovery period so its a kind of blessing in disguise as i can actually get my body back strong i need to be in a good head space and have confidence in my body to be able to push it to its limits it effects my performance a lot if i am not ready whilst some of the athletes used the pause in competition as time to reflect and recover in preparation for their return to sport others like jess reflected on the importance of alternative career paths jess spoke of her identity as a studentathlete and how having a dual career was protective for her wellbeing giving her something else to focus on during lockdown she shared a photograph of a pile of research papers to illustrate this the photo of all the research papers is to show my identity as student now and thats what i have been doing with the majority of my time being a studentathlete has been protective for my wellbeing definitely in terms of my identity it has shifted a little bit charlie also considered how the time afforded by his injury during lockdown had forced him to think about what he was going to do after he retired from rugby as he shared a photograph of an online apprenticeship programme he was studying the fact that we are in lockdown it has given me a lot of free time to look at other things and its important thing for me to have another route outside of rugby to make sure that when i come out whether its the next two years or ten years i have something to fall back on and have credentials so i can do what i want to do outside of sport before the lockdown i was playing rugby five times a week and there wasnt much time to look at stuff like this at that point in time i was coming home from a long days training and was pretty tired and it was hard to switch into the mindset of studying it has been nice to have it now as a flip from rugby the thing that lockdown has done is show 100 that you do need these things in place especially as rugby or sports careers are not everlasting at some point you will have to go out and do some sort of other work and with my injury that is something else that showed that overall the lockdown highlighted the fragility of the athletes careers and the extra time afforded by the cessation of their sport prompted them to explore alternative career paths that would help protect their wellbeing during subsequent periods away from sport discussion this study was conducted in response to the growing number of athletes seeking sport psychology support during the pandemic and the need to develop evidencebased interventions to inform best practice using a qualitative open photo elicitation method this study explored the impact of the covid19 social distancing measures on athlete wellbeing three main themes threats to wellbeing adapting routines and maintaining motivation and reflecting on participation in competitive elite sport were developed through the process of thematic analysis and the main findings are discussed below the loss of sport impacts wellbeing overall the athletes in this study provided narrative evidence for giles et als conceptualisation of wellbeing as an integrated measure of emotional mental social and physical health they shared their feelings of loss shock and sadness at the cancellation of their sporting events and spoke of the threat to their physical and mental health as a result of the social isolation during the lockdown the current research identified athletes feelings of loneliness from the lack of social interaction with their athletic peers and the negative impact this had on their wellbeing tomalski et al similarly identified studentathletes as a unique population at a heightened risk for the development of mental health problems coupled with a decreased willingness to seek help it has been reported that periods of reduced physical activity compound feelings of isolation from teammates distance athletes from the athletic community allow less interaction with coaches and this lack of social support can cause emotional and psychological distress athletes also discussed how social media was used as a crux in order to immerse themselves in their sporting world but which counterproductively encouraged downward social comparisons against fellow athletes who seemed to be coping better with lockdown and highlighted inequalities regarding equipment accessibility which heightened return to play competition anxiety whilst not athlete specific early research from wuhan china the first epicentre of the global pandemic has reported that excessive use of social media during lockdowns has led to an increase in mental health problems the authors recommended that taking a social media break during the pandemic may promote wellbeing and mitigate the mental health repercussions of the pandemic negotiating the covid19 athletic career transition the athletes identified numerous barriers to their athletic development and the maintenance of their wellbeing during the lockdown the lack of access to equipment impacted on their ability to train effectively and the difficulty buying specific foods needed to fuel their recovery slowed down their progress these stressors were further amplified by the lack of access to their usual coping resources particularly social support the literature suggests that upon removal of athletes sporting platforms for example through retirement or injury athletes lose access to vital coping resources such as social support which can threaten their wellbeing emerging research suggests that the covid19 crisis and lockdowns have caused athletes to experience a similarly enforced pause in their athletic career to that of forced retirement and chronic injury therefore it has been suggested that career transition support and chronic injury psychological rehabilitation strategies be used to guide interventions with athletes who are struggling to cope with this nonnormative transition stambulova et al suggests that covid19 can be interpreted as a career transition barrier that interferes with athletes ability to strive towards career excellence the present study findings suggest that from a holistic developmental perspective the social distancing measures impacted participants athletes psychological psychosocial academicvocational and financial development some athletes adapted their training routines to cope with this nonnormative transition whilst others experienced a crisis transition due to lack of resources and ineffective coping strategies for example some developed maladaptive behaviours such as disordered eating sleep disruption body image disturbance depression and anxiety these findings support the recommendation of stambulova et al that athletes need professional support in order to successfully negotiate this transition samuel et al conceptualised the covid19 pandemic as a longitudinal multifaceted unpredicted noncontrolled changeevent with four distinct stages a precoronavirus stage with unique career contextual conditions coronavirus stagea accompanied by instability and confusion emotional response and cognitive appraisal coronavirus stageb characterized by active coping or regression and coronavirus stagec instability endures or decreases depending on career trajectory the present study findings provide empirical evidence to support these proposed stages as the athletes negotiated this career changeevent by implementing changes across a number of the proposed dimensions and recommend strategies such as setting new goals to help boost motivation adapting their athletic career aspirations developing new social networks outside of sport and broadening their selfidentity in order to navigate the covid19 transition strategies to protect wellbeing whilst the current study suggests that athletes did experience threats to their wellbeing in response to the social distancing measures that restricted their participation in sport they also developed strategies to protect it during the crisis these included adapting training routines and setting new goals utilising social support and exercising outdoors to boost mood the athletes adapted their training programmes in order to provide a structure to their lives during the lockdown and shifted their motivational focus from enhancing performance to avoiding performance decrements these finding support the research by mascret who reported that during the lockdown athletes modified their achievement goals from selfapproach goals to selfavoidance goals similarly gupta and mccarthy reported that the incongruence experienced by athletes due to the lack of structure during the lockdown resulted in psychological distress negative emotions and loss of motivation social support was instrumental in protecting the athletes wellbeing during the lockdown and they identified how different structural support systems provided specific functions such as relying upon family members for emotional support and their coaches for feedback on their athletic accomplishments social support has been described in the literature as a multidimensional construct that is comprised of three interdependent dimensions structural functional and perceptual together with the present findings this evidence suggests that athlete support personnel working with athletes during periods of isolation need to assess and identify their social support preferences to ensure they are consistent with their needs and enhance its impact the findings of the current study support previous research which suggests that physical activity can help protect wellbeing during lockdown and this effect is amplified if the activity takes place outside indeed thompsoncoon et al suggested that participating in physical activity in outdoor natural environments has a greater impact on physical and mental wellbeing than physical activity indoors many of the athletes in the current study were motivated to not just train to enhance their athletic performance but to exercise to boost their mood as per previous research however in light of the current global crisis there is a growing concern that social distancing measures that restrict exercise will contribute to a rise in obesity depression infections and cardiovascular disease furthermore mehrsafar et al suggested that a certain level of anxiety regarding the pandemic is completely normal but that high levels of stress can have a devastating impact on daily life and the inability to manage stress can result in shortor longterm depression recent research conducted during the covid19 pandemic has reported that higher levels of physical activity were associated with lower levels of anxiety suggesting that physical activity can help protect against some of the stressors associated with the crisis suggesting that our athletes efforts to exercise improved overall wellbeing and were not in vein engaging in reflective practice encourages stress related growth the athletes in this study engaged in a process of reflective practice during the lockdown period and this helped facilitate stress related growth in response to the challenges presented by the pandemic it has been suggested that not all stressful experiences result in negative consequences and that the process of confronting them can help broaden perspectives develop new coping strategies enhance relationships and mobilise personal resources results from the current study suggest that athletes in lockdown were afforded a prolonged period of wakeful resting that allowed them to reflect on their athletic participation and make life changes that would protect their wellbeing during the confinement period and when they returned to sport these strategies included developing social support networks and engaging in activities and hobbies outside of their sport in particular they identified the importance of maintaining a dual career and how this was protective for their wellbeing during lockdown and this period encouraged them to consider their plans for retirement the recovery literature associates rest with the reduction or cessation of physical activity and is fundamental for physical and psychological recovery following training and competition athletes become well rested if they engage in the resting process which includes sleeping and wakeful resting athletes experience wakeful resting when they do not think about their sport for example through participating in activities outside of it the ability to engage in wakeful rest that facilitates a period of psychological inactivity can be protective for athlete wellbeing indeed the athletes in the current study reflected on how this enforced hiatus had allowed them to take a much needed rest from the physical and mental stress of competition although for some this was particularly challenging during the first few weeks of lockdown due to the loss of structure and routine in their lives some athletes used this time out of competitive sport to recover from past injuries and acknowledged their willingness to play hurt schneider et al suggested that participation in competitive sport despite being injured is risky but a common occurrence in athletes the authors reported that the older the athlete the higher the inclination for selfexploitation and selfendangerment as reflected in their willingness to play hurt others reflected on how the pause in their athletic schedule had allowed them to engage in nonsport related hobbies and build relationships with family and friends pink et al suggested that a break from the pressures of sport can provide perspective to the individual and encourage the development of a multidimensional identity which can enhance wellbeing it has been suggested that the development of an adaptive and resilient personality that enables athletes to control anxiety is fundamental to achieving success in high performance sport it may be that in order to cope with the social distancing measures that pose a threat to athlete wellbeing that particular personality traits could play a protective role indeed the current research suggests that athletes engaged in a reflective practice process during the crisis and this helped them evaluate their situation and employ appropriate coping strategies indeed recent research conducted with aspiring olympic and paralympic spanish athletes reported that the lockdown period did not increase anxiety levels perhaps due to their adaptive and resilient personality traits practical implications and future research the present study highlights athletes experiences of the covid19 pandemic in particular how lockdown restrictions have impacted athlete wellbeing findings of this study offer a number of more immediate practical recommendations firstly the findings can be integrated into current athlete wellbeing strategies provided by athlete support personnel it is paramount that intra and interdisciplinary collaboration between athlete support personnel is encouraged in order to coordinate efforts to help athletes cope with the current global crisis for example case conferencing between multidisciplinary team members and key stake holders to identify athletes with preexisting mental health problems injuries or poor social networks who could be at increased risk during periods of social isolation and mobilise appropriate professional support sport psychology support should focus on the maintenance of wellbeing and the development of selfcare strategies rather than performance gains during this crisis athletes are encouraged to adapt their athletic routines to facilitate a positive adjustment to the constraints of social distancing and help protect against the development of maladaptive coping behaviours goal setting strategies that focus on a mastery approach that encourages personal development over a performance approach that is focused on outperforming others should be encouraged in order to boost motivation it is recommended that efforts should focus on developing social support within teammates and coaches through incorporating team activities that provide an opportunity to check in and promote social connectedness these might include virtual team competitions such as quiz nights or guided discussions to help encourage mutual sharing of their experiences with the increased accessibility of virtual communication in response to the pandemic this is an opportune time to capitalise on these new technologies to help enhance athlete wellbeing in particular it is worth evaluating the effectiveness of teleconsulting and future research is encouraged to investigate how practitioners can deliver effective psychological support through teleconsulting and to consider whether their support is best focused on therapeutic counselling or mental skills training during the pandemic beyond the covid19 pandemic studies could explore how such technologies can be utilised to promote social connectedness during times of normal physical distancing such as injury and breaks between seasons lastly and in line with previous career transition research athletes are encouraged to pursue dual careers to facilitate the development of multiple identities that can help protect wellbeing during times away from sport in the very least athletes should be encouraged to participate in hobbies and activities outside of the sporting arena strengths and limitations qualitative methods of enquiry provide rich data and facilitate in depth exploration and examination of issues this qualitative study used an inductive approach which enabled the researchers to explore the perceived impact of social distancing measures during the covid19 pandemic on athlete wellbeing however the utilisation of an explicit wellbeing scale may have provided further validation to the findings this study has a number of key methodological strengths first the heterogonous sample included athletes of different ages and career stages as well as representing individual and team sports and from different countries however a potential limitation of this heterogeneity is that there may be different crosscultural conceptions of wellbeing the majority of the athletes in the study were white so future research must seek to include athletes from other racial backgrounds findings reported in this article are unique to this sample and this current pandemic thus generalization of findings should be avoided though it would be pertinent to conduct future research that surveys a larger number of athletes utilisation of the open photo elicitation method is another strength of this research having been previously used in sporting research the use of visual imagery in research is thought to evoke memories and facilitate greater immersion and more detailed storytelling by participants providing rich experiential data however the interview process and our interpretations of the athletes stories could have been influenced by the authors experience and knowledge as a sport psychologist although the participants were invited to verify the findings in order to decrease the risk of misinterpretation conclusion in summary the covid19 social distancing measures have had a considerable impact on athlete wellbeing the initial sudden loss of sport in the athletes lives posed a threat to their wellbeing but over the duration of the lockdown period the athletes developed numerous strategies to protect it such as adapting their routines setting new goals fostering social connectedness through technology and participating in new hobbies furthermore their time away from sport encouraged them to reflect on their athletic career and to make life changes that would protect their wellbeing should they experience any future lockdowns sciences humanities and law university of teesside the patientsparticipants provided their written informed consent to participate in this study data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the studies involving human participants were reviewed and approved by research ethics committee school of social 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

countries all over the globe have implemented mandatory social distancing measures in an attempt to suppress and control the spread of the coronavirus disease this enforced period of isolation disruption to normal training routines and competition cancellation could be having an adverse effect on the mental health and wellbeing of athletes this study sought to explore the perceived impact of the covid19 social distancing measures on athlete wellbeing fourteen elite athletes who were unable to train or compete due to government imposed lockdown measures were recruited to participate in this qualitative study utilising the photo elicitation method participants were asked to take a series of photographs that represented their experiences as athletes living in lockdown these photographs were used to guide discussions in follow up unstructured interviews reflexive inductive thematic analysis identified three main themes that captured athletes experience of social distancing measures and the implications for their wellbeing 1 threats to wellbeing 2 adapting routines and maintaining motivation and 3 reflecting on participation in competitive elite sport the initial sudden loss of sport in the athletes lives posed a threat to their wellbeing but over the duration of the lockdown period the athletes developed numerous strategies to protect their wellbeing furthermore their time away from sport encouraged them to reflect on their athletic identity and to make life changes that would protect their wellbeing during the rest of the lockdown period and when they returned to sport a number of immediate practical recommendations are offered for athlete support personnel working with athletes during the crisis these include developing selfcare strategies and social networks adapting routines setting new goals and encouraging the pursuit of dualcareers future research is encouraged to investigate how practitioners can deliver effective psychological support through teleconsulting and to consider whether their support is best focused on therapeutic counselling or mental skills training during the pandemic

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introduction using information and communication technologies can improve older adults overall wellbeing and can be a catalyst for social integration and inclusion into society 1 2 3 4 5 despite the potential benefits afforded by icts older adults have the lowest computer ownership and internet use among all age cohorts 6 only 59 of older adults report they use the internet compared to 85 of all american adults age 18 to 64 years of age 7 additionally only 47 of older adults in the united states report access to broadband service 7 the digital divide literature traditionally focuses on the various gaps between those who do and do not have access to the benefits of digital inclusion these divides are tied to factors such as age race gender socioeconomic status and population density 6 8 9 10 to categorize older adults ict use by age however may be too simplistic a descriptor for such a vast and diverse population for instance older racialethnic minorities report using icts less and having less experience with icts than white older adults 11 moreover older adults attitudes toward and use of icts are driven by past experiences with icts which may be fundamentally different from both an intergenerational and intragenerational perspective 1112 in other words while older adults are often compared to other age cohorts based on previous digital divide research there may be a significant amount of variation within older adult populations with regards to their ict experiences attitudes and uses our study seeks to explore the potential gap by examining and comparing ict uses views and experiences among older adults from diverse racialethnic and socioeconomic backgrounds diversity of ict usage among older adults racial and ses differences previous research indicates that digital inequalities such as the adoption of icts may replicate other social inequalities 14 for instance older adults with an annual household income of 75000 or more are nearly fivetimes more likely to own a tablet than older adults with an annual household income lower than 30000 7 older adults age 65 and older are also much less likely to have home broadband compared other age groups 14 moreover racial differences regarding ict use and adoption also receives limited attention prior research indicates that racial digital divides continue to exist africanamericans are less likely to have home broadband compared to white individuals 14 african american and hispanic american adults are more likely to rely on their smartphones for internet access compared to only 4 of white smartphone owners 15 yet some findings suggest that older african american and white adults have similar rates of cellphone adoption 7 furthermore african american adults are less likely to go online for any purpose especially when they have not attended college for example when holding constant socioeconomic status 45 of african american seniors use the internet compared to 63 of white adults 7 racial differences have been identified regarding other types of ict use as well 19 of white older adults and 12 of african american older adults use tablets 19 of white older adults compared to 11 of african american older adults use ereaders such as a kindle 7 despite these descriptive differences indepth research exploring a more nuanced understanding of racial and ses divides related attitudes experience and ict use is lacking importance of digital inclusion for older adults ict use yields various benefits for older adults wellbeing by facilitating access to social support networks information to make life decisions and promoting independence 411 ict use among older adults is linked to reduced feelings of isolation loneliness and depression 1 2 3 4 5 older adults reporting such benefits from ict use perceive icts to be positive for their personal relationships by increasing their feelings of social connectedness to family and friends 25 moreover older adults use icts for inclusion into modern social networks 1 to this end icts afford older adults the means to facilitate meaningful relationships with both their geographically close and distant social ties however no research has examined how these benefits may vary among racially and socioeconomically diverse older adults older adults ict use and the perceived benefits of ict use are driven by experience 1112 perceived usefulness enjoyment social influence confidence and ease of use are drivers of ict use among older adults 16 furthermore selfefficacy and experience with icts leads to lower levels of anxiety regarding ict use 611 as icts are such an integral part of social connectedness and wellbeing for older adults it is imperative to understand older adults experiences with ict use and how those experiences promote or detract from further adoption of ict use across various demographic lines almost no research has examined these processes among diverse racial and socioeconomic groups of older adults to facilitate a deeper understanding of how racial and ses differences may affect older adults experiences with and use of icts we pose the following question what are the ict experiences among racially and socioeconomically diverse older adults methods four semistructured focus groups were conducted with older adults from two separate cities in midmichigan in the united states greater lansing area and detroit us census bureau 17 estimates indicate that approximately 97 of lansing residents are 65 years of age and older and that 516 are female nearly 247 of lansing residents attained a bachelors masters professional or doctorate degree in terms of raceethnicity 612 of lansing residents are white and 237 are african american and the median household income is 36054 census bureau 17 estimates indicate reveal that a slightly larger percent of detroit residents are 65 years of age and older and 527 are female in contrast to lansing residents roughly 127 of detroit residents attained a bachelors masters professional or doctorate degree moreover 106 of detroit residents are white and 827 are african american and the median household income is 26325 the focus groups were held in november and december of 2015 and february of 2016 participants were recruited using several different strategies participants from the greater lansing area were recruited using the online sona community pool which allows local residents to view opportunities to participate in research conducted by michigan state university graduate students and faculty participants from the metrodetroit area were recruited by a coordinator from a prominent local senior center each focus group had between 8 and 12 participants and lasted approximately 90120 min participants were compensated 20 for their involvement in the focus group during the semistructured focus groups participants were probed to discuss their views experiences and use of information and communication technologies questions assessed the types frequencies and participants motivation for using icts participants were asked how they decide on what type of communication channel and device they use to contact specific social ties additionally participants were encouraged to discuss how they feel ict use impacts their relationships with others as well as the ways they feel ict use is beneficial or potentially harmful prior to each focus group session participants completed a questionnaire that consisted of 15 total questions questions assessed sociodemographic characteristics ict access and ownership how often participants use icts to communicate with various types of social ties as well as participants relationship satisfaction the ict use question used a 4point likert scale response options data analysis and procedure during each focus group session audio was recorded using smartphones tablets while two of the focus groups were also recorded using a high definition 360 degree video recording device the audio from each session was transcribed by a third party service additionally research assistants were present in each session and recorded detailed field notes upon completion of each focus group session the moderator and research assistants participated in an informal debrief to discuss their observations and potential themes field notes audio and transcriptions were reviewed independently by research assistants to identify themes which were relevant to the focus of this investigation data from the questionnaires was coded and entered into an spss dataset descriptive analysis was used to compare participants from the two sites results table 1 shows the demographic descriptive results of the focus groups demographic characteristics for the two locations were divergent however the ages are relatively similar the mean age of greater lansing area participants was 70 years old while the mean age of detroit participants was 73 years old both locations consisted of mostly females the racial composition of greater lansing area participants was 84 white 11 hispanic and 5 african american while the racial composition of detroit participants was 86 african american and 14 identified as other a single item question was used to assess perceived economic hardship which contained three response choicesmore than enough financial resources to get by just enough financial resources to get by and not enough financial resources to get by as shown in table 1 participants from the greater lansing area were more likely to report having more than enough to get by than participants from detroit the participants from detroit perceived more economic hardship with 45 reporting that they do not have enough financial resources to get by compared to only 11 of those from the greater lansing area the greater lansing area participants were also more likely to report being married while the majority of detroit participants reported that they were divorced level of education was also more diverse in detroit with 29 reporting a high school degree or less while all the lansing participants reported having some college or more icts and connectedness as shown in table 2 participants from both focus group locations reported using a variety of icts to communicate with family close friends acquaintances descriptive results suggest that compared to the detroit participants a larger portion of greater lansing area participants used mobile phones internet enabled laptops tablets and desktop computers to communicate with others meanwhile a larger portion of detroit participants reported using landline phones to communicate with others while only 53 of the greater lansing area participants use landlines to communicate with others preferred ict was one of a few areas where results suggest differences among older adults from different racial and ses backgrounds im from san diego we wouldve never made it to michigan as efficiently as we did without our smartphones and the gps because we would we would find out the hotels wed find out the best price we could negotiate the room rates wed find a restaurant that we liked in addition to utility aspects of icts other female greater lansing area participants discussed how ict ebooks have impacted their leisure time i like my kindle i have never been a real big reader and ive gotten hooked on my kindle i love to read at night now and i think i could get the same thing on my tablet though so i think im overlapping myself but i really like just holding it and i like the light i can turn it on when hes sleeping and it doesnt bother him when the greater lansing area participants were prompted to discuss their favorite ict one male participant stated well the gps gets me to the spot that i had previously marked in that there as a waymark and then my fishfinder tell me whether or not i should be staying there or be moving on or whatever so that old trick about putting a big x on the bottom of the boat doesnt work laughter another greater lansing area participant stated other advantages of icts my favorite ict is a pen on my ipad because i have the old technology and i would rather write than type and just keeping up in how you integrate the new with the old conversely participants in both of the detroit focus groups unanimously claimed that their favorite ict is their landline phone while only a couple of participants in each group maintained that their cellphone was their favorite device although a few participants in both detroit sessions indicated that the cellphone was their preferred ict most replied that their favorite ict in general and their favorite ict used to communicate with others was landline i love my landline landline when probed for why landlines are their favorite ict one respondent stated you dont have to worry about charging it you dont have to worry about dropping a call landlines are more convenient the landline does not cut you off the landline does not travel no signals the landline doesnt go through all of that …but the point is with the landline you dont have to worry about charging it unless youve got a cordless phone we had a three day black out or two and a half day black out the towers was down you couldnt use this cellphone but you could use the landline as long as it didnt need to be charged and sometimes you dont feel like getting tied up with trying to learn the technology cause its time consuming like she was saying … she trying to figure out how do i text how do i communicate with this thing and the benefits too with this new technology you can reach so many people but like i said its pros and cons …you dont have to charge the landline its on the phone automatically you can put a voice message on it and itll record the message if youre busy or something you dont have to get the phone call each all these different things you have to charge em and make sure theyre running these quotes illustrate the myriad reasons why older adults from detroit relied upon the landline phone other detroit participants though fewer in number felt that cellphones offered them similar benefits regarding convenience convenience too for me its convenience you know you dont have to be tied at home to receive confirmation that you need i do like the text feature when somebody needs to give you an address or something i just tell them to go ahead and text me the address it is very convenient i agree with everybody but it has this pros and cons the reason i like the cellphone is for convenience because you can pick it up wherever you at as long as its charged… i was very happy to have my cellphone because im able to do business and check with the doctors and the doctors call you and you got to call them and everything and we can have conference calls and take care of business even when im out in the street and that type of thing so… but i dont… a lot of people that know me they will say you didnt answer you phone when i called and i say im not a slave to my phone and i said thats why i have voice mail when detailing their salient experiences with icts one greater lansing participants discussed memories and experiences related to recreational activities and travel one greater lansing participant stated i was afraid to drive in a big city i was afraid of certain streets i never could figure out when my turn was coming up and im a good driver in general i never had an accident im a good driver but certain things really come unglued repeatedly and now that i have a gps i call her evelina laughter i stick her on my dashboard and she keeps me up to speed on traffic and doing all the right turns and limit my eta i text my husband my eta its totally given me freedom im not afraid to drive at night anymore another greater lansing participant added i do a lot of walleye fishing so i can find the shoals where the forage is and so forth and we know thats a hotspot so well waymark it a couple years ago we went out on the ice in the up we went out about two and a half miles and a little baby knock the ice is like 34 feet thick i mean i had no idea where were at and then you take your ice fi… or fishfinders down on the ice and there they are other greater lansing participants described experiences with icts that enabled them to connect with family one greater lansing participant said when i skype with my grandson i can at least see him because i think there is more of a… again you dont misread what the communication is because you can see them versus texting or emailing so that to me is helpful to feel connected because my kids live out of state so that has helped to feel connected greater lansing focus group participants recognized the amplifications provided to them through the use of icts whether these involved helping them navigate roads or their lives or communicate in more realistic modes given the twoway visual communication made possible through skype facetime and other icts participants from detroit on the other hand spoke of ict experiences involving anxiety and concerns one detroit participant recalled an experience involving learning how use icts for work on the job we have to keep up with todays times and i didnt know anything but i wanted this job i needed this job so i went to school for it i didnt know how to turn on the computer it was very scary cause it was just something strange out of this world a monster standing here i have to tackle and im like well i have to learn this so i was very fearful and i was very timid but once i got the hang of it you can constantly apply it and keep on applying it to newer and later technology out there but it was very fearful and i was so bad when i graduated the whole class gave me a standing ovation other detroit participants discussed specific concerns to information security with regard to icts and online banking one detroit participant stated i listen to what theyre saying about how they can steal all of your information therefore i dont do it online you know what i do it for i do it through my checking account i do the eft transfer thats how they get my money out of my checking account end of the month my check come everythings covered to me thats better another detroit participant followed and stated and what i do is i have a separate account for paying bills and i had all of my bills come out of one account now if they steal out of that one some of those checks are gonna bounce my savings and stuff i dont have that information online other detroit participants cited negative experiences with upgrading icts and concerns of cost as salient experiences that had affected their attitudes toward icts one detroit participant stated upgrading every time you turn around you cant hardly get a phone without it being obsolete and theres nothing wrong with the phone i mean it works perfectly it does… a smartphone does most of the stuff might have some more features but you feel youre always compelled to upgrade and spend more money unnecessarily another detroit participant echoed the previous sentiment and said and initially when stuff comes out the prices… and the one thing i really hate is that the retailers are just so driven by that almighty dollar that they… theyre always up to summarize participants in the detroit and greater lansing focus groups had distinct perspectives uses and experiences regarding icts participants from the greater lansing focus group reported a wider variety of icts used than the detroit participants detroit participants reported landlines and mobile phones as their primary icts of choice due to perceived convenience and reliability the participants from greater lansing experienced less economic hardship were more educated and they reported a wider variety of uses of icts for maintaining and amplifying aspects of their lives further implications of these results are discussed presently discussion our results show that older adults experiences uses and perceptions about icts differ down racial and socioeconomic lines the digital divide was originally conceptualized as the unequal distribution of ict hardware 189 however over the course of the past decade this conceptualization of the digital divide as one simple hardware based divide has shifted to include a series of more complex divides in particular it has been posited that there are four distinct access gaps which can have an influence on an individuals likelihood to use and benefit from icts material access gap mental access gap usage access gap and skills access gap 9 our findings echo earlier digital divide research suggesting that older adults ict use and perceptions may be driven by past experience 1112 furthermore our findings show that older adults appear to find themselves differently divided based on various demographic factors while the digital divide has been closing for certain populations 9 our findings indicate and confirm that the differential impacts of the digital divide remains 1718 particularly for older adults to elaborate the detroit based older adults reported very different experiences and attitudes towards ict compared to the more affluent east lansing group the experiences and circumstances of the detroit group may have prompted a shift from simply being information havenots to becoming information wantnots 9 in order to truly understand this traditionally digitally divided population we must first begin to understand the digital differences or subdivides that exist within older adults our findings suggest that more disposable income may promote greater opportunity to use a wider variety of icts and experience various benefits associated with ict use the predominantly white and higher ses of older adults from the greater lansing area reported using icts to facilitate a wider variety of activities that lend themselves to positive experiences with icts the predominantly african american and lower ses older adults from detroit appear to be driven in their ict use by more negative experiences or fear of technological failure such experiences may promote a strong loyalty to older icts such as landlines and simpler mobile phones and may serve as barriers to adoption of a wider variety of icts in essence for individuals from lower ses groups the perceived unreliability of certain icts may have an inverse relationship with their motivations and financial ability to adopt and use icts conclusion and limitations previous digital divide research demonstrates that the likelihood of ict access is affected by various demographic factors such as age race and ses later digital divide literature expands to include a number of divides rather than just access to icts our study demonstrates that there are potential subdivides within traditionally digitally divided populations in other words factors such as race and ses can compound to result in different levels of ict experience uses and attitudes while older adults are the age group with the lowest level of ict adoption there are stratified layers of access and use within this large and diverse group the results indicate there is a great deal of experiential variation within this generation which could be just as important as intergenerational differences one potential limitation of our study is that we focused specifically on older adults from suburban and urban locations furthermore all participants currently reside in michigan future research should consider older adults from more rural locations and from various regions throughout the united states in order to improve generalizability of the results despite some potential limitations our research indicates that in order to effectively promote older adults digital inclusion researchers must first develop an understanding of the digital subdivides that exist within the population of older adults moving forward it is important to realize that older adults comprise a vast and varied population which has a great diversity of ict uses experiences and attitudes differences in older adults ict uses experiences and attitudes should be accounted for when attempting to design interventions or create policies that affect this particular population

using information and communication technologies icts can improve older adults overall wellbeing and can be a catalyst for social integration and inclusion into society while older adults are often compared to other age cohorts based on previous digital divide research there may be a significant amount of variation within older adult populations with regards to their ict experiences attitudes and uses our study seeks to explore the potential gap by examining and comparing ict uses views and experiences among older adults from diverse racialethnic and socioeconomic backgrounds four semistructured focus groups n 40 were conducted with older adults from two separate cities in midmichigan in the united states greater lansing area and detroit our findings reveal that older adults experiences uses and perceptions about icts differ down racial and socioeconomic lines our study demonstrates that there are potential subdivides within traditionally digitally divided populations

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introduction contemporary organizations continuous quest for flexibility and competitiveness has entailed the reduction of personnel costs implemented by decreasing intermediate levels of management transferring production and labor to developing and underdeveloped countries and increasingly adopting atypical arrangements such as temporary parttime and outsourced work on the other hand reduced opportunities for career advancement within organizations and the availability of relatively wellpaid jobs have generated criticism targeting the traditional notion of career whose linear ascending longterm trajectory in an organization no longer responded to the nascent work dynamics to capture this new zeitgeist career studies have been striving to understand the changing landscape in all its complexity and dynamism to assist career planning and career management to this end new career models have been proposed over the past three decades particularly two that currently enjoy wide acceptance that is the boundaryless and the protean careers defined as a sequence of work opportunities transcending the boundaries of any single organization the boundaryless career prescribes the need for individuals to seek interorganizational mobility which is a prerequisite for employability in turn protean careers summon individuals to take charge of their careers and lead them according to their subjective values and ideals of success in both cases continuous learning usually translated as the acquisition of portable skills is proposed as a precondition for the adaptive potential of individuals and perceived as paramount for the constant adaptation of their careers to market demands for some critics however both modalities consist of optimistic and voluntaristic representations of careers whose excessive focus on ones agency corresponds to the legitimation of the neoliberal logic in which the responsibility for career management is transferred from organizations to individuals who become responsible for placing themselves in the labor market advancing their careers and achieving professional success in other words they disregard the multiplicity of external factors conditioning career placement and development among other aspects they tend to mask the overlapping of careers with the domination and exploitation relations inherent in the labor market implying for example the nonrecognition of the fact that careers are crossed by social class gender and race markers as a counterpoint to the emphasis on individual agency underlying new concepts of careers in the 2000s a relational perspective of analysis took hold with theoretical and empirical assumptions grounded on grand social theories particularly the theory of practice able to integrate career research into a broader social and organizational framework along these lines a career is perceived as a sequence of positions through which individuals move in one or more career fields and this trajectory is conditioned by the structure of the field capital and career habitus over the last two decades the bourdieusian perspective has contributed to the investigation of multiple contexts in recent analyses of career studies by emphasizing the critical incorporation of gender ethnicity and aging markers however despite the greater attention paid to the contextual dimension according to this perspective research focused on understanding the barriers imposed on careers from a class perspective is still scarce with few exceptions in this context the trajectories pursued by individuals from workingclass backgrounds often divergent from the conventional upward trajectory associated with traditional careers have been subjected to insufficient attention within the realm of career studies this limitation has motivated the authors of this article to investigate the multiple boundaries resulting from the barriers created by various contexts in the careers of outsourced cleaners in the brazilian scenario through the life story method overall this study expands the contemporary career debate into two different directions firstly reconstituting the careers of workingclass women allowed us to shed light on the contextual constraints they face in their professional trajectory which in turn jeopardized the optimism underlying the new careers typically centered on the individual adopting the life story method enhanced the critique of the excessive focus on the agency by uncovering material and symbolic constraints that impacted the personal and professional choices of the women workers surveyed in this study secondly this paper aimed to fill the gap in the literature of studies focused on socially marginalized workers situated in the lower social strata whose peripheral treatment in career studies seems to ignore the deepening inequality between social classes during the last decades hence we address the rhetorical acknowledgment prevailing within career studies which posits that every individual engaged in employment follows a career path proposition that stands in contrast to the actual research conducted in the field of careers as it tends to exclude laborers from lower socioeconomic strata in this regard this study enriches the comprehension of career trajectories which despite being marginalized constitute the vast majority of vocational journeys particularly within peripheral contexts like brazil theory of practice and career studies we present below a succinct overview of the theoretical framework underpinning this research which encompasses the core concepts of practice theory the notion of precarious habitus and considerations pertaining to the assimilation of the bourdieusian perspective by career studies this amalgamation has contributed to formulating a contextualized approach to careers diverging from the voluntarist perspective advocated by contemporary paradigms such as the boundaryless and protean careers theory of practice general remarks developed from a reduced number of concepts especially the notions of field capital and habitus the theory of practice consists of a relational approach privileging the twoway relationship between agency and structure it corresponds to an effort to rescue the centrality of habitual action in structuring social reality as well as to a frontal rejection of voluntarist perspectives especially the notion of the rational actor conversely the latter proposes the situated character of the economic habitus that is that calculating dispositions towards work saving housing fertility or education are tightly linked through the mediation of dispositions towards the future to economic and social conditions … of possibility and impossibility thus it acknowledges the unequal social distribution of socalled rational dispositions according to bourdieu the notion of field is defined as a multidimensional space of positions whose vertical and horizontal coordinates respectively correspond to the volume and composition of the capital of individuals belonging to a certain social class it represents a structure of differences in which dominant and dominated agents mobilize strategies for conserving or transforming the field rules to monopolize the criteria of symbolic classification we align the authors interpretation of the concept of field with a domain of forces or contestations in that case the diverse forms of capital are conceptualized as weapons used in the struggles waged in the fields to impose the principle of their organization and the primary power source whose amount and composition order the agents hierarchically in a given field among the various forms of capital four deserve special attention namely economic cultural social and symbolic a more common resource variant economic capital comprises goods and rights convertible into money and is characterized by a high conversion rate into other forms of capital high liquidity and express transmission particularly through the institute of inheritance in turn cultural capital can be found in three states institutionalized objectified and embodied in the first case one should speak of academic or professional credentials whose acquisition stems from the conversion of economic capital into cultural capital these qualifications can be ranked hierarchically and contribute decisively to defining their holders relative value in the labor market its objectified form materializes into various artifacts such as books works of art and scientific equipment finally the embodied state refers to the individual dispositional heritage which conditions aspects such as body language pronunciation and lifestyle as they are slowly assimilated usually equated with relatively institutionalized relationship networks of relationships and recognition the value of social capital is subordinated to the volume of economic and cultural capital that can be mobilized through it furthermore bourdieu adds symbolic capital as the fourth form of capital defined as a transformed form that is to say unrecognizable transfigured and legitimized from other forms of power by engendering practices and judgments adjusted to the doxa this resource confers prestige and power to its holders lastly the concept of habitus was introduced by bourdieu as an mediator between social structure and individual action or rather as schemes of action perception and valuation that mold individuals lived experiences according to their social standings the habitus represents the assimilation of collective norms by the individual primarily through experiential and subconscious learning revisiting bourdieu peripheral modernity and precarious habitus in the social construction of subcitizenship brazilian sociologist jessé souza presents a thesis about the brazilian modernization process that diverges from the prevailing culturalist viewpoint the author posits that the primary distinction between dominant western societies and peripheral ones lies in the reproduction in the latter case of a structural underclass which he named brazilian rabble a term employed to denote a social class lacking the psychological and social attributes necessary for participation in a competitive market such attributes include discipline selfcontrol and forwardthinking in the development of his theory souza critically amalgamates the ideas of philosopher charles taylor and sociologist pierre bourdieu from the former he adopts the thesis suggesting that previous moral configurations associated with individuals perceptual and evaluative frameworks underlie the rise of the modern conception of identity prevalent in the west this identity is rooted in the promotion of individualism freedom performance and reason forming the bedrock for notions of selfworth dignity and citizenship the latter framework provides the tools to articulate concepts of moral hierarchy power dynamics and social inequality souza offers a critique of the ethnocentrism inherent in the perspectives of both these thinkers a result of extrapolating the socioeconomic conditions prevalent in the developed western nations in relation to bourdieu the author underscores the necessity to transcend the depiction of habitus as a monolithic construct this view presupposes the universal sharing of a primary habitus borne from a historical learning process enabling members of a society to internalize a particular sense of dignity which intersects with notions of citizenship and equality comprising attributes such as discipline selfcontrol and forwardthinking this primary habitus facilitates an individuals social recognition and productive role within contemporary competitive society in contrast the secondary habitus assumes the incorporation of the primary habitus and introduces aesthetic competence or taste as a distinguishing criterion consequently the concept of authenticity supplants that of dignity in terms of a parameter for social recognition within the framework of the secondary habitus this structure tends to align with occupations that are most highly esteemed both materially and symbolically conversely the notion of the precarious habitus aims to delineate a personality structure devoid of the less apparent dispositions of the modern world discipline selfcontrol and forwardthinking behavior and thought the precarious habitus is thus theoretically and empirically linked to circumstances of dire poverty and disrupted family dynamics another facet challenged by souza is the failure to recognize the origins of inequality in brazil primarily due to the valorization of the performance ideology the exaltation of merit as a justification for individual triumph integral to the modern moral configuration contributes according to him to the concealment of the mechanisms underpinning the objective and subjective perpetuation of the precarious habitus as a result emotions like pride shame guilt and gratitude arise as symbolic mediators of an objective hierarchy of values emblematic of a process of selfassumed accountability for personal success or failure bourdieusian praxeology and careers bringing context to the fore in career studies the appropriation of the bourdieusian theoretical framework has entailed the acknowledgment of careers as spaces of power a notion associated with disputes over the imposition of dominant principles of classification therefore contrary to the dominant voluntarism in the field the power relations that condition the process of career construction are recognized while the career field is defined as a socially constructed environment endowed with a set of rules and practices that assign autonomy to it career capital corresponds to the portfolio of particular forms of capital to which value is assigned in a given field or else to the investment of different kinds of resources held by the actors in their professional trajectories amassed over the long term through socialization in multiple contexts in turn the career habitus concerns the actions and strategies individuals mobilize habitually and unconsciously in a given career field in the past two decades several contexts have been investigated considering the bourdieusian theoretical framework to understand their effects on careers for example the various barriers impacting careers in the canadian biotechnology sector have been addressed and a reduced turnover at the managerial level was barbrazilian administration review 20 e230026 2023 f s de souza a h da c lemos found contrary to the expectations of boundaryless careers in turn research aimed at understanding the impacts of national contexts on careers has concluded that these can condition individual motivations underlying occupational transitions as well as on ones conceptions of career paths similarly other studies have examined how women mobilize different forms of capital in their careers as resources capable of contributing positively to confronting ethnic and gender barriers additionally the barriers and strategies mobilized by skilled immigrants and refugees have been investigated regarding their placement and professional development finally a study framed by a class perspective concluded based on a survey of young icelandic adults that ones choice of career is associated with the practice of cultural and leisure activities which are in turn related to ones social background however despite the wide range of contextual dimensions evaluated the residual presence of the social class marker in these studies motivated the approach adopted herein we argue that social class through the imposition of numerous barriers along career trajectories plays a pivotal role in sculpting careers that inherently encompass fragility and social immobility as defining features and most likely outcomes methodology the adoption of a narrative approach is explained by our understanding that individual experiences constitute a privileged access route to systems of perceptions and individual meanings as well as the objective structures and processes that condition particular forms of material life production and reproduction labor and consumption to follow the respondents careers through multiple times and spaces we chose to employ the life story method which is suitable for investigating phenomena such as social mobility marginalization and exclusion and sociability by reflecting the impacts of multiple socializations performed by institutions such as the family organizations religion and education life stories situate social actors in a broader collective story thus constituting a nonlinear access to scientific knowledge of the social system a bourdieusian approach to life stories allows the unveiling of the generative structures present in the field and the habitus which are conditioning factors of an unequal structure of possibilities as for the research subjects outsourced workers in the cleaning sector were selected for reasons such as the importance of the services provided by organizations and workers in the sector the sociodemographic profile of workers mostly women from the lower classes as well as the relevance of the cleaning sector in terms of job creation in the first 20 years of the 21st century for example this sector ranked fourth in the generation of jobs in the brazilian market creating approximately 992000 jobs according to data from the general register of employed and unemployed of the ministry of labor and employment at first the respondents were selected from the relationship network of one of the researchers however the initial plan to conduct three interviews with each participant to investigate family educational and professional contexts proved to be an obstacle to the conclusion of the interviews as they were usually terminated after the first or second round due to the unwillingness of the interlocutors to carry on with the process consequently we opted to use a research company specialized in recruiting informants in this case lowerclass individuals living in favelas or suburban neighborhoods in the north and west zones of rio de janeiro two to three interviews lasting one hour each were conducted with each participant preferably in their residences for it enabled us to directly assess the living conditions of the respondents and created a more conducive environment for them to share their life histories comfortably table 1 presents the profile of the eight respondents and highlights information relevant to this study referring to the major contexts of analysis investigated family neighborhood educational and professional to ensure the anonymity of informants fictitious names were assigned to them it is noteworthy that despite the lack of a prior definition of gender and ethnicity in the selection process of the participants the respondents profile reveals a research focus combining class gender and ethnicity markers in line with data from the conservation and urban cleaning union according to which cleanliness and conservation activities are composed of a majority contingent of black women with low educational levels it is important to note that this article represents a segment of a more extensive study encompassing various other contexts such as leisure morality and religion however due to space constraints these aspects have not been included here we have thus opted to concentrate on those aspects that exhibited a more significant impact on shaping the respondents careers following the methodological framework proposed by bertaux which advocates for a blend of attentive listening and effective questioning when delving into sociostructural relations that influence individual and collective histories we employed a semistructured script for our research approach this strategy aligns with the guidelines outlined by lahire and macdonald et al incorporating bertauxs methodological framework we adhered to two additional aspects firstly we based the number of respondents on the saturation criterion aligning with the authors proposition furthermore we followed the recommended chronological sequence for gathering transcribing and analyzing the life histories in accordance with bertauxs approach we promptly transcribed and preliminarily analyzed each interviews information at its conclusion this method facilitated the timely identification of saturation indicating the point at which the inclusion of new participants becomes superfluous due to redundancy in acquired data adding minimal value to the existing material regarding the structuring of the life story analysis process we chose to employ thematic analysis that is the themes were structured from the combination of previously defined and emerging categories throughout the research process segregated according to table 2 while the firstorder codes indicate the target contexts of the investigation the secondorder codes indicate the most relevant aspects of the contexts that emerged from the reports sometimes associated with turning points such as early pregnancy and school dropout every interview underwent several readings and the coding process was initially facilitated using the proofreading tool within the text editor during this phase passages deemed particularly pertinent to the studys objectives were identified resulting in the assignment of firstand secondorder codes to facilitate a holistic examination of the interviews a spreadsheet comprising four tabs was designed each corresponding to a firstorder code within each tab excerpts from the interviews were meticulously associated with the corresponding secondorder codes this approach enabled a comprehensive visualization of the manifold narratives linked to each code this systematic mapping procedure in conjunction with the theoretical framework served as the foundational structure for shaping the subsequent analysis and discussion of the findings finally we believe that adopting the life story method allows us not only to analyze the process of construction of the respondents careers but also to privilege its constitutive dimensions space identity and time translated in the bourdieusian framework to the concepts of fieldcapital habitus and trajectory respectively results the operational logic proposed for presenting the results was to organize them based on the concepts of family educational neighborhood and professional contexts the first order codes thus illustrating how multiple spaces and times conditioned their careers it should be noted that the relational epistemological approach adopted in this study emphasized the interface between the individual contextual and structural spheres thus privileging the micro meso and macro dimensions of investigation family context early domestic work and early adulthood when combined the life histories shared by the participants and the observations made by the first author during his home visits to conduct interviews collectively depict a landscape of profound fragility one exception stands out moniques circumstances residing in a threebedroom rented dwelling situated in a rio de janeiro suburb this setting contrasts starkly with the norm where homes are typically smaller and nestled within slums at the far end of the spectrum lies brunas situation presently she cohabits with her two children and her mother in the very house that encompassed her upbringing the dwelling a mere 15 square meters in size devoid of wall plaster and featuring a bathroom door now accommodates five individuals in times past it contained not only bruna but also her parents and an additional six siblings analogously with few exceptions the other respondents spent their childhood and adolescence in densely populated slum dwellings the narratives of nazaré andréa and bruna are emblematic of pronounced levels of economic precarity these accounts mirror the landscapes of food instability homelessness and instances of familial mental health disorders we used to play but times were tough id head over to my aunts place and there wasnt even any lunch sometimes i still remember my aunt tossing a bunch of bananas on the fire and wed munch on roasted bananas you know you know what really sticks with me about those hard times its when my dad just woke up and disappeared he was kind of messed up in the head and even got himself sent to the hospital once hed talk about folks wanting to off him so he hopped in his truck and took off and my mom she was out of work at the time out of the eight cases six had the participants growing up in singleparent households where their moms handled both the breadwinning and nurturing roles similar to what bruna shared the life paths of monique and her sisters regina and alessandra all mirrored a common theme their fathers struggled with alcoholism my father he was always… well he was an alcoholic you know hed wreck the whole house sometimes … when i was 15 i met my first husband i thought id escape the torment i faced with my dad hed lash out at us i might even need a hearing aid in this ear from all the blows to my head we had to live through such a rough life my dad even tumbled into a ditch once while drunk wed hose him down in the backyard because hed come home covered in mud … he aint working anymore booze got the best of him and now hes out on the streets as evident from these accounts these situations highlight instances of family disruption and heightened levels of material precarity these attributes align with the characterization of the formation of a precarious habitus and entry into lowskilled roles within the job market proposed by souza although in this study the class condition is not restricted to the position occupied by an individual in the occupational structure we acknowledge the conditioning of the trajectories of children by the occupational and educational status of their parents indeed table 3 presents information concerning the professional activity and educational background of the respondents parents which attests to the objective correspondence between social origin and destination conditions represented respectively by the educational and occupational status of parents and children regarding the reproduction of the occupational activity the fact that the respondents mothers have followed occupational paths reflecting different combinations of the following activities stands out janitor cleaner and housewife in addition the early involvement with domestic chores and the support for the siblings education were present in many of the narratives collected according to regina she had no childhood her mother had many children and she had to look after her sisters and her younger brothers and clean the house a similar experience was portrayed by georgette the way i see it i started working when i was little … when i was little five or six years old i was already working at home because my mother had bronchitis people who have bronchitis cant go around dusting things can they as for schooling and educational background we found that most of the respondents fathers and mothers did not complete elementary school therefore like their daughters as we will see below they did not complete the minimum education required to occupy more valued positions in the competitive labor market materially and symbolically educational context early pregnancy school dropout and precarious placement in the labor market some critical events or turning points were present in a significant share of the narratives regarding the family dimension especially in what concerns early maternity and conjugality that led as a rule to the respondents transition from their parents home to a home of their own one of the frequent implications of this was the interruption of their educational trajectories consequently the respondents found themselves wholly removed from school to cope with maternal and domestic responsibilities or toward precarious placement in the labor market like their parents the respondents schooling is far from being an irrelevant aggravating factor in most cases since they did not finish elementary school they became unable to apply for most jobs including similar but better paid positions with higher levels of benefits and a stable employment relationship such as waste collectors working with the municipal company of urban cleaning alessandra for example associated her job as a cleaner with her low level of education like what happened to her mother who among the various precarious manual occupations she held found her most likely alternative in providing cleaning services however perhaps from personal experience alessandras mother did not want her daughter to follow in her footsteps look to be a janitor … my mother never wanted me to do this she wanted me to do something else go to school and get a job but a janitors job is as good as any other … it happened because i didnt graduate from school if i had maybe i wouldnt have this job im proud of this occupation though im not ashamed of it although unique these womens educational trajectories hold certain similarities such as their nonlinearity increased school dropout rates and the long hiatus between their dropout and school resumption no less relevant was the fact that school dropout corresponds not only to early motherhood but also to premature and precarious placement in the labor market a turning point in the trajectory of all respondents the early pregnancy portrayed by monique was an unplanned event in six of the eight life stories according to her she got pregnant when she was changing her medication … from shots to contraceptives to pills furthermore we highlight that on five occasions pregnancy occurred at the age of 17 or younger more specifically in the case of bruna the pregnancy occurred at the age of 12 consistent with the strongly patriarchal culture dominant in brazilian society the narrators took full responsibility for the care of their children relying on little or no help from the childrens fathers when questioned about the involvement of their partners in the domestic routine bruna declared no way boy he got nothing done he barely washed the dishes … he only took my daughter to school and back because he only worked weekends he is a dj for nazaré her former partner helped a little with the children but she was the one who prepared the food and dinner she did everything it should be noted that the negative consequences often associated with an unplanned pregnancy such as the eventual interruption or even a definitive school dropout with potential repercussions on future professional development vary according to ones social class indeed this factor penalizes young women from the lower social classes more severely as illustrated by the participants in this study once again we notice the impact of the intersection of class and gender markers in the configuration of careers another element that emerged from the participants narratives was selfblame manifested through emotions of guilt and shame this is clearly illustrated in alessandras story of her teenage pregnancy and how it influenced her educational journey we sort of feel a bit embarrassed you know like were not that strong for not making it i had to stop my studies because i got pregnant it was around september and i could have actually kept going because the pregnancy wasnt too far along i couldve at least finished my sophomore year i always had my goals straight in my head the only reason i didnt keep going with my studies was because i messed up … sometimes you end up reaping what you sow similar to alessandra georgette depicts her life journey as an outcome of personal responsibilities that she consciously did not meet thereby distancing herself from the various tangible and symbolic limitations intertwined with the shaping of her life trajectory but you know if i had been younger if id had the perspective i have now i think i would have had the determination i wouldve pursued my studies… aiming for a better income today you know to get into old age standing on a more solid ground the neighborhood context social capital local relational networks and inequality the configuration of respondents network combines a restricted number of local contacts and is established above all with relatives and neighbors this social capital is mobilized among other things for professional purposes according to some respondents reports my first time working in a family home was a referral by my moms coworker … who lived nearby and told my mother about it … my cousin took me to work at an apartment … as for my first job with a signed contract it was my exhusband who found it at the hospital it was his niece who was the boss and got me a job a similar situation was experienced by georgette who declared the person who referred my first job in a family household was my sisterinlaw … and the second was a neighbor because i was out of a job … he is my husband now laughs in another case we noticed the overlapping of interpersonal organizational and institutional dimensions since the religious institution attended by adriana in the community where she lives was related to one of her professional placements it was a friend from church he owns the company his name is marcelo he said he needed a reliable person to work with so my friend said how about adriana he called me and said can you bring your employment record card tomorrow and i said yes of course similar to the results found by perri 6 and macdonald and marsh the social capital held by the respondents proved to be a not very permeable frontier hindering the possibility of interand intragenerational mobility their search for job positions was usually associated with informal strategies based on referrals from relatives or neighbors constituting an additional frontier interposed along their professional trajectories the professional context interpersonal distancing and social humiliation perhaps the most frequent element in the respondents statements regarding their working conditions throughout their careers concerns the relationships they formed in the workplace for the purposes of this research the intersubjective relationships maintained by the respondents in their work environment were subdivided according to whether they were established with their peers superiors or customers it is worth pointing out in advance that varied experiences among the respondents were identified for example in the cases of bruna and andrea on some occasions social interaction with coworkers proved to be a crucial and positive element in their careers for the first one what she like most were the friendships … to go out and get to know other places the second mentioned that she liked to stay at the client with her counterparts … when they went for coffee and were always chatting on the other hand in other cases this relationship proved to be more ambiguous oscillating between positive and negative valences with a strong predominance of the latter especially due to the presence of intrigues and gossip in the workplace as can be seen in excerpts from reginas narrative employees are not friends you know you are dealing with someone now and they will later stab you in the back theyll go to your boss and ruin your reputation its a very strong burden and theres a lot of gossiping by the way when i met my husband the person in charge got very angry … she started to assign me to terrible tasks i cleaned basements sewers and all kinds of mens work it sucked but when i worked there at the hospital it was good the work was calm and the people in charge also treated me well you know such ambivalence can indicate a sense albeit ambiguous of belonging to a certain group of stigmatized workers the same ambivalence was present in the relationship with hierarchical superiors favoring in some cases relationships of friendship and camaraderie as bruna puts it in all my jobs i always got along well with my boss and coworkers i still have friends from work to this day however in most cases the reports revealed signs of physical and symbolic interpersonal distancing representing a clear segregation between hierarchically superior operational functions supervisor and foreman and those performed by subordinate workers leaders and janitors adrianas representation of the training she received to perform leadership functions in a previous job proved to be unusual to say the least according to her it consisted of training on how to mistreat people the difference is that the leaders are almost like janitors they take part in the same training the foremen however participate in the training with the supervisors its a separate differentiated training … the training teaches how to talk to the employees and what our attitude should be you cant discriminate against them but you cant laugh have coffee with them or even eat with them its like informal discrimination you know this paradox reaches even more significant levels when the focus of the investigation shifts to the interpersonal relationships that the respondents maintained with clients during their professional trajectories the notion of interpersonal distancing defined as dominant response to poor people from those who are not poor seems appropriate to a greater or lesser extent to deal with the scenario portrayed by the respondents when referring to the interpersonal relationships maintained with clients once again the experiences lived andor represented varied from case to case reflecting not only the diversity of the work contexts experienced by these women but mainly the intrinsic relationship of such contexts with the nature of interpersonal relationships two clear tendencies were identified highlighting in the first place the feeling of gratitude expressed by the respondents when they were treated with a minimum degree of attention and respect they were very polite i had nothing to complain about the clients none of them its like when i worked at locamérica car rental in penha … they even allowed us to use the bathroom that was exclusive to the clients marcos the boss at the time threw parties just for us he would do everything for us sometimes during the weekdays he bought snacks with his money for those of us who did the cleaning it was like that he focused a lot on us second experiences revealing variations of what was conceptualized as interpersonal distancing prevailed the following accounts were ordered to depict increasing levels of intersubjective alienation perceived by the respondents its all right with the clients because we are service providers so we must be careful about the sectors we go to you know we cant be too close to them we must avoid this as much as possible … because they are watching us the clients dont pay too much attention sometimes you say good morning to someone and the person wont even reply … i am always the first one to talk if the person answers by any chance ill say it a second time but if the person doesnt answer i wont say anything else … these people think that cleaning jobs are inferior you know there is a lot of discrimination and the demand is quite high it gets to the point where people say i pay you so you must clean … imagine what its like to hear that every day … i know i must clean but you dont have to say that to my face … some people put us down they dont see outsourced workers … with very good eyes some of these statements show that the condition of outsourced workers may imply a possible reduction in the sense of vertical solidarity that may exist between employees of different hierarchical levels in a diverse organizational framework those they refer to as customers or clients in the current scenario could correspond to employees of the same organization although occupying different positions and functions it seems that this separation occasionally resulted in setting less permeable boundaries indeed in a specific episode they were represented by the walls of a room in which outsourced cleaners would be confined so as not to cross paths with clients during their work routine the spatial segregation experienced by adriana was interpreted here as a significant boundary in terms of interpersonal distancing in which the relationship manifests itself through the interdiction of ones presence we used to get in in the morning the school opens at seven oclock we arrived at six oclock then cleaned and tidied up the rooms when it was time for the children to come in we went into a little room it was the room where the cleaning staff stayed … there was a folder that had the class schedules so we could clean the rooms for the afternoon shift … as for the restrooms we wouldnt go in there only during the childrens break … when they went to the classrooms we went to work in the yard or the restrooms concerning the cleaning activity the respondents clarified the remarkable influence exerted by the context in which they provided services both on their physical and emotional health and on their sense of dignity placement in small commercial stores university departments and car dealerships was usually associated with a more positive sense of duty due above all to a functional scope dissociated from the undesirable task of cleaning toilets in busy settings such as shopping malls schools and supermarkets the following narratives attest to a very specific type of demeaning operated through disregarding the consequences of certain individual practices on the wellbeing of another human being some people defecate all over the bathroom but i dont feel sick or anything … we had these fiveliter gallons wed pour the cleaning product all over and scrub everything with the broom we wore gloves masks and goggles and had all this stuff to work with it goes from lowering the toilet seat to defecating on the toilet seat and smearing poop on the walls some women leave … their stuff their bloody absorbents on the floor you know that kind of stuff and theyll say you must clean that up … and you cant say anything … you must look at the customer and sometimes you must laugh but i didnt laugh because i am what i am id frown instead to some extent these manifestations of the nonrecognition process are interpreted by some respondents as a symbol of a feeling of repulsion targeted at them by other people people think were nasty you know once i touched a guy and he went like this she makes an expression of disgust i said to him listen im not dirty … they think cleaners are nasty there is discrimination you know there are places where you cant get in … that is outsourced cleaning workers cant get in because we handle waste and garbage its not because we are working with the trash that we are dirty do you think i smell bad ive been cleaning this whole place but i dont stink it happens a lot though the fact that these workers are associated with a stigmatized and poorly paid occupation makes the respondents not want their children to follow the same path when asked about her aspirations alessandra did not hesitate i always want the best for my children you know i want them to grow up knowing the value of things and that everything comes from the sweat of our work i want them to have a good job a good house and not go through what their father and i had to endure however alessandra does not envision a better future only for her children encouraged by the teachers at the school where she currently works she has gone back to school and now dreams of attending nursing school when she finishes high school the following topic addresses how the habitus of class developed throughout these womens trajectories translated into the career habitus acts as a central component in the process of sedimentation of ways of acting thinking and perceiving which prove to be effective mechanisms of practical learning the professional context habitus career boundaries and social reproduction finally we must ask how these women find the strength to endure a professional trajectory combining physically exhausting work low wages limited benefits and eroded labor rights bourdieu is perhaps one of the authors who have paid the most attention to this question he proposed an answer based on the process of habitus incorporation throughout ones entire life as for work when asked about what they like most the participants all answered almost in unison i like to clean according to georgette she doesnt like jobs where she must stand still she like to clean while for monique her favorite part of the job was washing i liked it i love to use the washing machine i still love it to this day another participant agreed associating the work routine with that of a housewife i really like cleaning things i like it because i like to be a housewife i get a kick out of it you know i cleaned this room here with pleasure just because i was feeling it well im going to clean it i didnt even know you would be here and use this room but i did with all my love you know … i like it you know splashing water on the wall is my thing using the squeegee and all its a piece of cake the respondents have a practical way of living life inscribed in their bodies as opposed to the school way of learning consolidating their willingness to perform manual labor and their alienation from more intellectualized activities i was never much of a reader i only read at school our teacher was good at reading books to us but i was never a person who got books to read … the only thing i bought from newsstands was ponto de cruz … i learned how to do that and then there was a time that i started to do crossstitch and didnt want any other life for myself discussion the present section is dedicated to discussing in light of the theory of practice proposed by bourdieu the key contextual aspects underlying the respondents life and career trajectories that operated as boundaries circumscribing their professional opportunities and choices the discussion of these aspects allows us to reflect on the limits of the agency especially in the case of individuals who hold low amounts of economic cultural and social capital as illustrated in the previous section the barriers faced by the respondents in their personal and professional trajectories were numerous initially in the family context the findings reveal that social reproduction even today is the most likely outcome in turn this highlights the substantial conditioning of life opportunities by opportunity structures the cleaners job reproduces the occupations of their mothers who also devoted their time to similar activities such as janitor cleaner or housewife moreover the early placement of mothers and daughters in a domestic work routinepresent in most of the reports is interpreted by some authors as a learning mechanism for these subjects imbricated with a patriarchal ideology that associates femininity with the private sphere and masculinity with the public one hence reducing these womens occupational choices in this context the financial restrictions are further intertwined with symbolic limitations stemming from the ingrained patriarchal hierarchy these constraints shape the vocational trajectories of women hailing from workingclass backgrounds in addition to inheriting their mothers vocations the respondents were forced to reconcile work and school from an early age indeed this is a specificity of children and young people from poorer economic backgrounds and this tends to subtract the available time not only from leisure activities but also from educational practices this can be interpreted as a sign of early adulthood reported by some authors as a potential negative influence in the transition processes especially from school to the labor market early motherhood was another common aspect in the respondents trajectories it can be associated in the light of the bourdieusian framework as a particular manifestation of a more general disposition of the less privileged classes related to the lack of planning of activities daily or otherwise this event operated as another barrier to engagement in school activities and obtaining the minimum education required to grant the respondents access to better quality jobs studies addressing the relationship between the probability of continuing studies during early pregnancy and ones social background revealed that in the case of class a only one of every five young women interrupted her studies during pregnancy and resumed their schooling soon after the birth of their babies on the other hand when it comes to members of class d all the young women dropped out of school during pregnancy and none of them resumed their studies after the birth of the child furthermore the necessity to halt education due to early motherhood underscores not only the influence of social class but also the impact of a patriarchal culture that ascribes childrearing duties to mothers in simpler terms the responsibility of childcare often falls on young women rather than being a shared responsibility with their partners this norm has the effect of normalizing the decision for women from less privileged social strata to discontinue their education in spite of the economic and cultural factors contributing to the choice of discontinuing education the respondents hold themselves accountable for this decision in their accounts they attribute their current precarious professional status to the fact that they dropped out of school nevertheless we contend that by assuming ownership of this decision the respondents inadvertently propagate the contemporary neoliberal narrative that assigns individuals complete responsibility for the paths their careers take consequently the systemic constraints that push them into making this decision are obscured by the perception of a supposed agency regarding the neighborhood context in dealing with materially and symbolically precarious living contexts we argue that early placement in locally embedded relationship networks materialized in family and neighborhood networks of solidarity as observed in the respondents accounts constitutes a generative mechanism for the reproduction of social inequalities moreover the habitus developed in these contexts is strongly associated with occupational perception and the eventual choice of an unqualified career this scenario can also be examined from the perspective of network analysis according to rayder and burt ones individual relationship networks significantly impact career performance given their relationship with the generation and realization of professional opportunities influenced by granovetter the authors propose the socioprofessional superiority of networks whose configuration is characterized by the existence of disconnections between contacts corresponding to the notion of structural holes in other words the respondents social capital and socialization in an environment where the majority of individuals are engaged in precarious employment proved to be yet another boundary limiting the possibilities of interand intragenerational mobility the professional context reflected experiences characterized by ambiguities typical of this occupational group interpersonal relationships emerged both as a source of pleasure and as the occasion for experiences permeated by intrigues and psychological pain the ambiguity inherent in the professional identity of respondents ie workers in the cleaning sector was reflected in the alternating significance they gave to their work context sometimes as a place or a nonplace sometimes as a source of symbolic belonging or a mere physical environment ambiguities also characterized their relationship with clients some experiences reported by the respondents denote a certain level of interpersonal recognition while others reveal recurrent episodes of social humiliation defined as a form of suffering long endured and chronicled by people of the poorer classes … that in the brazilian case and several generations ago was sparked by the spoliation and servitude that fell heavily on natives and africans and later on lowwage immigrants ambiguity also emerged from the participants representation of the cleaning activity although some of them claimed to be proud and appreciative of what they do some reports referred to the negative social value attributed to this activity expressed in these womens low selfesteem and the experience defined as a form of social invisibility like the invisible men portrayed by costa in a study with garbage collectors in a university environment the respondents revealed themselves in some circumstances as invisible women victims of a perverse mode of sociability such perception is in line with the propositions by goffman about the phenomenon of stigmatization whose cruelest face would reside in its capacity to extend to the completeness of the discriminated subject a specific depreciative aspect the inherent precarious material conditions typical of such endeavors characterized by lowskilled manual labor lacking social recognition inadequate compensation and instability often coupled with the violation of labor rights and minimal prospects for career progression play a significant role in eroding the respondents selfesteem and inducing uncertainty about the paths they have managed to pursue finally the notion of habitus contributes to understanding the paths and processes that lead these women to conform to the vicissitudes of their professional lives marked by deprivation exclusion and lack of career prospects according to teixeira et al these individuals identities can be interpreted as spaces of confirmation of social structures indeed these women have been accustomed throughout their life stories to exercise survival as a way of life and have been building throughout their trajectories dispositional assets or habitus that have allowed them to develop ways of thinking acting feeling and appreciating coherent with the demands imposed on them socially final remarks this study investigated the multiple boundaries that visible or invisibly have influenced the trajectories of lowskilled women delimiting their career opportunities to carry out a critical dialogue with the assumptions underlying the new careers especially the accentuated centrality typically conferred to individual agency to the detriment of the importance exerted by contexts in the process of the social construction of careers the reconstitution of the researched workers life trajectories allowed us to reveal multiple boundaries faced in their professional path which questions the optimism underlying voluntaristic career approaches furthermore this study has uncovered the distinctiveness of a career trajectory frequently overshadowed within this research domain analyzing the reports allowed us to identify the decisive impact exerted by the intersectionality of class gender and ethnicity markers in the process of building the respondents careers characterized by early involvement with domestic work either in their own homes or as maids in other family homes by reproducing their mothers vocation for subaltern labor therefore we argue that the multiple blows dealt to them over time have created real barriers to the possibility of building a selfreliant personality taken as a reference by most mainstream organizational and career studies that overemphasize the role played by agency in the construction of a successful career in line with the theory of practice we argue that the unfavorable conditions experienced by the respondents cannot be dissociated from their career trajectories these proved to be precarious nonlinear and unstable alternating in most cases periods of work as outsourced cleaners and housemaids with occasional periods of unemployment the fact that most of them did not complete elementary school primarily due to early pregnancy events emerged as the most formidable barrier to qualified placement in the labor market the social capital locally embedded in the communities where they live is associated on the one hand with family and neighborhood networks of reciprocity and solidarity and on the other with social ties whose career returns are poor both qualitatively and quantitatively combined with the precarious habitus developed in this specific context acting as invisible mechanisms of social reproduction in turn their careers proved to be marked by ambiguities interpersonal relationships emerged as a source of pleasure and humiliation as blustein reminds us relational approaches offer an alternative discourse to perspectives that like boundaryless and protean careers articulate an optimistic worldview based on the generalization of a specific view on human nature corresponding to autonomous individuals who consciously pursue their goals and are guided by substantive values in contrast this author argues that the real world consists of most subjects lacking the social and symbolic conditions that allow them to cross the physical and psychological boundaries that limit their trajectories along these lines pontes defends the tendency even today to perpetuate structural inequalities translated either in terms of processes of social immobilityreproduction as this work has shown or in the form of ascending mobilities of restricted scope the phenomenological approach to the reality experienced by the respondents proved sufficient to show that the combination of the multiple boundaries faced by these women in their life trajectories ended up circumscribing the topography of their careers which have become largely limited to the provision of care services contrary to the centrality of agency in their careers the clash with boundaries erected in an increasingly selective and exclusionary world of work stands out in their trajectories however it is important to note that despite the structural limitations they have encountered the respondents tend to internalize responsibility for their uncertain professional destinies often attributing them to their decision to discontinue their education this selfblame combined with the development of a precarious habitus over a life marked by deprivation contributes to a sense of resignation and diminished selfworth present in the statements made by the respondents our findings deepen the criticism of the models in vogue in the field of career studies in recent decades which by emphasizing the role of individual agency have assigned little relevance to the contextual aspects that condition ones professional trajectories the study also contributes to expanding the debate sparked in career studies by the contextual approaches by illustrating based on accounts obtained through life stories the multiple barriers in the professional paths of workers from vulnerable social backgrounds this study also helps fill the research gap on socially marginalized lowerclass workers careers and contributes to an enriched understanding of professional journeys that are commonly marginalized in the realm of career studies it brings to light the existence of precarious careers hemmed in by multifaceted barriers as a contemporary phenomenon that coexists alongside the touted concepts of boundaryless careers and other novel models often praised within this field of inquiry in practical terms this research by revealing the difficulties faced by cleaners in their work routine can help organizations reflect on ways to ensure that their workers have the most dignified job possible regarding the cleaning sector future studies can be directed to investigate the individual and collective strategies adopted by cleaning workers to improve the conditions and organization of the work process to expand the debate that incorporates contextual aspects into career studies future research can focus on unveiling according to a class perspective the various boundaries interposed in the career paths of professionals who practice both skilled professions such as medicine engineering law and others and lowskilled occupations like those addressed herein forthcoming studies can delve into the exploration of other marginalized career paths with the aim of validating as careers the professional trajectories of their members conflict of interests the authors have stated that there is no conflict of interest authors felipe silveira de souza fundação getulio vargas escola de administração de empresas de são paulo rua itapeva n 474 cep 01332000 são paulo sp brazil ana heloisa da costa lemos pontifícia universidade católica do rio de janeiro iag business school r marquês de são vicente n 225 gávea 22451900 rio de janeiro rj brazil

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introduction and background the world health organization defines adolescents as individuals in the 1019 years age group the period between childhood and adulthood 1 it is a particular stage of human growth and development and is essential for laying the foundation for longterm health they grow in terms of their physical mental and emotional development this affects their feelings ideas choices and interactions with other people currently an estimated 600 million females worldwide are between the ages of 10 and 19 and approximately 90 of these females live in developing countries females in this age group are in a crucial stage of development where they go through lifechanging experiences and these lay the groundwork for the majority of the rest of their lives 2 menstruation is described as cyclical bleeding from the uterine corpus that takes place between menarche and menopause one of the most significant changes that females go through is menarche the start of menstruation 3 the first menstrual cycle in the adolescents life is called menarche menarche can begin as early as age 10 or as late as age 16 although it commonly begins between the ages of 12 and 13 in india the menstrual age spans from 10 to 16 years 4 in society menstruation is typically viewed as impure because of the stigmatization of menstruation of females and the restrictions placed on them in the household a negative attitude toward this phenomenon has been concealed 5 many menstrual ideas and perspectives which either oppose or support the health of adolescent females may be found worldwide studies have revealed that erroneous knowledge of the menstrual cycle menstrual hygiene and selfcare practices is less widespread than superstitions illogical beliefs and misunderstandings 6 adolescent females in rural settings have been concerned about menstrual hygiene management practices 7 the ability to manage menstruation hygienically and respectfully is a primary priority for females as are the tools resources and surroundings required 8 adolescent females who are more informed about menstrual hygiene and safe practices are less likely to get vaginal infections and the consequences that come with them menstruation is a normal occurrence but it is also linked to various attitudes and practices that occasionally have a detrimental effect on ones health in order to better understand the knowledge sanitary condition and menstrual practices of adolescent females in rural areas a review study was done 9 to avoid any embarrassment brought on by menstrual leakage some parents advise their daughters to remain at home until they have stopped menstruation during menstruation the mother may advise her daughter to stay at home to avoid humiliation and also to save them from ruining their school clothes it is preferable to keep them at home until their periods are finished because they have no space to go to clean their cloth and change in their school although females are educated about marriage at menarche female guardians asserted that the focus was on their need to refrain from playing which is another word for having sex as this would put them at risk of conceiving and backing out of school 10 there were prohibitions on bathing and a taboo against burying menstruation fabric that had been stained in various areas of the country clothes should be cleaned before being buried or reused in order to prevent others from seeing them washing and drying are often done in private or in a hidden location 11 it has been demonstrated that unhygienic menstrual practices might contribute to reproductive tract infections cervical cancer leaving or dropping out from school low selfesteem a bad quality of life and unsatisfactory academic achievement 12 understanding menstrual practices menstrual products and disposal ways was the goal of this review article the needs and management of menstrual hygiene are covered as well as a summary of the existing knowledge analysis review this narrative review focuses on challenges and problems faced by adolescent females in rural areas while practicing menstrual hygiene the database searched includes pubmed and google scholar as well as other sources such as the ministry of health and family welfare the united nations international childrens emergency fund the world health organization and google to identify the relevant articles and reviewed publications using fulltext search several keywords used to find relevant articles included the following menstruation menstrual hygiene adolescent health menstrual practice menstrual hygiene products and menstrual waste incineration mostly articles from 2017 to 2022 were taken the excluded articles were those with adolescent females from urban areas or with any disabilities and also those articles that are not available in the english language which is depicted in figure 1 figure 1 inclusion and exclusion criteria of this study discussion almost all teenage females who were menstruating used sanitary pads according to a review of literature from adolescent females in a rural puducherry area the target population did not use the government product as widely despite having a platform for promoting teenage menstruation practices there were not enough pads provided to complete a cycle and this served as a curb in surrounding clinics for those who used governmentsupplied pads the quality of pads was a problem 13 figure 2 reduced uptake of government supply about twothirds of rural school females of ugandan reported missing class at least once each month due to menstruation according to a survey only 54 of indian females reported attending class while having their periods 14 since standing to answer questions is a typical practice in many schools and writing on the board in front of the class may disclose menstrual stains leaks or odors females who frequently attend school while menstruating report feeling distracted unable to concentrate and reluctant to participate 15 according to several studies the unawareness and inadequacy of preparedness about puberty and menstruation raise myths and leave females vulnerable to low selfesteem and feelings of shame 16 families matter which is a widescale program 17 has demonstrated that through the government health and education systems and the use of evidencebased curriculum on health and sexual guidance interventions that improve parentchild sexuality communication can be successfully implemented on a large scale these programs might improve the general publics awareness of reproductive health these programs might be expanded to include puberty education which could aid these young females who lack information and understanding of their own bodies 18 menstrual products arunachalam muruganantham also known as the padman created the affordable environmentally friendly sanitary napkin that has helped countless females in rural india after watching his wife indulge in unclean behavior while she was menstruating he had the idea to create this device when selecting menstrual products convenience price safety females dignity and environmental sustainability must all be taken into account 19 throughout the menstrual cycle various absorbents have been employed which are mentioned in table 1 the absorbents made up of fabric are reusable prior to the following use they must be cleaned and dried in the sun plastic and cellulose are the main components of disposable sanitary pads the biodegradable environmentally sustainable sanitary napkins are made of water hyacinth banana bamboo fiber pads and sea sponges but they are not readily available tampons are available in both reusable and nonreusable varieties also menstrual cups are utilized these must be placed inside the vagina consequently they are not appropriate for all adolescent 20 menstrual products advantages disadvantages washable cloth pad 21 reusable and environmental friendly cloth menstrual pads need to be washed with soap thoroughly dried and maintained pads can cause reinfection if not sterilized commercial sanitary pad 22 easily available convenient to use and has fewer chances of infection cotton is not used in all pads some pads are made of synthetic materials and contain chemicals which may be prone to several health issues expensive and not very ecofriendly menstrual cup 23 ecofriendly lasts for a long time and reduces the risk of getting a bacterial infection such as toxic shock syndrome increased chances of vaginal infections might be caused if proper precautions and directions are not followed tampons 24 comfortable and convenient to use not ecofriendly and has a higher risk of tss rarely but can leave a residue in the vagina resulting in bacterial infections and inflammation banana fiber pads 25 biodegradable less expensive and specially designed for rural areas to handle health issues they can cause rashes and utis because they are not much skinfriendly sea sponge pads 26 reusable for up to six months biodegradable and less expensive they can break apart while inserting or removing water hyacinth pads 27 lowcost ecofriendly and biodegradable less risk of tss the lack of awareness utis urinary tract infections menstrual practice consequences females in rural regions are unlikely to have access to andor use menstrual products to manage their periods in addition to frequently lacking access to soap clean water safe bathrooms and functional latrines with trash disposal facilities these issues have an immediate and lasting effect on females selfworth and abilities as well as their ability to engage in regular activities such as education and employment and maintain good health 28 unhygienic menstrual hygiene management practices could lead to opportunistic infections such as candida due to abnormally wet conditions in the vulvovaginal area without thorough cleaning and drying it may be difficult to remove candida from clothes after they are contaminated 29 there was a 23 times greater likelihood of urogenital infection symptoms in people who used reusable pads a casecontrol research by das et al in odisha india discovered that females who used reusable pads were 28 times more potent to be diagnosed with any of these urogenital infections such as urinary tract infection or bacterial vaginosis than those who did not 30 a study reported that a significant ratio of females feels ashamed in buying pads signifying the high prevalence of stigma associated with menstrual pads a misconception that contributed to lowering their selfefficacy in achieving healthy mhm 31 sanitation systems cannot handle the menstrual absorption materials because they were created with urine and feces in mind due to their inability to move through the sewer pipes these absorption materials clog them resulting in system backflow and a major health risk menstrual waste is dumped into water bodies by residents who live along riverbanks polluting them sanitary products that have been soaked in the blood of an infected adolescent female or adult female may contain hiv viruses or hepatitis which can persist in soil for up to six months 11 menstrual hygiene management there are several ways to inform and educate people about menstruation including by providing them with thorough sexual education that is appropriate for their environment with the use of this knowledge people will be able to recognize menstruation as a typical biological occurrence and acknowledge it resulting in hygienic procedures such as cleansing the genital area washing hands with a disinfectant before and after using absorbents and replacing absorbent goods three to four times every day 32 when conducting interventions it is crucial to inform the public about the importance of mhm and teach adolescent females how to utilize the menstrual products provided in humanitarian operations 33 menstrual waste disposal can be managed using incineration which reduces volume and pathogens while also reducing trash hence reducing environmental issues brought on by inappropriate disposal as part of its swachh bharat initiative the indian government has encouraged the use of incineration for menstrual waste with an estimated 121 million females disposing of 123 billion pads yearly india has a very high volume of menstrual trash amounting to 113000 tonnes 34 along with her husband swati bedekar a member of the vatsalya foundation created a clay incinerator for the disposal of used sanitary towels the name ashudhinashak which in sanskrit means annihilation of impurities was given to the incinerator it is possible to nourish plants by combining the created ash with soil this groundbreaking invention reduces trash and enables females to dispose of their old napkins in an environmentally responsible manner 35 mobile phone messaging services have been utilized in numerous community health projects in india as well as other countries to broadcast health information and enhance the delivery of services and behaviors that promote health the success of these projects shows that it is possible to harness the widespread usage of mobile phones in rural india to convey the right information about menstrual hygiene practices and increase awareness among adolescent females 36 now menstrual health is considered a public health concern that is closely connected to a number of civil rights and the achievement of the sustainable development goals thanks to persistent and innovative sponsorship by a variety of shareholders and platforms alliances and networks at the international regional and national levels as a result government agencies and ministries are more willing and ready to act 37 interventions and schemes the unicef and who recommended installing wash or water sanitation and hygiene facilities in schools 38 every school in india has been equipped with wash facilities including soap and water for sanitation and private areas for menstrualabsorbent change and disposal as part of the swachh bharat swachh vidyalaya initiative the ministry of health and family welfare has started a campaign to encourage menstrual hygiene among teenage females between the ages of 10 and 19 in rural areas rural adolescent females were provided with a bag of six sanitary napkins known as freedays for rs 6 for each pack of six napkins as part of the initiative which was initially introduced in 2011 in 107 selected districts across 17 states 39 a free sanitary pad program has been in place in tamil nadu since 2011 for females living in rural regions additionally they are eligible to get three packs of pads every two months as well as iron supplements and information about menstruation from an anganwadi maharashtra and chhattisgarh have similar programs but are less established 40 conclusions menstrual hygiene should be recognized as a major public health issue as it is a leading cause of serious health issues in growing adolescent females and is also indirectly responsible for environmental hazards so they should be aware of the consequences of ignorance of safe menstrual hygiene practices menstrual hygiene can be promoted by delivering proper knowledge regarding safe practices the advantages of using biodegradable sanitary products properly disposing of menstrual waste products and the importance of menstrual waste management teachers can play a major role in imparting menstrual hygiene education not only to females but also to males so they also understand their roles and responsibilities and can help in changing the mindset or false perception of the societies or communities who thought menstruation was taboo and impure nowadays technologies can also act as an intervention in delivering knowledge on a public health issue many programs and schemes are implemented by the ministry of health and family welfare such as the offering of sanitary napkins at low cost in rural areas the installation of incinerators for disposable menstrual waste products and the distribution of iron tablets in rural areas of tamil nadu the who and unicef recommended having wash facilities in schools the core of many health issues is misinformation myths erroneous beliefs the lack of awareness and incomplete or incorrect knowledge about menstruation therefore it is essential to teach adolescent females about hygienic behavior and safe menstrual practices additional information disclosures conflicts of interest in compliance with the icmje uniform disclosure form all authors declare the following paymentservices info all authors have declared that no financial support was received from any organization for the submitted work financial relationships all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work other relationships all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work

menstruation is a vital sign of reproductive health and development menstrual hygiene practices are consequently a significant public health issue however menstrual practices are still tainted by taboos and other sociocultural constraints which adversely affect health since adolescent females in rural areas are unaware of the scientific facts regarding menstrual hygiene practices the indian government has recognized the significance of menstrual hygiene and developed and implemented several programs and schemes for menstrual hygiene management mhm but due to a lack of little or inaccurate knowledge and cultural practices and socioeconomic status adolescent females face many obstacles and suffer from health issues a comprehensive literature and data search was done using key databases such as pubmed and google scholar and other sources such as the ministry of health and family welfare mohfw the united nations international childrens emergency fund unicef the world health organization who and google to identify the relevant articles and reviewed publications using fulltext search a total of 40 articles out of 1461 were selected for review after the screening and elimination of repeated articles the objective of this literature review is to assess the awareness and knowledge of the importance of menstruation the understanding of safe menstruation practices the significance of properly disposing of menstrual products and the knowledge of how to guard against reproductive system infection and its consequences and also to identify the problems and challenges faced by adolescent females during their menstrual hygiene practices or management the core of many health issues is misinformation myths erroneous beliefs lack of awareness and incomplete or incorrect knowledge about menstruation therefore it is essential to teach adolescent females about hygienic behavior and safe menstrual practices

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introduction approximately onethird of australias population lives in regional or remote areas but only 15 of medical specialists are employed in these areas these figures may underrepresent the true shortage of specialists in rural areas which has been obscured by a heavy reliance on locums and internationally recruited medical specialists shortages of specialists in rural areas result in service gaps which may have serious consequences for the health of local people with an ageing rural medical workforce and increasing specialisation the problem of maldistribution of the specialist workforce is a pressing issue according to data from the australian health practitioner regulation agency 247 medical specialists are working in tasmania there are no publications describing the distribution of this workforce within tasmania however there are anecdotal reports of workforce saturation in hobart and shortages of specialists in the north and northwest of the state like many rural areas the health service where this research was conducted has struggled to attract and retain medical specialists there are local reports of an increasing reliance on international medical graduates and locums to fill positions and as for other areas of rural australia there is concern about service gaps given the scant literature in this area the present study aimed to describe the factors that contribute to specialist workforce retention and attrition within a regional health service methods following ethics committee approval currently employed specialists in the health service were emailed an invitation to participate in the research specialists who had left the service were identified through the payroll office with current email addresses identified for 93 leavers two were returned to sender as addressee unknown three specialists replied declining to participate and eight accepted the invitation this indicates a 9 response rate although it is likely that a substantial proportion of the invitation emails were not received or read by recipients twentytwo interviews were conducted 12 with stayers eight with specialists who had left the service and two with specialists who intended to resign the interview guide was developed according to the themes identified by may et al in a study of general practitioner and specialist recruitment and retention in regional new south wales all interviews were taperecorded transcribed verbatim and imported into qsr nvivo v10 for thematic analysis transcripts were coded according to the themes noted by may et al with emergent themes also identified responses were grouped into three main domains professional factors location factors and social factors the data were then investigated by comparing stayers and leavers ethics approval the university of tasmania human research ethics committee reviewed the research proposal and granted ethics approval for the study results the 22 interview participants were specialists in emergency medicine anaesthetics general medicine paediatrics psychiatry orthopaedic surgery general surgery geriatric medicine palliative care and urogynaecology while professional factors played a dominant role in the retention decisions of both stayers and leavers they had considerably greater salience for leavers as evidenced by the thematic maps professional factors influencing specialist workforce retention afterhoursoncall work the most common theme discussed by all participants was oncall work with a diverse range of perspectives on this topic stayers and leavers made positive and negative comments however for a small number of specialists who described their commitments as particularly arduous this was a significant cause of job dissatisfaction and a contributing factor to their decision to leave some specialists commented that their oncall workload was easily manageable due to senior registrar support while others noted that the absence of senior registrars in their specialty made their oncall commitments particularly taxing specialists in both groups recognised that the oncall workload was inevitable due to the small size of the service and lack of critical mass to enable a sustainable oncall roster workload workload was the second most common theme there was a wide spectrum of perspectives on this topic some participants noted that their working hours were comparable to those of other regional centres some noted that their working hours were favourable to regional centres and others noted that their working hours were considerably longer despite some specialists describing heavy workloads autonomy in determining workload was a key factor in work satisfaction those who felt they had little control over their workload expressed dissatisfaction while those who had autonomy noted their heavy workload was due to personal preference it was noted that historical visiting medical officer contracts limiting the number of working hours resulted in an inequitable workload distribution with the burden continuing to fall on staff specialists health service management there was a considerable difference among stayers compared to leavers in their discussion of health service leadership five of the 12 stayers and 8 of the 10 leavers discussed this theme leavers were more critical of senior health service management however many of the comments related to historical events characterised by frequent changes to the staffing of senior management posts this created a sense that the service was operating in perpetual crisis mode there was acknowledgement that the tumultuous period of senior health service management had eased however there was a continued perception of a fractious relationship between clinicians and senior health service managers some leavers also discussed the need for transparent competitive external processes to select leaders such a process helps to provide a mandate for effective leadership it was also recognised that leaders should receive training and appropriate financial remuneration to attract and retain quality leaders teamwork and workplace culture all 12 stayers and seven leavers discussed the theme of teamwork positive and negative comments were made in relation to interactions with nursing staff although overall hospital nurses were described as very committed comments about teamwork were mainly positive among stayers although there was a mix of positive and negative comments among the leavers noncollegial behaviour was raised by 4 of the 10 leavers some locums were described as behaving inappropriately towards specialist colleagues additionally there was the perception of organisational reluctance to address the issue of inappropriate behaviours among locums with this seen as stemming from difficulties in attracting a locum workforce professional fulfilment all 12 stayers but only 3 of the 10 leavers made comments on professional fulfilment providing treatment and care to sick patients was fundamental to professional satisfaction however there was also recognition that feeling valued by the health service was an important source of professional fulfilment and a factor in deciding to remain working in the service half of the participants in each group discussed the importance of work variety in contributing to their professional satisfaction the rural setting was recognised as providing an opportunity for generalist work while the unique population and socioeconomic status of the area resulted in interesting clinical cases additionally the opportunity to establish new services was pivotal to job satisfaction for two participants professional isolation is a subtheme of professional fulfilment discussed by four stayers and four leavers it was suggested that the absence of a local specialist network for advice and support is a significant contributor to workrelated stress it was also noted that connecting with peers within the state and interstate is fundamental to managing stress arising from professional isolation however metropolitan specialists were sometimes seen as reluctant to provide support registrar workforce stayers and leavers recognised the importance of the registrar workforce for maintaining the quality of the service perceptions of the standard of registrars varied across the specialities some registrars were senior and highly skilled while others were described as junior and of lower standard compared to those in metropolitan centres there were concerns that the teaching and support provided to registrars needed to improve the locum workforce and the lack of support from metropolitan colleagues in preparing registrars for exams were also identified as barriers to the provision of quality supervision to registrars some leavers noted that the loss of specialist college accreditation for trainees was a red light warning flag indicating wider systemic problems within the hospital model of practice most stayers and leavers commented that they preferred the generalist model of specialist practice rather than a subspecialty however for some specialists their career preference for subspecialisation was abandoned due to personal factors that kept them living in the area some leavers commented that they preferred working as a subspecialist however the health service required a generalist role two leavers noted that the health service was inflexible towards their subspecialty preferences so they sought a permanent position interstate professional development accessing continuing professional development training courses and conferences was a main theme although there was greater discussion on this theme among the stayers there was common acknowledgement of the need for additional professional development leave days to compensate for the extra day of travel required for departure from and arrival back to the region when attending interstate and international events there was also consensus that funding allocated for professional development should be increased in consideration of the higher costs associated with travelling from a rural location increased cpd leave and funding were noted as particularly important for helping to alleviate professional isolation and improving specialist retention employment contracts participants were critical of the inequity across the state in the provision of permanent contracts which is a legacy of the state having three separate health organisations previously while most were not concerned about their lack of a permanent contract it was noted that for some specialists a permanent contract provides reassurance and a feeling of being valued remuneration and financial incentives were discussed by 9 of the 12 stayers and 8 of the 10 leavers participants felt that the pay scale in the service was lower than that of metropolitan centres and regional areas in other states with interstate colleagues estimated to earn three times the salary paid locally a few participants suggested that their overall remuneration was similar to that of consultants in other states although this was not taking into account oncall hours which when factored in considerably reduced their hourly rate for approximately half the group this was not considered important for their overall contentment or when making decisions about where to work personal and location factors influencing specialist workforce retention the main personal factors that influenced specialists decisions to stay working and living in the area were rural origin or experience family or social connections within the area lifestyle a desire to maintain location stability for children and a preference for rural living ten of the 12 stayers either grew up in a rural area or had extensive rural workplace experiences prior to arriving in the area while most of the leavers also had rural workplace experience only three were of rural origin two participants both longtime stayers grew up in the area and stated that they had strong desire to return to their families and local communities after completing their specialist training the nine stayers who discussed lifestyle spoke positively about the ease of living in the area the ability to achieve a healthy worklife balance the relaxed pace of life low traffic volumes the friendly community a scenic environment and access to both the coast and mountains tipping points six of the 10 leavers discussed professional tipping points relating to their decision to leave these included excessive oncall workloads difficult relationships with other specialists unreasonable demands and managerial styles of historical health service leaders the appeal of a challenging position interstate fear of not being able to secure a position in a metropolitan hospital in the future family pressure to live in a metropolitan area and concerns for patient safety resignations were also timed to fit with family preferences for children to attend private schools in metropolitan areas family preference to live in an urban area was the overriding factor that led to two overseastrained specialists leaving both of these participants were content working in the health service but social isolation experienced by their families resulted in a decision to leave discussion the present studys findings corroborate previous research that identified professional factors as dominating retention decisionmaking secondary considerations relating to personal and location factors played a greater role in decisionmaking among stayers compared to leavers this was evidenced by the thematic maps indicating the low importance of personal or location factors among those who were unhappy in the professional sphere some of the professional factors that contributed to specialists leaving are nonmodifiable such as personality clashes while related factors such as the collegial environment are modifiable onerous work demands particularly oncall resulted in exhaustion and burnout and were an impetus to leave the service for some specialists this finding is similar to that of humphreys et al who found oncall arrangements were the most significant factor overall in rural general practitioner retention regardless of location excessive oncall demands are not unique to rural tasmania as may et als recent research in regional new south wales also reported that afterhours work demands were among the top three professional factors that influence rural specialist retention it is notable that 17 years have passed since the research of humphreys et al was published this indicates that there has been a lack of significant progress on reducing the burden of oncall work among rural specialists the failure to address this issue reflects a lack of critical mass to cover rosters and limited financial resources available for locum cover there was recognition that excessive oncall demands were a result of the small hospital environment where a lack of critical mass impacted oncall rosters to prevent burnout it is imperative that an adequate number of senior specialists are employed to cover the roster without placing excessive workload demands on individuals the authors agree with humphreys et al that a strategic longterm solution is required to alleviate the pressure of oncall demands the findings also emphasise the importance of autonomy in determining oncall workloads those who achieved autonomy were able to find the appropriate balance to suit their preferred way of working and tended to stay in the service specialists were appreciative of recent efforts to allocate oncalls to locums continuation of this informal policy is crucial to retain specialists with a recognition of the higher threshold of oncall expected by recently fellowed specialists the present research found difficult relationships among specialists were a strong contributing factor to the decision of some specialists to leave the service there is good evidence that positive cultures within hospitals promote staff retention the present studys finding is similar to that of may et al where workplace culture was the third most important factor in specialist retention in rural new south wales it is important to note that a single persons behaviour can have a disproportionate impact upon teams in a small hospital while the impact of the individual is diluted in a larger hospital given the importance of harmonious collegial relationships within small hospitals a zerotolerance policy for bad behaviour is vital as are clearly defined mechanisms for escalating and managing complaints much of the criticism of health service management expressed by specialists related to historical events and periods of high turnover of health service leaders previous research indicates a 26 twoyear turnover rate among swedish health service managers and 40 within 4 years burnout excessive workloads lower levels of job control an inability to ensure quality patient care insufficient resources and clinical workloads are associated with turnover additionally a systematic review of nurse manager turnover found organisational valuesculture humanfiscal resources and organisational commitment were commonly reported organisational reasons for manager turnover it should also be noted that the interface between clinicians and managers is often a vexed one with both groups perceiving themselves at odds with the other group there is a long history of challenging relationships within this arena with cliniciansenior health service manager conflict prevalent across the globe tensions between clinicians and service managers observed by participants in this research are a local version of the global issue of autonomy versus accountability open dialogue between senior health service managers and clinicians improved understanding mutual respect transparency around organisational change decisions and transparency in resource allocation may improve relationships financial remuneration was not a primary factor in retention decisionmaking however there was acknowledgement that health services have a responsibility to ensure equitable pay scales given the fact that all of the specialists needed to elect to come to the area or to come back to the area after training the importance of professional satisfaction in their decision to stay was heightened this has repercussions for the health service as satisfaction with their work environment is pivotal to retention decisionmaking specialists who stayed in the area developed strong social connections within the region through their children community groups or recreational pursuits as most specialists who move to the area do not have a preexisting social connection to the area it is important for the health service to organise socialising opportunities and provide social support to specialists and their families it is also imperative to provide medical care for family members of overseastrained specialists for some overseastrained specialists a feeling of social isolation among their family members was the primary motivation for leaving the service the study was limited by its small sample size and low response rate among leavers which limits generalisability additionally some of the issues discussed were historical and had already been resolved at organisational level by the time of interview the recruitment of stayers and leavers was designed to avoid a sample biased towards either negative or positive experiences however it is possible that findings are skewed towards disaffected leavers conclusion specialists who had rural backgrounds who established strong personal connections in the area and those who had a preference for rural living were more likely to stay however professional factors dominated retention decisionmaking the importance of professional factors which has been identified previously is critical whilst there were clear issues such as heavy oncall demands the responses of participants to these challenges were not uniform this research underscores the importance of flexibility and autonomy in workload determination and equity with interstate and intrastate contractual conditions and pay scales efforts to reduce specialist isolation and increase senior registrar rotations may reduce specialist turnover a zerotolerance policy for bad behaviour should also be adopted and enforced it is crucially important for services to monitor specialist workforce turnover to identify and address issues within the workplace that create tipping points for specialists exit interviews and access to accurate electronic human resources data are essential to prevent high rates of specialist turnover in the future

introduction rural health services throughout the world face considerable challenges in the recruitment and retention of medical specialists this research set out to describe the factors that contribute to specialist workforce retention and attrition in a health service in rural tasmania australia methods this qualitative study utilised indepth interviews with 22 medical specialists 12 currently employed by the service and 10 who had left or intended to leave interview transcripts were thematically analysed to identify professional social and location factors influencing retention decisionmaking results professional and workplace factors were more important than social or location factors in retention decisionmaking tipping points were excessive workloads particularly oncall work difficult collegial relationships conflict with management offers of rural and remote health rrhorgau

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introduction the mental health and mental wellbeing of university students in the uk is of increasing concern to policymakers researchers charities university staff and students 1 2 3 4 young adulthood is a critical age for emotional psychosocial and cognitive development 5 6 and first onset of mental health problems suicidality and substance misuse problems 7 8 9 young adulthood is also the time that many enter and navigate university in the uk there are approximately 24 million university students in the uk the majority being young adults 10 which means higher education institutes are in the best position to provide prevention and intervention to many young adults during an important transitional period throughout the university life cycle 11 students are exposed to a range of experiences that make higher education a highrisk period for maladaptive coping and possible onset of mental health problems including individuation separation from family increased autonomy and responsibility academicrelated stress financial concerns sleep disruption balancing conflicting demands of studying strengths and limitations of this study ► the current study is designed to be the first uk national multisite study to explore from black undergraduate and postgraduate university students perspectives the life events and experiences that affect their mental health and wellbeing throughout the university life cycle ► a multidisciplinary coding team will ensure the inclusion of multiple perspectives to reduce researcher bias and provide opportunities to discuss disagreements in interpretations ► this study will contribute to the evidence base on race mental health and higher education provide relevant recommendations for interventions and encourage further study into black student mental health ► the current project is exploring the lives of 2025 black students studying at 10 uk universities so may lack generalisability representativeness and transferability of findings open access with personal and family life and exposure to risky behaviours including recreational drug use and alcohol binging 12 13 14 15 16 unsupported mental health problems are associated with progression to other comorbid disorders substance use disorders selfharm and suicide ideation and attempts 17 18 19 20 a growing body of evidence explores inequalities and inequity in student admissions experiences and outcomes in uk heis by race gender class and ability 21 22 23 24 25 26 27 black students with a mental health problem studying at uk hei are less likely to complete their course achieve a firstclass or upper secondclass degree and progress to further education 28 29 the office for students 2 reported that black students with mental health conditions are being failed throughout the student cycle but that there are limited data or research available to explain how and why available research indicates the following factors and dimensions may explain the inequality and inequity observed in higher education at the expense of black students racism and structural racism discrimination mental health stigma sexism cultural incompetence and insensitivity of healthcare professionals 30 31 32 it is essential to know more about the experiences of risk factors for and challenges that affect black university students mental health in uk higher education in order to design develop and deliver appropriate mental health and wellbeing services critical race theory critical race theory offers an interpretive theoretical approach to explore and challenge racial inequality in society it is based on the understanding that racism is embedded as normal practice within society and institutions rooted in slavery and colonialism and race is a socially constructed concept that is used by white people to further their socioeconomic and political interests and power at the expense of racialised minorities this racial bias causes discrimination within law employment housing healthcare politics and education disadvantaging racialised minorities 33 34 crt in the educational context explores and challenges the white supremacist patriarchal structures and assumptions that have historically shaped education 33 35 crt theorists explore racial inequality in admissions curriculum and pedagogy teaching and learning institutional culture campus racial climate and policy and finance within uk further and higher education 36 37 38 39 40 crt is also used as a conceptual lens through which to interrogate the generational impact slavery and colonialism has on an individuals and families as well as psychological research and practices at the expense of racialised minorities 41 42 therefore crt will guide the direction of this current study by providing a framework to support the study team to interrogate the methodology analyses and interpretation throughout the research process 32 aims the aim of this study is to document and explore black university students accounts of their mental health experiences as they transition throughout their university lives and perceptions of key turning points of biographical change to their mental health in their lives as they move through the university student life cycle objectives this study uses biographic narrative interpretive method 43 44 interviews and interpretative phenomenological approach 45 46 47 48 49 50 51 52 to get an indepth understanding of the educational and mental health of experiences black uk university students research questions 1 from the students perspective what life events and experiences do black university students perceive affect their mental health and wellbeing 2 how does institutional and structural racism within uk education systems affect the mental health and wellbeing experiences and outcomes of black university students methods and analysis study design this is a qualitative study data are being collected through bnim interviews 43 44 this interview technique enables the researcher to study how participants make sense of themselves and account for the complexities of their life experiences from their own perspectives and choice of language 43 44 for the current study ipa 45 46 47 48 49 50 51 52 offers insights into what black students studying at uk universities report affects their mental health and wellbeing data collection for this study commenced in october 2020 data collection and analyses are planned to be completed by january 2022 recruitment a webpage was set up specifically for the study on the health inequalities research network website which is general data protection regulation complaint the webpage has the lead researcher s contact information the studys rationale expression of interest form information sheet consent form list of support services and updates about the timeline of the project the study is advertised on social media accounts set up specifically for the study social media posts with a short summary of the study were designed and sent out on this social media page to recruit participants the social media posts include the studys website and qr code which means that potential participants can access the webpage with one click recruitment emails were sent to student unions student groups and student services completed expression of interest forms are automatically sent to a kings college london study mailbox which was set up for the study ns monitors the incoming forms two times a day and screens the participants based on the inclusion and exclusion criteria open access to complete an attached consent form which they are asked to email back to the researcher participants have a minimum of 48 hours to decide whether they would like to participate in the study if the participant has not responded after 2 days they are sent a reminder email by ns and subsequent two reminder emails until they are considered nonresponsive sample size purposive sampling 51 is being used to recruit black university students who meet the inclusion criteria fifteen to twenty students are being recruited from nine russell and nonrussell group universities across the uk data from the higher education statistics agency 10 for uk higher education student enrolments by higher education provider and ethnicity for the academic years 20142015 to 20182019 were used to decide which universities to recruit from in microsoft excel the data were sorted into higher education providers with the highest percentage of black students enrolled to the lowest after this iqr was calculated to divide the higher education providers into quartiles of median lower and upper range three higher education providers that fall into each range were chosen sample two universities are in ireland one university is in scotland and seven universities are in england of the universities based in england three are in london one is in the east midlands one university in southeast england one in the west midlands and the final in east of england five universities are russell group universities and five are nonrussell group universities russell group universities are defined as a group of units with a shared focus on research and a reputation for academic achievement 53 while data from the national student surveys suggest there are no statistically significant differences in student satisfaction between russell and nonrussell group universities 54 there is some evidence that ethnic minority applicants to russell group universities may be less likely to receive offers to study compared with similarly qualified white applicants 55 six universities are based in the city where the campuses and facilities are spread out across the city and four universities are campus universities situated in rural settings inclusion and exclusion criteria the inclusion criteria for students are deliberately broad to include students who selfidentify as black are currently studying at within a year of graduating from or are within a year of dropping out of a university course selfidentify as having struggled with their mental health andor wellbeing while studying at a uk university are aged 18 or over as an ipa study 45 46 47 48 49 50 51 52 this will allow for a wide range of black university students from different backgrounds to be eligible for study inclusion as the study processes the exclusion criteria are people who have never been enrolled on a course at a uk university are enrolled at a university outside of the uk do not identify as black graduated or dropped out of university over a year ago are aged 17 or younger potential participants are asked to complete an expression of interest form online with sociodemographic information to determine their eligibility for the study data collection data collection for this study commenced in october 2020 data collection and analyses will be completed by january 2022 all interviews are being conducted by ns in order to generate a narration that allows the interviewee to begin construct and end their narrative on their own terms students are invited to participate in a hybrid adapted version of 43 44 designed by ns in collaboration with the authors the bnim approach to data gathering is an open narrative interview process where the interviewer is encouraged to participate in active listening and not interrupt with questions the students are asked a single question called a single question inducing narrative 43 44 to describe their life in terms of their mental health and wellbeing the squin reads as follows as you know i am researching mental health and wellbeing experiences of black university students in the uk i understand that you have had such experiences so please can you tell me the story of your mental health experiences before university and while studying at university please include all the events and experiences that were important for you personally up until now theres no rush you can start wherever you like weve got 2 hours in total ill listen first i wont interrupt ill tell you if we are running out of time ill just take some notes and when youve finished telling me about it all we will have a 15 min break after the break i may ask you further questions about your story as the student is talking ns takes notes on what wengraf terms particular incident narratives 43 44 which are significant events that have occurred in each students life surrounding their mental health and wellbeing using the keywords that they use students are then invited to take a 15min break and during this time ns identifies questions called narrativenpointed questions 43 44 to clarify or pick up on pins 43 44 the second session begins with ns asking the student to reflect back on the identified pins and continue with the npointed questions the interview ends with the question before we finish is there anything you would like to add that we didnt talk about interviews last up to 2 hours in total the interviews elicit two transcripts of narrative for data analysis from each student interviews are conducted virtually using microsoft teams and are recorded with the students permission ns transcribes the interviews by hand using microsoft open access teams automated speechtotext transcript programme before analysis a bnim pilot study was conducted to assess comprehension of the bnim question relevance timing and research burden 56 two black university students were invited to participate in the pilot study data were presented to the fifth sixth and seventh authors of this paper to collaboratively agree whether they matched the study objectives no amendments were made to the study data analysis data analysis began after the first interview in october 2020 data are being analysed using ipa 45 46 47 48 49 50 51 52 on nvivo qualitative data analysis software an inductive analysis of each students account is conducted before moving onto group analysis 47 analysis began with multiple readings of each students transcript by ns who makes notes on the students language and structure emotional responses and any insights into the students experience and perspective on their world that is codes this is to interpret what and how the student is communicating their story as the analysis develops ns looks for patterns in the codes to create emerging themes themes identify recurring patterns of meaning presented by the student and interpreted by ns throughout the text themes will eventually be linked and grouped together to create subordinate themes the final set of themes will be summarised arranged into clusters to form master themes and placed into a table quotations from the students will be selected to illustrate each theme all the transcripts will be collated and reexamined by ns who will pay attention to thematic overlap and differences in students accounts and will make links to existing psychological and sociological literature concepts and theories which provide an indepth understanding of the phenomena and strengthen the robustness of the data analysis the authors will be careful to apply a critical race lens on the existing theoretical knowledge within this area of research to explain the phenomena 55 in ipa the participants are trying to make sense of their world the researcher is trying to make sense of the participants trying to make sense of their world 51 the dialogue between the researcher and the participant is described as a double hermeneutic and ipa recognises the importance of constant selfawareness and reflexivity 57 ns writes notes in a reflective diary throughout study conception to dissemination to draw their observations and reflections about the interview experience data analysis and interpretations or any other thoughts and comments of potential significance 57 58 59 a second coder a black university student will code 20 of the interviews using ipa for crossvalidation of the themes 60 61 the authors of this paper will form a multidisciplinary coding team and participate in conversation circles over microsoft teams to validate the data participate in theme development and promote reflexivity and dialogue 60 62 the authors all have extensive knowledge and experience on student mental health and mental health inequality in the uk the circle mediator will participate in the conversation to present and clarify ideas or issues and encourage the dialogue the conversation circle will be audio recorded with verbal consent of the attendees during the conversation the objectives methodological process and research results will be presented the authors will be encouraged in a dialogic process to give their opinion about the codes and emergent themes a second conversation circle will be arranged for the subordinate themes data protection all confidential data are kept for 10 years according to kcl records and data retention schedule 63 data are stored on passwordprotected computers in password protected encrypted folders on kcl sharepoint which are only identifiable by the code number and only accessible to members of the research team during transcription audiorecordings are anonymised with all identifiable information removed prior to using nvivo software all audiorecordings are destroyed immediately after transcription this is important to ensure that their identities are protected and they are not at risk of harm due to damage of their reputation or social standing for example should they express controversial or negative opinions or experiences this is particularly relevant considering the sensitive topic of study and the fact that participants are invited to consider current as well as historical experiences at university public and patient involvement the lead author is a black caribbean phd student who designed and wrote up the study protocol and the second author is a black african masters student who was involved in the design of this protocol ethics and dissemination full ethical approval has been granted by kcl psychiatry nursing and midwifery research ethics subcommittee written informed consent to participate and audiorecorded interviews is obtained from all participants participants consent to the inclusion of material pertaining to themselves that they acknowledge they cannot be identified via the manuscript and that the participant has been fully anonymised by the author data management and storage is subject to the uk data protection act 1998 and gdpr 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 safety considerations potential risks of participating come as a result of the participant disclosing a historical or current distressing open access experience during the consent process and at the beginning of the interview the interviewer informs each participant that confidentiality needs to be broken if they disclose personal details which raises concerns to ns about their safety the safety of others safety of someone under the age of 18 or about a previously nondisclosed serious crime they or someone else has committed or is about to commit when a participant discloses a serious immediate risk the interview is stopped a conversation is had with the participant to ensure they understand why and how information is shared for their safety and the emergency services is contacted immediately the cosenior author is informed immediately after incidents are reported to the chair of the ethics committee when a participant becomes distressed during the interview ns asks the participant if they would like a break when the participant would like to terminate the interview or ns decides the participant is no longer able to continue she offers to reschedule the interview at the next convenient time time is explicitly allocated to a debrief period at the end of the interview for all participants to reflect on the session ask any questions or raise anything that may be of concern participants are asked is there anything you would like to share regarding your experience talking to me today a list of support services available across the uk is listed in a document created for this research project which is available on the research website in case participants need professional support every participant is sent an email directing them to this list of support services after the interview output and dissemination findings will be disseminated via an internal report peerreviewed journal articles theoretical article write up of the main findings and conference presentations the study team will seek funding from the london interdisciplinary social science doctoral training partnership kcl and the esrc centre for society and mental health to design and deliver internal and external public engagement events to discuss the study findings and potential recommendations for interventions an anthology book will be written as a collection of the participants stories the lead researchers story and the lead researchers reflections of the stories the purpose of this anthology is to disseminate the research findings to people interested in black university student mental health including current students and academic staff families of students mental health practitioners community organisations policymakers advocates and charities from the study findings we aim to contribute to the evidence base on race mental health and higher education provide relevant recommendations for interventions and encourage further study into black student mental health discussion to our knowledge the current study is designed to be the first multisite uk study to explore from black undergraduate and postgraduate university students perspectives the life events and experiences that affect their mental health and wellbeing throughout the university life cycle this qualitative approach has not been previously employed to understand what and how individual institutional and structural factors within uk education systems impact the mental health and wellbeing experiences of black university students the usefulness of the data and subsequent recommendations are dependent on what is derived from the data a multidisciplinary coding team will ensure the inclusion of multiple perspectives in order to reduce researcher bias and provide opportunities to discuss disagreements in interpretations 60 ipa is one of the appropriate methodological choices to offer insights into how a person in a particular context makes sense of a given phenomena 64 65 combining narrative inquiry with phenomenology and hermeneutics is a suitable approach to attempt to gain insight into black students subjective experiences of life in university while at the same time encouraging black students to tell their own stories and have their voices heard the study findings will be limited to the time and context of this study as realities and perspectives will differ across contexts and time 66 interpretation of study findings will take into account potential limitations regarding the generalisability of the findings the current project is exploring the lives of 2025 black students studying at 10 uk universities so the findings are not generalisable representative and transferable to all black university students studying at uk heis however in ipa research samples in ipa studies are usually small which enables a detailed and very timeconsuming casebycase analysis 57 ipa is not concerned with generating a generalisable theory however comparisons of multiple ipa studies on the mental health of black university students and student mental health inequalities over time may provide insights into generalisable patterns and mechanisms 51 57 future research may include a mixedmethods study of black students across the uk educational pipeline as well as further exploration of the mental health experiences of black students who face multiple marginalisation for example disabled firstgeneration carers and lesbian gay bisexual transgender and other queeridentifying community black students

introduction there is an increasing concern about the mental health and mental wellbeing of university students in the uk black university students who report a mental health condition are less likely to complete their course achieve a firstclass or upper secondclass degree and progress to further education this study will document black university students accounts of their mental health experiences and perceptions of key turning points of biographical changes to their mental health as they move through the university life cycle methods and analysis this is a qualitative study data will be collected through a biographical narrative interpretive method interviews will enable the researcher to study systematically how participants make sense of themselves and account for the complexities of their life experiences from their own perspectives and language an interpretative phenomenological approach will be used to offer insights into what black students studying at uk universities report affects their mental health and wellbeing

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background depression and anxiety affect one in five people in the uk and are an increasingly important public health priority 1 experiencing mental health difficulties can be accompanied by personal suffering stigma and difficulties engaging with society as well as a lower likelihood of employment greater likelihood of poor physical health and lower life expectancy 2 in england mental health is estimated to cost around £225 billion a year in health services and £28 billion in lost earnings and these costs are expected to increase by 45 by 2026 3 several systematic reviews have found that religiosity a term used to describe religious affiliation beliefs attendance at services and practices has been associated with better mental health outcomes 4 5 a recent metaanalysis of 48 longitudinal studies built on these reviews by estimating the effect size of religiosity on mental health rather than the proportion of studies reporting a positive effect the authors confirmed a positive effect of religiosity and spirituality on mental health but found the total effect size was small 6 a limitation of these reviews is that due to the heterogeneity religiosity measures it is difficult to know which aspects of religiosity are associated with mental health or account for the possibility that religious attendance and religious beliefs may impact health in different ways a systematic review by braam and koenig focusing on 152 prospective studies found that just over half of the studies showed an inverse association between religiosity and depression with the authors highlighting the need for research assessing the possibility of bidirectional associations 7 this review identified 12 studies that evaluated bidirectional associations of which four studies suggest that depression is associated with a decrease in religion and spirituality with the remaining eight studies showing no association although most of the research on the associations between religiosity and mental health has been conducted in the usa a recent study from the uk using household panel data suggest that religious attendance and beliefs are associated with subsequently better mental health and wellbeing 8 to date there have been no investigations of the potential bidirectional relationship between religious involvement and mental health in the uk the aim of this study was to investigate bidirectional associations between religious attendance and mental health using data from the medical research council national survey of health and development also known as the british 1946 birth cohort based on previous research we predicted that religious attendance would be associated with better mental health and that poor mental health would be related to a decrease in religious attendance methods design and participants the mrc nshd is a nationally representative british birth cohort selected from all births in original research has been followed up 24 times to date details of the data collection and response rates have been previously described 9 10 11 we included study members who took part in the most recent data collection at age 6869 details of the study members excluded from the analysis are shown in figure 1 mental health symptoms of anxiety and depression were measured by a selfcompleted questionnaire at ages 53 6064 and 6869 using the 28item general health questionnaire the ghq28 contains four subscales somatic symptoms anxiety and insomnia social dysfunction and severe depression 12 each item was scored from 0 to 3 giving a minimum score of 0 and a maximum score of 84 with a higher score indicating higher psychological distress the ghq28 had a skewed distribution in this sample and was logtransformed for use in the crosslagged model religious attendance frequency of religious attendance was assessed at ages 43 6064 and 6869 by postal questionnaire the phrasing of this question and response options varied slightly between waves at 43 they were asked if they helped to run church activities or participate in religious services and at 6064 and 6869 they were asked how often they participated in churchrelated groups or religious activities response options were harmonised across waves so that religious participation was categorised as weekly monthly less often and never covariables models were adjusted for gender and educational attainment as preliminary analysis showed these were confounding variables measures of social class were not included as these were not found to be associated with religious attendance above and beyond education educational attainment was measured as the highest level of qualification obtained by age 26 based on the burnham scale 13 this was grouped into no qualification up to ordinary level advanced level or equivalent and higher statistical analysis an autoregressive crosslagged model was used to simultaneously assess reciprocal longitudinal associations between mental health and religious attendance over time using threerepeated measures for each of these variables this model can be used to test the direction of associations between two variables of interest with repeated measures in this analysis religious attendance reported at ages 43 6064 and 6869 were analysed with mental health at ages 53 6064 and 6869 the model was applied with equality constraints across waves which is recommended if there is no loss of model fit 14 religious attendance and ghq28 score were modelled as continuous variables a sensitivity analysis modelling religious attendance as a categorical variable was conducted autocorrelations between religious attendance variables and mental health were calculated between all included waves of data collection the analysis was limited to participants who had complete data on ghq28 at age 6869 missing data on all other variables were addressed using full information maximum likelihood 15 16 17 the proportion of missing data for each variable is described in the online supplemental tables s2 and s3 along with analyses comparing ghq28 at age 6869 between those with and without missing data by religious attendance at ages 43 6064 and 6869 results participants study members characteristics are presented in table 1 approximately half of the participants were women and onethird had no educational qualifications the majority reported never attending religious services at all ages there was a slight increase in associations between religious attendance and mental health table 2 shows the auto correlations over time for ghq and for religious attendance both track strongly over time figure 3 presents the results of the autoregressive crosslagged analysis between religious attendance and mental health at three time points doubleheaded arrows represent crosssectional associations between variables measured at the same time as shown by the autocorrelations in table 2 previous religious attendance was strongly related to later attendance similarly mental health at baseline was strongly associated with later mental health scores poorer mental health at age 53 and 6064 was associated with more frequent religious attendance at age 6064 and at age 6869 respectively there was no association at the 5 level between religious attendance and later or concurrent mental health sensitivity analysis which modelled religious attendance as a categorical variable found the same pattern of associations discussion summary this study tested bidirectional associations between religiosity and mental health using an autoregressive crosslagged model to analyse data across 26 years we found that religious attendance and mental health both track in middlelife and that poorer mental health is associated with more frequent religious attendance but that religious attendance was not associated with subsequent mental health comparison with existing literature our findings do not support our stated hypotheses and are in contrast with the majority of previous research on religion and mental health 5 6 7 the most relevant study is by li et al who used longitudinal data from more than 48 000 female nurses in the usa to investigate associations between religious attendance and depressive symptoms and change in religious service attendance and subsequent depression 18 they found that after 8 years those with depression at baseline were less likely to attend religious services and that attending religious services was associated with a lower risk of depression our findings are also in contrast to those from a uk based longitudinal study where aksoy et al found a positive association between religious attendance and mental health in a sample of over 50 000 people 8 our novel findings are likely to be partially due to methodological differences we employed a crosslagged method to simultaneously assess reciprocal associations whereas other studies examined bidirectional associations independently it is also possible that differences in sample characteristics such as age ethnicity and religious affiliation may explain the contrasting results there is likely to be variation between the uk and usa where most previous research on this topic has taken place due to cultural differences in the relationship people have with religious organisations and in denomination between the two countries 19 for s5 previous comparisons of religious practices and beliefs between the uk and usa show that the usa is more religious on every measure 20 21 furthermore many studies on religion and mental health are with populations that are not generalisable to an adult community sample for example populations from clinical settings or children 22 23 24 differences could also be due to the extended followup with birth cohort data previous studies investigating bidirectional associations had followup times ranging from 10 weeks to 8 years 7 when comparing our findings it is also important to consider the potential impact of cohort effects as previous research using data from repeated crosssectional surveys and other cohort studies suggest a decline in the rates of religious attendance and belief in god across cohorts 25 26 a possible explanation for the findings is that participants may be using religious attendance as a coping mechanism in response to psychological distress religion is frequently reported as a coping mechanism for stressful life events particularly in response to health problems 27 28 this process has been conceptualised as religious coping which proposes that religious involvement can be protective of mental health by providing meaning in life and a framework for which to understand and deal with difficult situations offering a sense of control and through the provision of social support and social cohesiveness through ritual and traditions 29 30 this hypothesis is supported by posthoc analysis which found that study members who were experiencing high levels of psychological distress at age 53 the same pattern was found when examining psychological distress at age 6064 and an increase in attendance from this age to 6869 details of this posthoc analysis can be found in online supplemental table s6 it is possible that being part of a religious community and regularly attending religious services confers access to emotional support advice and practical help which are perceived to be beneficial for mental health 32 for example ross and mirowsky found that people belonging to religious groups were more likely to talk about their problems than those in a nonreligious groups 33 some studies have found that religious beliefs and attendance are associated with reduced risk of loneliness via higher levels of social integration and social support 34 35 despite there being several plausible mechanisms for how religious attendance may be beneficial for or protective or mental health no such associations were found in this study it is possible that the potential therapeutic effects of religious attendance may dissipate over time and therefore may not be evident several years later future research investigating study members who consistently attend religious attendance may help to understand this further strengths and limitations the potential for reverse directionality has previously been identified in research relating to religiosity and health but has not been extensively researched 7 the results presented in this paper are the first examination of the bidirectional prospective associations between religious attendance and mental health in the uk this analysis was enabled using an autoregressive crosslagged model which has many strengths but also several limitations 36 the main strength is that it can use repeated measures from cohort studies in order to better investigate reciprocal associations between two variables in this case religious attendance and mental health and obtain standardised estimates allowing a comparison of the associations in both directions 14 37 a limitation of the model is that the lagged effects reported in this study are a combination of betweenperson and withinperson change with an additional crosslagged influence of the factors investigated within the same individuals over time however despite the longitudinal nature of these analyses it is still challenging to demonstrate a causal relationship between mental health and religious attendance furthermore the time period was not equal between waves and the measures of religious attendance and mental health were not always collected at the same time this may lead to biases as crosslagged models assume synchronicity between measures at the same time point and equidistance of time intervals 38 the phrasing of the questions to measure religious attendance varied slightly from wave to wave and therefore it is possible this was interpreted differently by study members and may not measure the same construct missing data are a common problem in longitudinal studies and can potentially lead to biased estimates and reduced statistical power in this investigation it was found that study members with missing data on religious attendance were more likely to have worse mental health compared with those with complete data since it was possible that implementing complete case analysis would overestimate associations between religiosity and mental health and wellbeing missing data for exposure variables and covariates were handled by using fiml allowing parameter estimation using all available data 15 16 17 this study only presents findings for religious attendance as these were the only religionrelated variables for which comparable repeated measures were available future research should explore how different aspects of religion such as beliefs and prayer are associated with mental health although participants from nshd provide a nationally representative sample it is not possible to generalise these findings to younger generations religions other than christianity or different cultures 39 the analyses presented in this paper should be extended accordingly implications and further research religious institutions can offer social and psychological support in times of distress by providing hope meaning and social contact and support 30 future research should explore this more explicitly by investigating whether religious attendance or other aspects of religiosity can moderate the impact of stressful life events on mental health while it is not reasonable to advocate joining a religious group or taking up religious practices for those who do not identify as religious further research using more indepth measures into the mechanisms of how religion is associated with mental health could identify areas for intervention development for example research on aspects of religiosity such as gratitude forgiveness and compassion has suggested some beneficial associations with mental health and are considered to be universal aspects of eudaemonic wellbeing that extend beyond religiosity 40 on original research conclusion poor mental health was associated with later religious attendance but not vice versa future research should aim to confirm these novel findings and examine the processes through which mental health and religious attendance are associated what is already known on this subject ► there is some evidence that religious attendance is associated with benefits for mental health with some studies suggesting that the relationship may be bidirectional and that religious attendance is a marker for good health most of the previous research has taken place inthe usa and are not generalisable to the uk where the topic has remained unexplored what this study adds ► this study represents the first exploration of bidirectional associations between religious attendance and mental health using data across 26 years from a british birth cohort study we found that religious attendance was not associated with later mental health but that higher levels of depression and anxiety was associated with a later increase in religious attendance as these findings are novel and contrary to most of the existing research future work should aim to investigate potential mechanisms between mental health and religious attendance such as effect moderation of stressful life events twitter aradhna kaushal aradhnakaushal acknowledgements the authors are grateful to nshd study members for their continuing support we thank members of the nshd scientific and data collection team at the mrc unit for lifelong health and ageing at ucl contributors ak and ms conceived and designed the analysis ak and dc carried out the analysis ak wrote the paper all authors contributed to the interpretation of the data contributed critical revisions and provided final approval of the version to be published ak is the guarantor of the research project and accepts full responsibility for the finished work the conduct of the research had access to the data and controlled the decision to publish competing interests none declared patient consent for publication not required ethics approval

background there is evidence that religious attendance is associated with positive outcomes for mental health however there are few longitudinal studies and even fewer which take into account the possibility of bidirectional associations this study aimed to investigate bidirectional associations between religious attendance and mental health methods participants were 2125 study members who provided data at age 6869 from the medical research council national survey of health and development 1946 british birth cohort study mental health was assessed using the 28item general health questionnaire at ages 53 6064 and 6869 religious attendance was measured using a 4point scale weekly3 monthly2 less than monthly1 or never0 at ages 43 6064 and 6869 crosslagged path analysis was used to assess reciprocal associations between mental health and religious attendance adjusting for gender and education results previous religious attendance was strongly related to later attendance r062074 similarly mental health at baseline was strongly associated with subsequent mental health scores r046054 poor mental health at age 53 and 6064 was associated with more frequent religious attendance at age 6064 b004 95 ci 002 to 006 p 005 and 6869 b003 95 ci 002 to 006 p 005 respectively there was no evidence that religious attendance at age 43 6064 or 6869 was associated with later or concurrent mental health conclusion using birth cohort data from the uk it was found that poor mental health was associated with later religious attendance but not vice versa future research should confirm these novel findings and explore the underlying mechanisms between religious attendance and mental health

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introduction typically it is assumed that adults are autonomous and that children are vulnerable in this article the example of the right to sexuality education for disabled under18s is used to demonstrate the fluidity of the autonomyvulnerability divide sexuality education is understood here broadly to refer to education and information from various arenas on sex sexuality and relationships historically such educationtypically manifesting as a state activity or obligation within the context of formal schoolinghas been denied to disabled people generally and disabled under18s in particular perhaps ironically this has primarily been on the basis that disabled people need protection from knowledge of sexuality and from engagement in sex it is argued here that when it comes to sexuality education there tends to be undue focus on childrens vulnerability and a disregard for the potential for autonomy there is an inclination to err on the side of protecting under18s rather than recognising and facilitating their autonomy rights normative neoliberal adulthood is revered and it is therefore often unrecognised that disabled under18s will have intimate lives and that they will therefore require information and education on sex and relationships this article brings together the strands of childrens autonomy disability and sexuality education providing interdisciplinary analysis through a childrens rights framework it is global in focus although approached from the perspective of the liberal democracy we draw upon examples from the uk context in which the researchers are situated to consider the positions and perspectives of disabled under18s we are focusing primarily on under18s as this is the distinction between childhood and adulthood for most purposes we are also examining the experiences of this group because so much of the research conducted around disabled people and sexuality is centered around over18s and consequently neglects childhood we are theorising generally about under18s with disabilities of all kinds whilst acknowledging the differing experiences amongst this group it is argued in this article that discourses of sexual vulnerability can actually be dangerous in themselves sexuality education rather than being a threat to disabled under18s isamongst other thingsa way to increase their autonomy rights by equipping them with tools of knowledge around sex and relationships the fact that sexuality education will likely boost decisionmaking demonstrates how the autonomy of under18s is not something inherent in them but can be enhanced through recognition of rights such as education and information as well as through recognition of adult responsibilities to facilitate this it is argued that recent theory emerging from disability studies can challenge the rigid autonomyvulnerability divide in positive constructive and transformative ways the first section of this article considers the various terms and concepts of agency autonomy and vulnerability in the second section it is highlighted that disabled people and particularly under18s are frequently seen as other in a world prioritising the liberal individualthis applies to perceptions of sexual activities and relationships too recent academic theory relating to disabled people and sexuality is considered the third section involves a closer examination of the nature of sexuality education and how it is failing disabled under18s it is argued that sexuality education is a means of overcoming vulnerability and that this demonstrates the fluid nature of the autonomyvulnerability divide it is also argued that having to consider the rights and interests of disabled under18s in this context will benefit all humans by encouraging a rethink of gender and sexual norms autonomy vulnerability and the right to sexuality education there has been a distinct transformation in the past three decades in how under18s are viewed in both the social sciences and the legal arena alike the work emanating from the new social studies of childhood has portrayed under18s as competent social actors it has emphasised that under18s have the capability to influence their environments independently of adults that they have agency this notion of agency perhaps mirrors the participation element to be found in the un convention on the rights of the child there is other terminology which has become ubiquitous when it comes to denoting childrens agency crc article 12 refers to childrens right to be heard and to have their views accorded due weight daly argues that autonomy is a preferable term in some contexts the autonomy ideal is the norm for many standards in liberal democraciesin social care for example the international human rights law framework is based on prioritising the autonomy of the individual in the face of state power autonomy can mean different things in different contexts it can be seen as the ideal that we should all have personal freedom in our lives to the extent possible personal autonomy is understood as the individuals capacity for selfgovernance autonomy can also mean the capacity to make decisions including the legal right to take those decisions yet the word autonomy evokes a relatively clear messageit denotes the desire to determine our own future it is crucial to bear in mind that outside of laws upholding it essentially autonomy is just an ideal noone is truly autonomous as our wellbeing is rooted in our relationships with those around us and we are all constrained in our autonomy by factors such as finances and abilities this is the case for both adults and under18s in reality but nevertheless the law generally assumes that adults are autonomous and that under18s are not standards such as legal minimum ages create and reinforce this situation it is assumed that under18s do not have the cognitive capacity to make decisions though the reality is that under18s are often capable and adults are often vulnerable this is perhaps why in spite of the increasing appreciation for children as autonomous agents it is the term vulnerability that is commonly associated with under18s as opposed to adults childrens vulnerability is regularly cited as a reason why under18s should not enjoy rights it is also used as justification for a particular protection approach to under18s in law and practice the heavy protection theme of the crc reflects the perception in law and in popular discourse of the vulnerability of under18s though the term vulnerability does not appear explicitly in that instrument concern for the perceived vulnerability of under18s is also to be seen clearly at domestic level the welfare principle in the children act 1989 and in the laws of other common law jurisdictions for example is often supported in the name of protecting children in relation to sexual abuse and exploitation it is inarguable that under18s are particularly vulnerable there is generally speaking an obvious power imbalance between children and adults and children therefore must have some element of special protection to account for this but power imbalance is not exclusively a childrens problem herring argues that the emphasis on the vulnerability of children is part of an attempt to hide from the vulnerability of adults it helps bolster the image of the autonomous independent man we must therefore aim to distinguish between the denial of autonomy where under18s genuinely need protection on the one hand from unjustifiable paternalism on the other increasingly there are calls in academia to recognise our common vulnerabilities as human beings fineman argues that we are all subject to vulnerability in many areas of life and that the focus of law should be on the vulnerable individual rather than the autonomous liberal individual a failure to recognise vulnerability permits the state to shirk responsibilities and results in substantive inequalities and the allocation of privilege to the powerful this is particularly relevant for under18sperceived as the opposite of the rational competent invulnerable adult herring argues that vulnerability need not be seen as an inherently negative thing instead urging us to embrace it as part of the human condition fineman urges that greater equality and democracy can be achieved by accepting that we all need support vulnerability is a fluid state of coursefactors such as information and education will make a difference disabled children are seen as a vulnerable group when it comes to sexuality education and therefore may be excluded from it altogether rather than being equipped with information tailored to their needs a point addressed more substantively below tisdall opines that understandings of child protection frequently fail to address structural issues focusing instead on interpersonal relationships such as those between under18s and exploitative adults similarly the structures surrounding how and whether disabled under18s can access sexuality education is crucial under18s must be involved in identifying their own concerns and solutions in sexuality education as in other areas as considered further in section 3 it should be noted that there are of course numerous types of disabilities and these can range from having mild to profound effects on childrens lives due to the confines of this article we are being general here we encompass all disabled under18s in our central pointthat sexuality education rather than being a threat is a way to increase autonomy by equipping under18s with tools of knowledge around sex and relationships sexual autonomy youth and intimate citizenship constructing vulnerable subjects disabled children and young people viewed as primarily vulnerable sexual autonomy is a powerful ideal in cultures and contexts where ableism and disablism thrive and where normative neoliberal adulthood is revered campbell defines ableism as a network of beliefs processes and practices that produces a particular kind of self and body that is projected as the perfect speciestypical and therefore essential and fully human ableism is embedded in western humanist and capitalist values which demand ability sanity rationality physicality cognition and autonomythe universal human defined in the liberal tradition as integral to both the human condition and social order such values denote a compulsory ableness the idea that ablebodied identities ablebodied perspectives are preferable and what we all collectively are aiming for disablism however is the resultant oppressive treatment of disabled peoplediscrimination prejudice exclusion marginalisation and a denial of access to multiple areas of private community and public life and participation in civil society when we use the term disableism we are referring to the iterative processes of ableism and disablism which casts disabled people as a diminished state of being human in disableist cultures disabled people are routinely denied access to their sexual lives selves and bodies across multiple areas of their lives as a marginalised group they experience institutional and legal restrictions on their intimate contact characteristically refused social and sexual power agency and autonomy disabled people experience an absence of rights to what plummer calls intimate citizenshipthat which concerns our rights and responsibilities to make personal and private decisions about with whom and how we are in intimate relations in the context of under18s intimate citizenship becomes even more difficult to claim as the impacts of infantilisation developmentalism protectionism and desexualisation construct disabled young people as either sexless andor hypersexual this binary means that there can be a failure to provide disabled children and young people with the education information or safe spaces needed to carve out a desired sexual selfhood and identity there can be an erotophobic approach which can lead to hierarchies based on attributes such as age and physical and mental ability thus in the contexts of childhood youth and disability sexual and intimate relations are confined and contained according to an ableist imperative that dictates normative desires practices behaviours and ways of being this effectively excludes disabled children and young people from most of the dominant socialisation processes that help teach and prepare people for love sex and intimacy historically sexuality education has been denied to disabled people as outlined further below where sexuality education is offered to disabled young people it has been criticised by disabled scholars for its focus on normative bodies and normative bodily experiences which can serve to alienate and further marginalise disabled children and young people as well as propagate disableist myths such as disability implies asexuality it is also critiqued for generating raced cisgendered heteronormative and disableist expectations of what it is to be or become adult rather than serving to protect then discourses of sexual vulnerability ascribed to disabled bodies minds and selves can materialise as danger in the lives of disabled people as part of the disableist justification that disabled people are too vulnerable andor at risk to negotiate the sexual realm critical knowledges forms of information and sexual supportas well as the necessary space and access to sexual and intimate lifeare habitually disallowed paradoxically this is argued to increase disabled peoples sexual vulnerability particularly for those with the label of learning disability disabled women and disabled people who identify as lesbian gay bisexual andor trans in effect putting them at a greater risk of sexual abuse and violence individualist notions of vulnerability exacerbate this problem placing the onus on the individual rather than the institutional arrangements of domination and subjugation that determine disabled peoples bodies as sites of violence ironically the vulnerability label may serve to render disabled children and young people even more vulnerable putting them at greater risk where they are denied information education and space to learn and experience troubling the human disability and desire through disability however we may in fact be able to reframe thinking about the intimate lives and knowledge of under18s goodley and runswickcole argue that disability has the radical potential to trouble the normative rational independent autonomous subject that is so often imagined when the human is evokedbringing into view a new politics of vulnerability such a position offers the potential to see value in and the collectivity of vulnerability to move from associating it with victimhood and to reclaim it for its potential in describing a universal inevitable enduring aspect of the human condition that must be at the heart of our concept of social and state responsibility vulnerability can instead be an arena for human exchange empowerment and growth necessary for human being and human understanding it can offer alternative ways of understanding the human subject and be embedded in the posthuman condition this will insist that we consider alternative kinds of citizenship and ways of being human pulling disability politics into posthuman theory goodley et al put forward the dishuman a mode of understanding that simultaneously acknowledges the possibilities offered by disability to trouble reshape and refashion the human while at the same time asserting disabled peoples humanity disabled people are fighting to be recognised as humans and in the process are in engaging in activism and art this pushes us to think imaginatively and critically about the posthuman disabled peoples exclusion from the category of the human affects their sexual and intimate lives on a number of levels compromising their entry into normative sexual categories it resists their sexual agency and their calls for rights relating to sexuality yet disability can be a transformative element in normative constructions of sexual ableness ability and humanness disabled bodies and minds contest prevalent myths of the sexual body as selfgoverning autonomous contained and in control disabled bodies quite often require sexual support and assistance in ways that challenge sexual normalcy the sexual body emerges as a space of relationality and interconnectedness corporeally interwoven with other bodies and selves in multiple and creative assemblages therefore dishuman and posthuman modes of thought draw upon disability to invoke posthuman modes of sexuality which value interdependence queer radical relationality collaboration and collectivity in ways that can be emancipatory for all sexual subjects therefore requiring systems to accommodate sexuality education and information for disabled children will likely have the positive effect of challenging normative constructions of sexuality this will in the process educate teachers students policymakers and others about different experiences needs and wishes when it comes to relationships sex and education it will insist that we think outside the box about what sexual normalcy is sexuality education vulnerability and disabled under18s it is necessary to consider what sexuality education is how it is failing disabled under18s and what a transformed approach to sexuality education should involve although a detailed proposal for the content of childrens rightsbased sexuality education for disabled under18s is beyond the scope of this article some key components of how to get therea rights basis childlead curricula and a rethinking of sexuality from the perspective of disability for examplewill be outlined sexuality education for disabled under18s accessibility and content international human rights standards are clear that children and young people have a right to sex education the un committee on economic social and cultural rights is the implementing body of the international covenant on economic social and cultural rights which enshrines the right to the highest attainable standard of health the committee states that article 12 obliges states to ensure that … u ptodate accurate information on sexual and reproductive health is publicly available and accessible to all individuals in appropriate languages and formats and to ensure that all educational institutions incorporate unbiased scientifically accurate evidencebased ageappropriate and comprehensive sexuality education into their required curricula the crc states in article 17 that children have the right to access information aimed at the promotion of their health and in article 24 that states have the obligation to develop preventive health care education and services the committee on the rights of the child emphasises that children have the right to ageappropriate comprehensive and inclusive sexual and reproductive health education based on scientific evidence and human rights standards and that special consideration should be given to disabled children states who have signedup to these instruments have agreed to abide by them they are after all minimum human rights standards some countries like the uk have not yet enacted the necessary domestic legislation which would permit these international treaties to become legally enforceable in courts however judges do sometimes rely on these international standards in interpreting domestic law with the advent of childrens rights in the past three decades it is unsurprising that there is broad international acceptance that sexuality education is a human right research shows that sexuality education has become the norm throughout europe and central asia which at the very least shows that its importance is broadly recognised at domestic level too much of the problems of implementation of international human rights standards lie in the interpretation of what those standards entail neither sexuality nor sexuality education have specific definitions but the latter encompasses several components sex relationships and sexual health in other words it goes beyond mere technicalities of sex to encompass attitudes and feelings about the contexts in which sex should happen importantly sexuality education takes place across a variety of settingsin school in the family home amongst friends on the internet television music magazines religious organizations through personal experiences and more it also takes place across the lifecourse of the individual including in school although of course parents peers and other arenas such as the internet will be key in the learning of children and young people sexuality education is often denied to under18s borne out of a fear that knowledge of sexuality will make them immoral more sexual and adult before their time this relates inherently to the idea that under18s are vulnerable and unable to make the right decisions in relation to the exercise of their sexuality consequently they should be protected from sexual knowledge until they become capacious adults if sexuality education is contested for children and young people in general it is even more problematic in the context of disabled under18s the perceived asexual or alternatively hypersexual nature of some disabled under18s means that sexual activity or expression is often discouraged and prevented by parents guardians or carers it is often assumed that sexual knowledge which opens up possibilities for such activity should also be prevented ostensibly to protect under18s from becoming exploited or from becoming sex offenders it has been shown that disabled people receive less sexuality education it has been found that there can be a sense amongst those caring for disabled people that it is someones elses job to provide this education and indeed it has been suggested that a coordinated approach from a combination of school health professionals and parents is necessary for those with physical disabilities it has been demonstrated that disabled children have less knowledge of sexual matters such as puberty and safe sex practices compared to nondisabled peers of course the right of parents to withdraw their children to opt outfrom sexuality education is a prominent matter in the arena of sexuality education the right for parents to withdraw persists to a large extent for example in the uk although it is a fundamental parental right to determine the nature of their childrens education it has been argued that it is proportionate to override parental preferences in the instance of sexuality education in the words of one teacher of disabled under18s our guys cant opt out of puberty it is likely that parents of disabled children may be particularly worried about the appropriateness of sexuality education this makes it all the more crucial to insist on framing such education as a means of decreasing vulnerability as well as providing the tools to form positive relationships it is not just the accessibility of sexuality education but also the content which fails many disabled children in her participatory research with disabled young people liddiard found that learning about sex and sexuality is generally done through a lense of dominant expectations of ableist sexual normalcy these disableist constructions of disability and sexuality shape the extent to which disabled young people learn about sex and intimate relationships with the result that disabled people may internalise feelings of otherness for example here terry a 20yearold man with a disorder involving muscle weakness recalls learning about sexuality in school the lesson was focusing on how to put a condom on i remember saying to be fair youre talking to someone who cant even open a chocolate wrapper so i havent got much hope have i i remember it was almost like a shock because he teacher said does that mean youre not going to use contraception and i said well no obviously id just ask the other person to put the condom on… liddiard states that this indicates that even in education ostensibly tailored to people with a specific disability learning can be defined by how disabled peoples experiences deviate from the ableist sexual cultures and practices which are dominant these kinds of exclusionary approaches can further myths that disability implies asexuality and education can in fact serve as a means of reproduction of the otherness of disabled people sexuality education as a means of overcoming vulnerability sexuality education rather than being a threat to disabled under18s is amongst other things a way to increase their autonomy rights by equipping them with tools of knowledge around sex and relationships the un special rapporteur on the right to education emphasises that sex education provides the tools that are needed for decisionmaking in relation to sexuality corresponding to the lifestyle which each human chooses in the context of her situation effective comprehensive and appropriate sexuality education equips children and young people with sufficient knowledge and understanding to navigate the waters of sex and relationships it facilitates them to exercise autonomy to make informed choices and to exercise their sexual rights it provides them with the language to describe and report incidences of sexual abuse and breaks down taboos around discussing sexuality which can prevent such reporting sexuality education curricula can also address issues like body image selfidentity and selfesteem which often undermine the confidence of children and young people with disabilities as such effective sexuality education is capable of eradicating some of the existing barriers to the exercise of sexual autonomy and expression by people with disabilities and is a necessity for sexual selfdetermination and selfadvocacy although information on positive relationships and on staying safe is obviously relevant for everyone and for all disabled under18s it is particularly important for girls because of the nature of gender relations in other words access to sexuality education is important to reduce sexual vulnerability and promote resilience it is impossible to eliminate all vulnerabilities and risks inherent in the human condition yet educating and empowering children and young people to understand and assess risks and to take action to protect themselves is crucial there are clear problems of accessibility and content plaguing traditional sexuality education routes for disabled under18s there is a need to consider particularly in a context such as england and wales where sexuality education is being rethought how to carveout a space for assumptions that amongst children in all of their diversity disabled children will be one group who will absolutely need to some extent at least a curriculum specific to them within this cohort of course there will be the need to breakdown education further in accordance with age and different disabilities whilst the department of education guidance on sexuality and relationship education makes reference to the needs of disabled children it is seriously lacking the guidance states that disabled children will require teaching that is differentiated and personalised when it comes to sex and relationships however there is little detail on how teaching and learning can and should be personalised for pupils within schools the guidance also refers to exceptional circumstances in which a disabled childs special educational needs will be taken into account when making a decision on the parental right to withdraw their child from sexuality and relationship education without giving examples of such circumstances which runs the risk of disabled children unduly being removed from such lessons forms of delivery outside of school and the family will be crucial currently the internet is a prominent source of sexual advice and education amongst children and young people not least because it is generally affordable available anonymous and private further an internetbased model for teaching sexuality education has the potential to be interactive specific and individualised in relation to disabled under18s in particular online sexuality education could provide several additional benefitsfirstly in that they would open up access to sexuality education where none such may have existed before but secondly and more importantly in that they may allow such education to be tailored to the specific disabilities of the individual hence this could potentially overcome some of the problems arising from the current lack of specificity when it comes to sexuality education for individuals with differing types and degrees of disabilities more research is required to consider access issues and other specific risks for disabled under18s it should not be assumed however that disabled under18s are more susceptible than others to online risks or that they have less ability to cope with adverse online experiences it is not just the content and development of curricula which require attention a rethink is needed around the extent to which they are resourced and how to deal with structural discrimination when it arises this should be approached in a rights framework the committee on the rights of the child in emphasising the state obligation to provide sexuality education state that the necessary human financial and technical resources should be provided to design and implement such programmes furthermore that instrument recognises state obligations regarding the special needs of disabled children in article 23 the un convention on the rights of persons with disabilities emphasises that states must take all necessary measures to ensure the full enjoyment by children with disabilities of all human rights and fundamental freedoms on an equal basis with other children at a recent event at the university of liverpool on sexuality education for disabled under18s the issue of resources and the discretion which schools have concerning how and whether they implement sexuality education was a prominent perhaps the most prominent theme this is particularly significant in countries in which dramatic cuts to public services have been enforced including in the education sector the knowledge of children and young people about their sexuality should not be dependent on whether schools wish to prioritise it there are many ways in which sexuality education could be tailored to account for the needs and common characteristics of groups with particular disabilities it was found by schaafsma et al that for adults with cognitive impairment interviewed in the netherlands the frequency of sex education sessions appeared to be low as participants did not remember having received sex education they make the point that it is not just sexuality education but continuous sexuality education which will be necessary for people with intellectual disabilities in order to maintain high levels of knowledge it is also important to note that east and orchard have found that what literature exists indicates that the majority of sexuality and disability research tends to be focused on sexuality education for youth who have cognitive impairment while often disregarding the experiences of people with physical disabilities that do not affect their cognitive functioning they theorise that this is due to a fear of sexual abuse and exploitation of those with cognitive impairment what this perhaps indicates is heightened attention to the vulnerability of certain subgroups of disabled people and simultaneously a tendency to neglect the rights and needs of other groups of disabled people when it comes to sexuality education this highlights the amount of work which needs to be done around adequate attention to different groups our own research indicates that the vast majority of the research also focuses on the education and experiences of disabled adults rather than on the experiences of disabled under18s this runs the risk of failing to appreciate the importance of supporting the autonomy of disabled children to understand matters such as power dynamics from an early age of course crc article 12 emphasises that children and young people have participation rights and it has been examined in detail what this means in the case of education in a similar vein in disability studies and practice the nothing about us without us approach is prominent and it is disabled children and young people who should be developing the curriculum and even delivering it guidance should be taken from good practice examples in sexuality education generally such as in norway sweden the netherlands and elsewhere where such education is considered consistent with international guidance and based on the premise that under18s are rightsholders who have an entitlement to information and to enjoy their sexuality there is also much work to be done in countering curricula and attitudes which are contrary to the dignity of disabled under18s at the same university of liverpool event a number of attendees were teachers providing such education some outlined how in their experience disabled children were sometimes excluded from mainstream lessons concerning sexuality education on the basis of presumptions that it was not suitable for them or that they would be disruptive such segregation and inferior education for disabled people is presumably in violation of the uks equality act 2010 for such discussions to move forward international human rights frameworks must be harnessed it must be emphasised through discussion lobbying and litigation that disabled under18s have a right to sexuality education and that an insincere vulnerability discourse cannot be instrumentalised by state institutions or others for the purpose of shirking responsibilities conclusion the exclusion of under18s from the prioritisation of autonomy in the liberal democracy appears to be based on the assumption that adults and childrens worlds and the experiences inherent in them are entirely separate of course they are notunder18s sometimes engage in sex are exposed to sexual abuse and have views and wishes about matters such as medical treatment and family life yet the priority for childrens autonomywhether within relevant laws or popular discoursedoes not exist to any degree similar to that pertaining to adults instead there is generally a binary approach whereby adults are assumed to be autonomous and under18s are not caution is needed in framing autonomy as simply valuing the liberal individual however autonomy must be understood with an appreciation for our relationships with others and of the fluid nature of our knowledge and capabilities in that failing to provide support from autonomy may render children vulnerable this need to emphasise autonomy and support for autonomy is demonstrated well when it comes to sexuality education for disabled under18s in disableist cultures disabled people are routinely denied access to their sexual lives selves and bodies they experience restrictions both institutional and legal on their intimate contact in the context of under18s intimate citizenship becomes even more difficult to claim as disabled under18s are portrayed as sexless andor hypersexual disabled children and young people may then be excluded from education and other socialisation processes which prepare people for love and sex stigmatising vulnerability discourses reinforces dominant expectations of ableist sexual normalcy and cause anxiety for young disabled people individualist notions of vulnerability place the onus on the disabled child rather than institutional inequality inequality which features a failure to consider the diversity of the lives of under18s and the diversity of those entitled to sexuality education such narratives frequently prevent information and sexual supportas well as the necessary space and access to sexual and intimate lifefor disabled people paradoxically then this may increase the sexual vulnerability of disabled under18s considering the many ways in which under18s do not fit their mandatory legally incapacitated status prompts us to think about vulnerability where under18s may wish to engage in sexual learning or encounters where they are themselves parents for example where they engage in behaviours that we do not usually associate with under18s it becomes clear that the adultchild dichotomy is not so straightforward it prompts questions as to whether holding adults as entirely responsible unless they are deemed to entirely lack mental capacity is sensible as herring has argued in the context of consent to medical treatment and other matters likewise being compelled to consider what kind of sexuality education is desired useful and appropriate for disabled under18s will encourage us to rethink sexuality education itself it compels us to ask how the content structure and delivery of sexuality education must be tailored to meet the needs of those who do not fit normative stereotypes it prompts us to question how it can be delivered without perpetuating and reinforcing inequalities already in existence between adults and children and between disabled and nondisabled people it is disabled under18s themselves who must lead this discussion and lead the design and delivery of sexuality education where systems are compelled to accommodate sexuality education and information for disabled under18s it will have a positive effect of challenging normative constructions of sexuality this will educate populations more generally as it will insist that we think outside the box about what sexual normalcy is and about what autonomy and vulnerability really mean in this and other contexts

international human rights standards are clear that children and young people have a right to sexuality education nevertheless the delivery of such education is often considered questionable particularly for groups of children perceived as more vulnerable in this article the example of the right to access sexuality education for disabled children is used to explore the autonomyvulnerability dynamic historically sexuality education has been denied to disabled children ostensibly to protect them from information and activities perceived as inappropriate due to their perceived greater vulnerabilities it is argued however that discourses of sexual vulnerability can actually be dangerous in themselves sexuality education rather than being a threat to disabled under18s serves as a way to increase their autonomy by equipping them with tools of knowledge around sex and relationships this case study demonstrates how the autonomy of under18s is not something inherent in them but something which can be enhanced through recognition of rights such as education and information as well as recognition of adult responsibilities to facilitate this 1

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introduction european societies are heavily characterized by migration and cultural diversity in 2015 more than 240 million international migrants were recorded approximating 33 of the worlds population from 2015 to 2017 europe and germany have witnessed the largest immigration movement in their recent recorded history 1 according to the federal office for migration and refugees 2 approximately 500000 asylum applications were submitted in germany in 2015 almost a third of these applications were submitted by youth under the age of 20 2 next to refugee youth youth of immigrant descent represent a large proportion of germanys population they are defined as those who have at least one foreignborn parent or grandparent and either have been born outside or within germany 3 as the federal government expert commission 4 has recommended to use the term immigrants and their direct descendants to aggregate immigrants of second and later generations we use the term youth of immigrant descent to describe the youth in our sample who are descents of immigrants for youth who have recently migrated to and sought refuge in germany we use the term refugee youth when applying the term ethnicminority youth in our study we encompass both refugee youth and youth of immigrant descent together refugee youth and youth of immigrant descent aged under 20 cover more than onethird of the agematched population in germany 5 it is thus clearly in the best interest of the german society to promote the positive adjustment of these young immigrant populations similar to their nonimmigrant descent peers ethnicminority youth face numerous developmental challenges such as forming relationships with friends and family a cohesive and secure sense of identity and developing responsibility 36 in contrast to their nonimmigrant descent peers they further have to cope with significant acculturative challenges 7 8 9 acculturation can be described as a dynamic process through which individuals and groups from different cultures who are engaging in sustained contact adapt to one another 10 for ethnicminority youth specifically salient stressors can arise from the acculturation process 11 in this study we focused on perceived ethnic discrimination as a major acculturative hassle which has been found in several studies to have detrimental consequences for the adjustment of ethnicminority youth 12 13 14 ped can be defined as the experience of being treated negatively based on ones ethnic background 15 and has been identified as a powerful predictor of minority youth maladjustment 16 17 18 the adjustment of immigrants and their descendants can be structured as encompassing both psychological and sociocultural outcomes 1920 while psychological adjustment captures their general wellbeing and mental health sociocultural adjustment addresses cultural skills and functionally adaptive behaviors 2122 as a safe school environment with positive teacher and peer relations has substantial influence on youth development 23 and school forms one of the most important acculturative contexts for minority youth we focus on ped at school by teachers and peers although there has been already research on ped in relation to adjustment for ethnicminority youth 1624 there is still little research specifically on refugee youth given this insufficient research and the rising numbers of refugee youth in germany we are particularly interested in possible differences between refugee youth and youth of immigrant descent in our study when studying the influence of ped on adolescents psychological development the work on risk and protective factors offers a useful framework 25 while risk factors can be defined as individual or environmental hazards that increase an individuals vulnerability for negative developmental behaviors events or outcomes 26 protective factors serve as buffers so that the relations between risks and negative developmental outcomes are mitigated 252728 thus beyond viewing ped as a risk factor this perspective considers factors that can protect the positive development of ethnicminority youth in the face of ped in the past studies on the effects of ethnic discrimination have been criticized for focusing mainly on maladjustment and deficit environments 16 in response to this criticism the model of developmental risk and protective factors addresses psychological and environmental protective factors that can buffer against negative adjustment outcomes related to ped in this study we specifically explore the role of ped at school by teachers and peers on ethnicminority youth positive adjustment while considering peer and parental support as possible protective factors it extends previous research 29 30 31 32 in five ways namely by specifically examining the role of ped in the context of school instead of focusing on the general living environment of minority youth in germany focusing on different aspects of positive adjustment including three psychological and one sociocultural indicator of adjustment while most studies with immigrants only focus on psychological outcomes 33 considering the distinct roles of two key relational contexts by simultaneously testing parental and peer support as buffering factors concerning the relation between ped and adjustment and by including both refugee youth and secondand thirdgeneration youth of immigrant descent thus allowing us to explore potential differences in the risk and protective roles of ped and social support for their adjustment perceived ethnic discrimination as a risk factor for positive adjustment being in an unsupportive and rejecting environment where individuals do not feel a sense of acceptance and relatedness has been found to be a serious risk factor for adjustment 28 studies have shown that youth who are teased or called names by their peers at school have a higher chance to have a lower selfesteem and to do poorly in school 3435 in addition adolescents who feel that their teachers do not respect or care about them were identified to show more negative socioemotional and academic outcomes 3637 overall these messages of devaluation by teachers and peers can lead to negative developmental outcomes similarly minority adolescents experiences of ethnic discrimination at school by teachers and peers can evoke the feeling of being devaluated because of ones ethnic group membership thus and as stated by suárezorozco and colleagues 3 in their riskandresilience model ped can act as a risk factor for minority youth increasing the probability of negative developmental outcomes in their metaanalytic study benner et al 16 showed the pernicious effects of ped for adolescents on different indicators of wellbeing such as poorer selfesteem more depressive symptoms greater psychological distress and lower academic achievements in addition paradies et al 38 and priest et al 24 highlighted ped as an important predictor negatively affecting ethnicminority youth adjustment in the current study we specifically focus on ped at school by teachers and peers drawing on social identity theory the asymmetric power relationship between teachers and students can promote differential treatment across groups of students based on teachers own socialgroup membership in relation to their students 39 teachers can use this asymmetric power relationship either in a positive and supportive way or in a negative and destructive way studies revealed that experiences with ethnic discrimination by teachers are related to lower selfesteem a weaker sense of school belonging and a poorer mental health 254041 greene and colleagues 42 found that also experiences of racial discrimination at school from ones peers predict declines in mental health including increases in depression and decreases in selfesteem and psychological resilience these results accord with several metaanalyses 142438 which all identified a strong association between ped and poor adjustment in ethnicminority youth indeed the experience of ethnic discrimination was associated with low levels of selfesteem life satisfaction sense of coherence and high levels of depressive symptoms and other forms of psychological distress 142438 considering the potential threat of ped to the healthy development of minority youth ped can be classified as a highrisk factor for minority youth positive adjustment 2526 keeping in mind that most research on ped and possible adjustment outcomes has been conducted with ethnicminority youth in the us we are particularly interested in studying these associations amongst refugee youth and youth of immigrant descent in germany in light of the past findings we expect that ped at school decreases positive adjustment amongst refugee youth and secondand thirdgeneration youth of immigrant descent in our current study two potential protective factors parental and peer support while examining to what extent ped provides a risk for positive adjustment amongst ethnicminority youth in germany it is necessary to identify factors than can buffer these effects within a risk and resilience framework in developmental psychology protective factors can ensure that children and adolescents exhibit positive developmental outcomes despite atrisk contexts and challenges during adolescence 43 protective factors serve as buffers ensuring that the relation between risks and problematic development is attenuated 2728 several studies 4445 showed that individuals with access to protective factors are likely to demonstrate more positive adjustment in comparison to those who do not there are a number of different strategies minority youth use to respond to ethnic discrimination 46 in the present study we examined whether social support acts as a protective factor while diminishing the detrimental effects of ped on the positive adjustment of ethnicminority youth when confronting ped social support has been considered as an emotionfocused strategy 47 that indicates the availability of network members who express concern love and care for the individual 48 several studies have shown that individuals are better able to cope with difficult circumstances when there is social support 49 50 51 and emphasized the role of social support as a facilitator for the positive adjustment of immigrants 52 further the risk and resilience framework 50 emphasizes social support as an important protective factor for youth while several studies identified social support as a commonly used coping strategy in the face of ped 53 54 55 56 we specifically look at parental and peer support as two potential protective factors whose mitigating effects are understudied in the field of ped and as protective factors of ethnicminority youth adjustment in this study we added to the literature by simultaneously testing the role of parental and peer support for the relationships between ped at school and multiple outcomes as well as by studying these associations across two groups namely refugee youth and secondand thirdgeneration youth of immigrant descent the quality of the parentchild relationship is an important factor for the development of children and adolescents claiming that parents provision of consistent and responsive support leads to a sense of trust and competence in children the attachment theory 57 emphasizes the importance of supportive parentchild relationships for childrens and adolescents emotional wellbeing a number of studies have revealed that supportive parentadolescent relationships characterized by secure attachments are related to positive psychological outcomes for youth such as fewer mental health problems lower levels of antisocial and aggressive behavior and more adaptive coping strategies 58 furthermore parental support seems to have a similar beneficial effect on adjustment and health outcomes across racialized groups 3059 for example the metaanalysis of sun et al 60 revealed that positive relationships between minority children of various racialized groups and their parents play a significant supportive role for their mental health better parentchild relationships were related to fewer mentalhealth problems and better mentalhealth outcomes parental support has also been claimed as a protective factor for youth by fostering a closer bond between the parent and the child and consequently allowing for more open communication within the parentchild relationship and creating a sense of security for the child 57 indeed studies of african american adolescents revealed supportive parental behavior as a buffer in the associations between perceived discrimination and behavior conduct problems and substance use 2932 additionally nurturinginvolved parenting that includes emotional support instrumental assistance and communication about potential areas of concern between parents and their children revealed to weaken the association between perceived discrimination and depressive symptoms however others have found that socialsupport networks do not moderate the perceived discriminationmental health association 40 supportive peers may also serve as a protective factor against the negative effects of ped developmental considerations indicate an increased importance of peer support during adolescence 61 as the relationship with ones peers becomes increasingly important during adolescence the protective effects of peer support seem to especially grow in importance in this developmental period 62 studies have found that supportive peer relationships increase the psychological wellbeing of ethnicminority youth 3163 in addition having a strong attachment with ethnic peers have been found to facilitate acculturation and enhance levels of wellbeing 64 from an attachment theory perspective and especially for older ethnicminority youth close peers can provide alternative attachment relationships with similar benefits to parents 13 concerning the question whether peer support would moderate the relation between ped and positive adjustment outcomes a stressbuffering model suggests that peer support would interact with ped to protect ethnicminority youth from the negative effects of ped 65 regarding possible differences between refugee youth and youth of immigrant descent peer support may act especially for refugee youth as a protective factor as their parents often cannot support them because of mental strains and stress arising from the acculturation process thus in our study we tested parental and peer support as possible buffers for both refugee youth and youth of immigrant descent in addition we had a closer look at possible similarities and differences between refugee youth and youth of immigrant descent considering the insufficient research on ped and possible buffering effects especially in the case of refugee youth the present study as shown in figure 1 we investigated the associations of social support and different aspects of positive adjustment among ethnicminority youth in germany in the event of experiencing ped at school using a risk and resilience perspective we expected that high experiences of ethnic discrimination at school would be associated with less selfesteem selfefficacy and optimism for minority youth in germany but also with less school integration consistent with research showing that higher parental 305859 and peer 316364 support have beneficial effects on ethnicminority youth mental health and adjustment we moreover expected ethnicminority youth to show high positive adjustment outcomes when receiving high parental or peer support few studies have simultaneously tested parental and peer support as moderators for the association between ped and adjustment based on the risk and resilience perspective and some previous findings on the buffering effects of social support 66 it was hypothesized that parental and peer support will buffer the negative effects of ped on ethnicminority youth selfesteem selfefficacy optimism and school integration finally we also explored if our hypothesized model differed among refugee youth and secondand thirdgeneration youth of immigrant descent materials and methods data and participants we used data from n 104 ethnicminority students in germany including n 55 refugee youth and n 49 youth of immigrant descent data were collected in 2019 across various local contexts including secondary schools mosques youth migration services refugee shelters and german language courses for refugees before starting data collection the study received ethical approval from the ethics commission at bielefeld university secondary schools with high numbers of ethnicminority students along with mosques youth migration services refugee shelters and german language courses were materials and methods data and participants we used data from n 104 ethnicminority students in germany including n 55 refugee youth and n 49 youth of immigrant descent data were collected in 2019 across various local contexts including secondary schools mosques youth migration services refugee shelters and german language courses for refugees before starting data collection the study received ethical approval from the ethics commission at bielefeld university secondary schools with high numbers of ethnicminority students along with mosques youth migration services refugee shelters and german language courses were contacted personally and via phone prior to the administration of the paperandpencil questionnaire informed consent from participants and their parents was obtained participation was voluntary and not remunerated anonymity was guaranteed and the participants were able to choose the language in which they wanted to answer the survey participants aged between 12 and 23 could take part in the survey the refugee status was based on the refugee definition presented in article 1 of the united nations convention relating to the status of refugees 67 consequently adolescents who indicated in the questionnaire to have left their home country because of ethnic religious andor political persecution discrimination fear of violent conflicts andor war were considered as refugees refugee youth primarily stated syria turkey and iraq as their countries of birth next to n 45 youth of immigrant descent who specified to be born in germany and to have at least one parent or grandparent who had immigrated to germany n 4 indicated turkey or iran as their countries of birth ages of the total sample ranged from 12 to 23 and 61 identified themselves as female measures 221 positive adjustment in this research we assessed positive adjustment in terms of four indicators of psychological wellbeingnamely selfesteem two aspects of selfefficacy and optimismand school integration all positive adjustment outcomes were measured with items taken from the developmental resources questionnaire for children and adolescents by lohaus and nussbeck participants responded to the items on a scale ranging from 1 to 4 the four indicators of psychological wellbeing were measured as follows selfesteem was assessed with three items i can be proud of myself i feel good when i think about myself and i have many good feelings when i think about myself the two dimensions of selfefficacy were also assessed with a total of five items the first dimension taps into how selfefficacious the ethnicminority participants felt in reaching their goals when i set a goal i see the positive when i set my mind to something i manage to do it and when i really want to achieve something i also succeed the second dimension captures selfefficacy in terms of abilities with my skills i can achieve anything and i can achieve a lot with my skills optimism was assessed with a fouritem scale including the following items i have a positive basic mood even if i have problems i see the positive if i am not doing so well i know i will be better soon and i believe that everything somehow turns out for the better finally school integration was measured with six items i feel comfortable at school i get along well with my classmates i really like the climate at my school all in all i enjoy being together with my classmates my classmates are kind to me and i feel comfortable in my class perceived ethnic discrimination at school perceived ethnic discrimination at school was assessed with five statements adapted from the adolescent discrimination distress index by fisher wallace and fenton 40 first the ethnicminority adolescents read a short introduction after each statement tell us if you have experienced each of the following types of discrimination because of your race or ethnicity remember we are only interested in occasions when racialethnic discrimination was at least partly responsible for your experience afterwards they were presented with five statements asking for a yes or no answer you were discouraged from joining an advanced level class you were wrongly disciplined or given afterschool detention you were given a lower grade than you deserved peers did not include you in their activities and people acted like they thought you were not intelligent as in previous research the overall score was calculated by counting the items which were answered with a yes answer social support to assess peer and parental support we again used items from the developmental resources questionnaire for children and adolescents by lohaus and nussbeck and ethnicminority participants responded to the items on a scale ranging from 1 to 4 peer and parental support were measured with six items each the following items were used to measure peer support i have friends i can rely on i also meet with friends after school i feel good when i am with my friends my friends like me as i am i think i am liked by others my age and i have a lot of contact with my peers for parental support the youth answered the items if i need support my parents are there for me if i am afraid of something i can always approach my parents my parents are good at comforting me when i am in a bad mood my parents take care of me i can always ask my parents for advice and i can rely on my parents control variables to estimate net effects of the main predictor variable age gender status school form and ethnic identification were included as statistical controls in our models as previous research 68 69 70 71 found significant links between our sociodemographic variables and the wellbeing and school integration of ethnicminority youth we included them as control variables in our study further several studies 2572 found a significant link between ethnic identification and indicators of wellbeing and school adjustment for adolescents therefore we decided to include ethnic identification as a control variable it was measured with the item how strongly do you feel connected to your country of origin and for those who were born in germany with the item how strongly do you feel connected to the country of origin of your parents or grandparents the ethnicminority youth answered the question that applied to them on a scale from 1 to 4 analyses to test our hypotheses we employed a structural equation modeling procedure using mplus 8 version 16 73 in our model we controlled for status age gender school form and ethnic identification concerning our additional analyses multigroup analyses were performed with the aim of examining similarities and differences between refugee youth and youth of immigrant descent note that we do not have theoretical reasons to expect differences between refugee youth and youth of immigrant descent concerning the associations however we wanted to acknowledge these two distinct subgroups in our sample by testing whether our associations of interest are similar across the two subgroups three fit indices were considered to evaluate the model fit comparative fit index tuckerlewis index and rootmeansquare error of approximation 74 results descriptive results mean scores standard deviations and ranges for our main study are presented in table 1 our participants reported a moderate number of experienced instances of ped at school concerning their psychological wellbeing the mean scores of ethnicminority youth selfesteem selfefficacy and optimism were all close to the value 3 on their fourpoint scale indicating psychological wellbeing on a rather high level similarly school integration showed a high score of 301 finally the mean scores of peer and parental support were close to the positive end of their fourpoint scale suggesting rather high perceived support of parents and peers for ethnicminority youth in addition we report bivariate correlations between the main study variables in table 2 surprisingly ped only showed a negative correlation with school integration but not with any other adjustment outcomes whereas both types of social support were associated with better school integration more peer support was also associated with higher selfesteem while more parental support was also associated with higher optimism we also found a negative correlation between ped and parental support while our adjustment outcomes were mostly positively related significant positive correlations were found between selfesteem and selfefficacy between selfesteem and optimism and between selfefficacy and optimism in addition better school integration was accompanied by higher selfesteem and optimism main analysis perceived ethnic discrimination at school and positive adjustment outcomes we tested our hypotheses about the role of ped at school for ethnicminority youth positive adjustment in a structural equation model modelfit indices indicate that this model fits our data well the results of our model while controlling for status age gender school form and ethnic identity are presented in table 3 unstandardized regression coefficients are reported we did not find significant relations between ped and minority youth psychological wellbeing ped at school was unrelated to selfesteem selfefficacy and optimism similarly ped was unrelated to school integration thus we have to reject both hypotheses 1a and 1b our findings do not provide evidence that minority youth who experience higher numbers of different instances of ped at school will show lower levels of psychological wellbeing or school integration parental and peer support as protective factors regarding hypotheses 2a and 2b our model results show that both measures of social support were positively related to ethnicminority youth psychological wellbeing and school integration more precisely ethnicminority youth who received more parental support were also more optimistic felt more selfefficacious in terms of their abilities and more integrated in school for peer support significant relations with selfefficacy selfefficacy selfesteem and with school integration were found overall these findings support hypotheses 2a and 2b namely that ethnicminority youth who receive high amounts of parental and peer support will score higher on psychological wellbeing and school integration however as parental support was not significantly related to selfesteem and selfefficacy and minority youth who received more peer support were not significantly more optimistic hypotheses 2a and 2b were only partly confirmed concerning hypotheses 3a and 3b there was a marginally significant twoway interaction effect between ped at school and peer support to further examine this interaction we conducted simple slope analysis 75 we examined the effect of ped at school on minority youth optimism under two conditions low and high peer support as shown in figure 2 ethnicminority youth were less optimistic when they perceived ethnic discrimination but only when there was low peer support no significant effects were found when the amount of peer support was high while hypothesis 3b was partly confirmed hypothesis 3aassuming that a interaction effect between ped and parental supportcould not be confirmed effects of ped at school on ethnicminority youth optimism dependent on the level of peer support note † p 010 ns not significant effects of control variables on outcomes in main analyses with regard to our control variables we found that refugee youth were significantly more optimistic and reported more selfesteem and school integration than youth of im effects of control variables on outcomes in main analyses with regard to our control variables we found that refugee youth were significantly more optimistic and reported more selfesteem and school integration than youth of immigrant descent moreover compared to boys girls revealed less selfefficacy concerning their abilities and less selfesteem age ethnic identification and attending secondary vs postsecondary education did not have a significant effect on ethnicminority youth positive adjustment outcomes as ethnic identification is known to be a significant protective factor in the face of ped 776 we also checked if our model results would change when leaving ethnic identification out as a control variable regarding this our model results did not show significant changes additional analyses exploring differences between refugee youth and youth of immigrant descent although we did not have theoretical reasons to expect differences between refugee youth and youth of immigrant descent concerning our model results we still wanted to acknowledge these two subgroups in our sample and contribute to the closure of the aforementioned research gap therefore we tested whether mean levels and associations are similar across the subgroups independent ttests revealed that refugee youth showed better adjustment than youth of immigrant descent regarding their school integration t 302 p 0003 d 061 95 ci 060 012 further youth of immigrant descent reported significantly more types of experienced ethnic discrimination at school t 268 p 0009 d 053 95 ci 020 132 both significant differences embody medium to largesized effects for parental and peer support and our other adjustment outcomes no significant differences between refugee youth and youth of immigrant descent were revealed in the next step we tested for possible group differences in multigroup models that split our sample into the subgroups of refugee youth and youth of immigrant descent to ensure sufficient statistical power we ran four separate multigroup models for selfesteem optimism the two selfefficacy measures and for school integration as independent variables respectively the results of our multigroup models while controlling for age gender school form and ethnic identity are presented in table 4 concerning the effect of ped at school on ethnicminority youth psychological wellbeing and school integration results indicated a significant positive effect of ped on refugee youth selfefficacy and selfesteem while for youth of immigrant descent no significant effects were found taking a closer look at our socialsupport measures several differences between refugee and youth of immigrant descent were revealed while for refugee youth no significant effects on optimism were found for youth of immigrant descent a significant positive effect of parental support on optimism was revealed concerning our measures of selfefficacy the results indicated significant effects for both refugee youth and youth of immigrant descent for refugee youth we found significant positive effects of parental and peer support on selfefficacy for youth of immigrant descent we also found a significant positive effect of parental support on selfefficacy as well as a positive effect of peer support on selfefficacy furthermore our results presented significant positive effects of peer support on refugee youth and youth of immigrant descents selfesteem lastly we found positive effects of peer support on refugee youth and youth of immigrant descents school integration additionally parental support was positively related to school integration for refugee youth only taking a closer look at the relations between ped social support and our positive adjustment measures model results for refugee youth regarding optimism indicated both a significant twoway interaction effect between ped and peer support and between ped and parental support figure 3 shows that refugee youth were less optimistic when they perceived ethnic discrimination but only when they received low peer support taking a closer look at the effect of ped on refugee youth optimism under low and high parental support no significant effects were revealed for youth of immigrant descent significant twoway interaction effects between ped and parental support regarding optimism and selfesteem were revealed figure 5 shows the results of the simple slope analysis for youth of immigrant descents optimism youth of immigrant descent were more optimistic when they perceived ethnic discrimination but only when there was high parental support as indicated in figure 6 youth of immigrant descents selfesteem was negatively affected by ped when the amount of parental support was low discussion the research literature showing that greater ped is related to poorer adjustment for ethnicminority youth 16244077 is growing however much less is known about potential protective factors that can buffer the detrimental effects of ped on ethnicminority youth positive adjustment the present study adds to the literature by simultaneously examining parental and peer support as buffering protective factors concerning the potential negative relation between ped at school and adjustment in addition we explored possible differences between refugee youth and secondand thirdgeneration youth of immigrant descent regarding the risk and protective roles of ped and social support for their adjustment discussion the research literature showing that greater ped is related to poorer adjustment for ethnicminority youth 16244077 is growing however much less is known about potential protective factors that can buffer the detrimental effects of ped on ethnicminority youth positive adjustment the present study adds to the literature by simultaneously examining parental and peer support as buffering protective factors concerning the potential negative relation between ped at school and adjustment in addition we explored possible differences between refugee youth and secondand thirdgeneration youth of immigrant descent regarding the risk and protective roles of ped and social support for their adjustment contrary to some previous research and our established hypotheses we did not find that ethnicminority youth show lower levels of adjustment in the form of lower selfesteem selfefficacy optimism or schoolintegration when experiencing higher numbers of different instances of ped at school a possible explanation for this nonfinding could be minority youth ethnic identification next to social support ethnic identification is known to be another significant protective factor in the face of ped 776 referring to the rejectionidentification model by branscombe and colleagues 78 it may be that most of the minority youth highly identified with their ethnic group after they have experienced discrimination against their ethnic group which protected them from the negative effects of ped future research is needed to examine our models while also including ethnic identification as another protective factor although we did not find significant changes in our model results when leaving ethnic identification out as a control variable future research should further examine ethnic identification as another protective factor moreover contrary to our expectation we found in our additional analyses that refugee youth who experienced more instances of ethnic discrimination also reported higher selfesteem and more selfefficacy in achieving their goals a possible explanation could be psychological reactance 79 as stated in brehms reactance theory 80 psychological reactance describes a motivational state caused by a perceived threat to an individuals freedom while wareham and colleagues 79 have found experiences of discriminatory events to cause individuals to experience a reactive state in our study refugee youth higher selfesteem and selfefficacy could be effects of their psychological reactance caused by high ped the fact that we only observed a possible reactive effect amongst refugee youth may also be an indicator of higher levels of resilience compared to youth of immigrant descent this may be a result of their flight experience and many challenges they had to face and overcome additional research is needed to examine in more detail the psychological mechanisms underlying the found associations furthermore our study results suggest that both parental and peer support are beneficial for ethnicminority youth positive adjustment as expected and found in previous research 6165 minority youth who experienced more parental or peer support also reported higher selfesteem as well as greater selfefficacy optimism and school integration moreover similar overall patterns were found across refugee youth and youth of immigrant descent interestingly parental support was positively associated with school integration only for refugee youth and positively associated with optimism only for youth of immigrant descent this shows that parental support can affect refugee youth and youth of immigrant descent in different ways thus highlighting the importance of distinguishing between the two groups future research should study the mechanisms that underlie and can explain these different associations across the two groups with regard to parental and peer support as protective factors in the face of ped we found that ethnicminority youth who experienced low peer support were less optimistic when experiencing ped in contrast optimism was unrelated to experiences of ped when peer support was high here our results examining associations across refugee youth and youth of immigrant descent suggest that this buffering effect of peer support is mainly driven by refugee youth for youth of immigrant descent we found that high parental support protected against negative effects of ped on selfesteem while it may even have contributed to an overcompensation for optimism which was not affected by ped in the first place we propose that parental racial socialization may explain the sustained selfesteem and optimism of youth of immigrant descent when experiencing ped racial socialization by parents includes teaching their children about race and ethnicity enhancing their sense of ethnic identity and preparing them for experiences of ethnic discrimination 81 previous research has shown that parental racial socialization can be associated with positive outcomes for instance in black youth experiencing racial stress 82 as many parents of youth of immigrant descent have already spent much time in germany and have gone through processes of acculturation and possibly also experiences of ethnic discrimination themselves they may be better equipped to racially socialize and empower their children than parents of newly immigrated refugee youth this in turn may explain why youth of immigrant descent in our study were able to sustain their selfesteem and optimism in the face of ped when parental support was high it would be interesting for further studies to examine parental support in the form of racial socialization in relation to ped and youth adjustment additionally it may be interesting to explore if the socioeconomic conditions of the parents could explain the sustained selfesteem and optimism of youth of immigrant descent considering that parents of youth of immigrant descent have a higher socioeconomic status than parents of refugee youth they possibly have more resources to support their children future studies should therefore collect more data about the ses conditions of parents including parental education and income another interesting avenue for future researchespecially in view of the rising numbers of refugees in germany and also the rising numbers of racial attacks and racismwould be to examine how parents of refugee youth in germany can be empowered to provide the kind of support that their children need in the face of ped taking into account that parents of refugee youth similar to their children are going through the process of acculturation and must cope with salient stressors arising from the acculturation process refugee youth possibly seek more support from their peers to not put additional burden on their parents for that reason receiving support from external sourcessuch as from the schoolin the process of acculturation is important for parents and needs to be further enhanced while parents would be relieved refugee youth would dare again to ask their parents for support and share their experiences of discrimination with them limitations and future research the present study should be considered in the light of some limitations and qualifications first we used crosssectional data and therefore could not provide evidence for causality we analyzed ped and parental and peer support as predictors of ethnicminority youth positive adjustment but there could be reciprocal influences however there are a handful of longitudinal studies suggesting ped to have deleterious effects on youth adjustment 4283 future studies should use longitudinal designs to replicate our findings additionally future longitudinal studies are needed to test directional longitudinal moderation enabling to understand to what extent family and peer processes offer protection against ethnic discrimination over time as a second limitation we acknowledge that the present study used measures for ped that only captured the number of different instances of ped but not their frequency and intensity in a given period of time it could be the case that ethnicminority youth experienced the same instance of ped at school multiple times and in different intensities at the same time youth may have responded to the items with different timeframes in mind with some only thinking about their recent experiences and others thinking about all experiences they ever made this may make responses on this scale less comparable across individuals and may be another reason for less associations of ped with other variables compared to studies using measures that are more standardized in terms of the timeframe they address so these flaws of the measure of ped may have contributed to an underestimation of ped effects in the given study future studies should use measurement instruments for ped which also enable to make statements about the amount and intensity of ped and not only about the experienced number of instances of ped and which state a specific time frame such as experiences in the last month or year furthermore our socialsupport measures were not specifically matched to the needs that might be elicited by ped future studies should therefore go beyond questions that ask about general peer or parental support to assess specific support needs when dealing with ped specific support needs may for instance be linked to parental racial socialization practices 82 and the roles of coethnic and otherethnic peers 84 as juang et al 13 recommended one way forward could be for instance to study how parents and peers react when they are told about discrimination experiences implications the results of our study suggest several practical implications as both parental and peer support were associated with ethnicminority youth positive adjustment and especially peer support was found to be a significant protective factor for refugee youth in germany implementing programs at schools to promote peer and parental support is of high importance taking into account that positive intergroup contact has been found to reduce prejudices against outgroup members 8586 and considering the positive effects of interethnic friendships for minority youth adjustment 87 supporting the interaction and experiences with peers of other racial groups represents a favorable recommendation for action in this context therefore the early creation of opportunities for positive contact experiences especially between refugee youth and nonrefugee youth is of central relevance by giving the opportunity to break down prejudices and promoting the development of peer networks joint sports activities and programs where ethnicminority youth and youth from the majority society form a tandem have high potential to enhance ethnicminority youth positive adjustment 88 having the aim to support schools in helping ethnicminority youth to develop a positive ethnic identity and promoting their social integration by forming such tandems programs as the one developed by zander and colleagues 89 in germany present suitable interventions for schools in tandems youth learn more about their own and others values and emotions and reflect on friendship and the changeability of established normed it becomes clear that joint activities are paramount and need to be promoted by schools within and outside the classroom referring to the significant role of parental support for ethnicminority youth positive adjustment a good cooperation between schools teacher and parents is essential previous research has shown that such successful cooperation can have positive effects on youth development academic outcomes and future opportunities 90 in this context it needs to be considered that for parents of refugee youth who are generally very interested in their childrens school career and positive development insufficient language skills constitute a major barrier 91 consequently schools in germany would do well in providing interpreters and cultural brokers enabling parents to take part in parent nights and consultations and receiving and understanding the information they need to better support their children furthermore the establishment of meeting places where parents can have a mutual exchange would make it possible for parents to create new contacts to exchange about how to support their children best and at the same time also manage their own acculturation process 88 referring to the finding that refugee youth often are able to integrate more quickly than their parents and thus become cultural brokers for their parents 92 the provision of support for parents regarding their own acculturation process would be beneficial for refugee youth while their parents would be relieved refugee youth would no longer have the feeling to burden their parents and would dare to open up and seek parental support regarding their discrimination experiences thus they could experience parental support as an important buffer for their discrimination experiences it becomes clear that the strengthening of cooperation between schools and social community agencies is of central importance conclusions ethnicminority youth spend a considerable part of their waking hours at school while interacting with peers and teachers the relations between ped parental and peer support and positive adjustment as well as research on possible similarities and differences amongst refugee youth and youth of immigrant descent regarding these associations have received little attention so far the results of our study show that ped may hurt less for some youth depending on their level of support by parents and peers further our study provides information on the differences between refugee youth and youth of immigrant descent regarding their experiences of ped and needs for support in the german context future research should examine the mechanisms that underlie and can explain these different experiences and associations across the two groups moreover schools and teachers in germany would do well to implement programs that strengthen peer networks and the ability of parents to support their children while also addressing the issue of ethnic discrimination at school data availability statement not applicable int j environ res public health 2021 18 12016 informed consent statement informed consent was obtained from all subjects involved in the study

applying a risk and protection perspective this study paid special attention to the protective roles of parental and peer support in the face of perceived ethnic discrimination ped at school responding to the inconsistent findings of previous research the survey study provides greater clarity regarding the interactions between ped at school social support and positive adjustment selfesteem selfefficacy optimism and school integration the sample comprised 104 ethnicminority youth m age 1773 sd 329 61 female including refugee youth n 55 and secondand thirdgeneration youth of immigrant descent n 49 structural equation models across the whole sample confirmed peer support as a significant moderator indicating that ethnicminority youth who received low peer support were less optimistic when facing ped in multigroup models we tested whether results differ across refugee youth and youth of immigrant descent results revealed betweengroup differences concerning the moderating roles of parental and peer support for youth of immigrant descent while more ped was associated with lower selfesteem when receiving low parental support we found a positive association between ped and optimism when receiving high parental support based on the findings that refugee youth were shown to be less optimistic when obtaining low peer support the main interaction effect for peer support on optimism seemed to be driven by refugee youth the results of our crosssectional study highlight the importance of identifying specific social support factors for specific adjustment outcomes and also the importance of differentiating between minority groups further the findings offer practical implications for the educational sector in terms of programs focusing on the development of peersupport networks to especially promote refugee youth resilience and resettlement in germany

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s ince its rise to popularity in the 1960s and 1970s during the second wave of the womens movement topics surrounding various issues of family violence have permeated both scholarly publications and academic discourse in general despite the relative continuity of violence topics the focus of these studies especially with regard to intimate partner violence has changed drastically over the years for example the literature regarding battered woman syndrome was quickly rebutted with concerned discussions of an equally alarming and a possibly more silent epidemic of the battered husband phenomenon p 503 more recently partner violence researchers have been charged with the task of moving in a new direction to make distinctions among types of partner violence to understand the nuances of partner violence research scholars have broadened the focus of their studies to include various types of violence considering both males and females as victims and perpetrators of ipv one of the more recent trends in the family violence literature focuses around examining the prevalence and predictors of bidirectional violence 1 which generally refers to situations in which a respondent reports being both a victim and perpetrator of violence in the context of an intimate relationship because few studies have employed measures of bidirectional ipv little is known about the predictors that are specific to this form of violent behavior and how they compare to individuals involved in unidirectionally violent relationships and nonviolent couples consequently the purpose of this article is to examine whether childhood adolescent and demographic predictors differ across three partner violence groups those who experience bidirectional partner violence those who experience unidirectional violence and those who do not experience either form of violence identifying the risk factors associated with both bidirectional and unidirectional violence will not only provide guidance for future research endeavors but may also assist clinicians with designing appropriate treatment and intervention strategies literature review child maltreatment because the family is often considered societys most violent institution it is important to look at the different forms of family violence simultaneously one of the most consistent predictors of partner violence is a history of child abuse physical abuse sexual abuse and neglect have been found to predict partner violence perpetration and victimization as such individuals who experience maltreatment within the family of origin may be vulnerable to revictimization at the hands of an intimate partner depressive symptomology although previous research has found that those in violent intimate relationships are more likely to have depressive symptoms in the aftermath of their ipv experiences other studies have explored whether depressive symptoms occur prior to the violent interactions for example lipsky caetano field and bazargan found that depressive symptoms predicted both ipv perpetration and victimization in contrast caetano and colleagues found that rates of depression did not significantly differ among their perpetrator only victim only and mutual violence couples because of these contradictory findings it is important to consider whether depressive symptomology is a precursor to different types of ipv experiences substance use substance use has also been linked to ipv in both general population and clinical samples although some researchers find no differences between mutually violent and perpetrator or victimonly couples in terms of alcohol use others report that drinking is a risk factor for bidirectional violence males and females who reported binge drinking in the past month were at an increased risk for mutual ipv among a national sample of cohabiting and married adults elbassel wu go and hill found that although frequent crack and marijuana use increased the likelihood of subsequent physical and sexual ipv the findings were inconclusive for cocaine heroin and frequent binge drinking in other words these findings indicate that the relationship between frequent drug use and bidirectional ipv may vary by type of drug relationship status relationship status has an impact on being involved in a violent relationship with cohabiters having the highest rates of violence followed by married and dating couples brown and bulanda examined the association between relationship status and ipv perpetration and victimization and found that cohabiting women were the most likely to perpetrate or be the victims of ipv followed by married and dating women respectively for men those in dating relationships were least likely to perpetrate or be victimized by ipv cohabiting and married men did not significantly differ in their rates of perpetration or victimization as such accounting for relationship status may be an important factor for bidirectional violence demographic characteristics there have been mixed findings with regard to whether males or females are more likely to be perpetrators andor victims of partner violence several researchers have found that females are victimized more often by an intimate partner than their male counterparts according to rennison and welchans women are victimized by intimates at approximately five times the rate of men others however report that women victimize men more often for example in their nationally representative sample of adolescents whitaker haileyesus swahn and saltzman found that women reported more partner violence perpetration and victimization than men alternatively some researchers find that men and women use approximately equal levels of violence toward one another and report similar levels of victimization cunradi for example found that approximately the same proportion of men and women reported experiencing mutual ipv other demographic factors that have been linked to ipv perpetration and victimization include age racial and ethnic background and sociodemographic status in general younger individuals are at higher risk for both perpetrating and becoming victims of ipv with females aged 20 to 24 having the highest risk of nonfatal ipv in terms of race and ethnicity field and caetano found that african american and hispanic couples reported higher frequencies of mutual physical partner violence than their white counterparts similarly weston temple and marshall found that african american women in mutually violent relationships experienced significantly more sexual and physical violence than their euroamerican and mexican american counterparts finally those with lower socioeconomic attainment as measured by the educational level of the respondents their parents or their partners are at increased risk for partner violence johnson created a typology of violent couples that has been used by other social science researchers to provide context to contradictory findings in the dating violence literature in a series of articles beginning in the 1990s johnson has revised and expanded his typology of violence which is based on the degrees of control and violence that are present in the relationship to include the following categories intimate terrorism mutual violent control violent resistance and situational couple violence previously referred to as patriarchal terrorism intimate terrorism refers to a form of terroristic control whereby one partner systematically uses violence as well as a broad range of other power and control tactics in this way intimate terrorism can be understood as a general attempt to control an intimate partner by any means necessary and is more likely to escalate over time compared to other forms of violence although little is known about this rare form of violence mutual violent control occurs when both partners are violent and controlling toward each other violent resistance on the other hand occurs when one partner is violent and controlling and the other partner responds with violence in a manner akin to selfdefense finally situational couple violence which was previously referred to as common couple violence occurs when either one or both partners are violent but is not typically connected to a general pattern of control this form of aggression usually occurs in the context of a particular situation in which conflict occasionally gets out of hand and rarely escalates to severe lifethreatening violence although some researchers have not found support for using these categories of relationship violence this typology postulates that there are important differences between unidirectional and bidirectional violence as such it is important to learn more about these distinct forms of aggression to inform prevention and intervention efforts theoretical perspective johnsons ipv typology the current study despite the relatively large body of literature on ipv there have been few studies that have simultaneously addressed the relationship between child maltreatment experiences internalizing behaviors and personal characteristics and bidirectional violence furthermore researchers have not determined whether the predictors of ipv vary across different partner violence groups as such it is largely unknown whether factors that are usually linked to unidirectional violence are also associated with bidirectional ipv existing studies also generally utilize crosssectional data which makes it difficult to establish temporal order the current study addresses each of these shortcomings by examining the following research question using a nationally representative longitudinal sample do childhood adolescent and demographic factors vary between bidirectional unidirectional and nonviolent relationships in young adulthood method data the analyses are based on waves i and iii of the national longitudinal study of adolescent health the data are from the restricted access core sample of over 15000 individuals who were first interviewed in grades 7 through 12 and then completed a wave iii inhome interview in young adulthood the analytic sample was restricted to the 6563 wave iii respondents who reported having one current romantic partner and had valid data on the variables of interest all of the independent variables were measured at wave i with the exception of the child maltreatment items which were asked retrospectively during the wave iii interview measures dependent variable intimate partner violence was a nominal variable with four categories bidirectional violence perpetration only victimization only and no violence based on two questions from both a victim and perpetrator perspective during wave iii the perpetration questions asked the respondent how often in the past year they threatened their partner with violence pushed shoved or threw something at their partner that could hurt and slapped hit or kicked their partner these items were combined and dichotomized such that 0 no perpetration in the past year and 1 at least one incident of perpetration in the past year for victimization respondents were asked two questions about the same behaviors that were in the perpetration items with the exception that the introduction to the questions asked how often their partner did the following things to them respondents who reported both physical perpetration and victimization in the past year were classified as bidirectional those who reported only perpetration were categorized as perpetration only whereas respondents who reported only victimization were categorized as victimization only the nonviolent group consisted of people who did not report any violence in the past year independent variables the childhood abuse measures are modified versions of questions administered in previous surveys such as the revised conflict tactics scale childhood physical abuse was a continuous variable based on the question by the time you started 6th grade how often had your parents or other adult caregivers slapped hit or kicked you responses ranged from 0 never to 5 more than 10 times this variable was transformed using a square root to reduce positive skew childhood sexual abuse was measured by the question by the time you started 6th grade how often had one of your parents or other adult caregivers touched you in a sexual way forced you to touch him or her in a sexual way or forced you to have sexual relations a dichotomous variable was created where 0 no sexual abuse and 1 at least one childhood sexual abuse experience childhood neglect was measured by asking two questions by the time you started 6th grade how often had your parents or other adult caregivers not taken care of your basic needs such as keeping you clean or providing food or clothing and left you home alone when an adult should have been with you responses for each question ranged from 0 never to 5 more than 10 times these items ranging from 0 to 10 were summed into a scaleand then transformed using a square root to adjust for positive skew depressive symptoms consisted of 15 items from the center for epidemiological studies depression scale the cesd requires respondents to reflect upon their experiences during the week prior to the interview and includes items such as i felt that i could not shake off the blues even with help from my family and my friends and i was bothered by things that dont usually bother me responses ranged from 0 to 3 positive items were reverse coded so that higher scores indicated more depressive symptomology the scale ranged from 0 to 42 and was logged to account for positive skew three substance use items were included in the analyses alcohol use was a single item that asked during the past 12 months on how many days did you drink alcohol response categories included 0 none 1 1 or 2 days 2 once a month or less 3 2 or 3 days a month 4 1 or 2 days a week 5 3 to 5 days a week and 6 every day or almost every day marijuana use was measured by asking respondents during the past 30 days how many times did you use marijuana this variable was logged to account for the high positive skew illicit drug use was a single item that asked respondents how often they used the following drugs in the past 30 days cocaine inhalants any other type of illegal drug such as lsd pcp ecstasy mushrooms speed ice heroin or pills without a doctors prescription or an illegal drug using a needle this item was dichotomized into 0 did not use in past 30 days and 1 used at least one form of an illicit drug at least once in the past 30 days relationship status was measured by three dichotomous variables indicating whether the partners are currently married cohabitating or dating demographic characteristics female is a dichotomousvariable where 0 male and 1 female respondent age measures the respondents current age with a range from 18 to 27 years respondent race was measured by five dichotomous variables representing white black hispanic asian and native americanother respondent education included four categories that capture the highest level of education completed partner education measured the respondents partners highest level of education as reported by the respondent parent education was a measure of the educational attainment of the respondents most educated parent all of the education variables included the following categories less than high school degree high school degree some college and 4year college degree or more reports were taken from the parent survey unless there were missing data and then the respondents report of their parents education was used results univariate fiftyseven percent of the sample was female and the average respondent age was 22 years the majority of the sample was white followed by 13 black 7 hispanic 4 native americanother and 3 asian in terms of educational attainment 14 of the sample had less than a high school education 32 had a high school degree 38 completed some college and 15 had a 4year college degree or above almost half of the respondents were dating 26 were cohabiting and 25 were married overall 26 of the sample experienced physical child abuse 4 were sexually abused and 38 indicated that they had been neglected on at least one occasion twentyfive percent of respondents experienced ipv with 13 reporting bidirectional violence 7 reporting perpetration only and 5 reporting victimization only multivariate multinomial logistic regression was performed using sas to predict the probability of being in relationships with different ipv experiences mlr which is an extension of standard logistic regression analysis includes more than two categories in the dependent variable one group is selected as the reference group and each of the remaining groups is compared to the reference group in separate logistic regression models that are estimated simultaneously in table 1 nonviolence is compared to bidirectional violence in columns 1 and 2 perpetration only in columns 3 and 4 and victimization only in columns 5 and 6 bidirectional violence is compared to perpetration only in columns 7 and 8 and victimization only in columns 9 and 10 childhood physical abuse is a risk factor for bidirectional violence and perpetration only when compared to no violence exp 136 and exp 123 respectively individuals with childhood sexual abuse histories were also at increased risk for bidirectional compared to no violence exp 171 and neglect is a risk factor for victimization only compared to no violence exp 116 there were differences for mental health and substance use people with higher depressive symptoms were almost twice as likely to be in a bidirectionally violent relationship compared to a nonviolent relationship exp 197 although frequency of alcohol consumption was not associated with a greater risk for violence of any type compared to no violence for people who were in a violent relationship alcohol use was associated with bidirectional violence rather than perpetration only exp 119 additionally people who have used illicit drugs in the past month were more than twice as likely to be perpetrators only compared to those in nonviolent relationships exp 240 in terms of relationship status people who are dating compared to cohabitating were less likely to experience any type of violence including bidirectional perpetrator only or victim only exp 43 exp 48 and exp 52 respectively gender was the most consistent predictor across all models for example females are less likely to experience bidirectional violence compared to perpetration only and more likely to experience bidirectional violence than victimization only exp 22 and exp 367 respectively although age is a protective factor against both bidirectional violence exp 88 and perpetration only exp 92 compared to no violence it may be a risk factor for victimization when older individuals are in a violent relationship they are less likely to experience bidirectional violence compared to victimization only exp 89 with regard to race blacks are consistently more likely to be in a violent relationship of any type compared to a nonviolent relationship for example blacks were almost two and a half times more likely to be in a bidirectionally violent relationship compared to a nonviolent relationship exp 246 asians and people who were classified as native americanother were more likely than whites to report being in a bidirectionally violent relationship compared to a nonviolent relationship exp 148 and exp 209 respectively in terms of education respondents with some college experience were more likely to report victimization compared to no violence exp 166 and were less likely to report bidirectional violence compared to victimization only exp 62 alternatively respondents with 4 or more years of college were less likely to report victimization only compared to no violence exp 35 but more likely to report bidirectional violence compared to victimization only exp 307 partners education was also associated with different forms of ipv for instance those who had partners with less than a high school degree were more than twice as likely to experience bidirectional violence compared to no violence exp 230 and perpetration only exp 205 than those with a high school diploma compared to their high school counterparts having a partner with 4 or more years of college was a protective factor against both bidirectional exp 29 and perpetration only exp 44 when compared to no violence when those with 4 or more years of college education were in a violent relationship they were less likely to be involved in bidirectional violence compared to victimization only exp 31 discussion the current study set out to empirically test whether the childhood and adolescent risk factors and demographic characteristics that are commonly associated with partner violence such as depressive symptoms and gender vary between bidirectional unidirectional and nonviolent relationships overall 13 of the young adults in this study reported bidirectional violence and 12 experienced unidirectional aggression with 7 reporting perpetration only and 5 reporting victimization only within a current relationship all of which place them at greater risk of continued partner violence throughout their adulthood the multinomial logistic regression results also reveal that important differences exist between the different relationship violence categories in terms of child abuse histories depressive symptomology substance use relationship status and demographic characteristics consistent with previous research those who have experienced childhood physical abuse are at higher risk for bidirectional violence and perpetration only and victims of childhood sexual abuse are at higher risk for bidirectional violence when compared to nonviolent relationships additionally those who have experienced childhood neglect are at an increased risk for victimization only compared to nonviolence it is possible that young adults who experienced childhood maltreatment learn that this type of behavior is an acceptable and appropriate way to interact with people they love and thus are more likely to be violent within their own intimate relationships andor be more accepting when it occurs the current study also reveals that depressive symptoms are another risk factor for ipv which is consistent with the work of others that is those with higher levels of depressive symptoms are more likely to be in bidirectionally violent relationships compared to their nonviolent counterparts this finding is consistent with previous research that has found that individuals who have a history of depression are more likely to have intimate relationships characterized by high levels of discord which may contribute to an increase in violent altercations finally although individuals who drink more alcohol are at higher risk for being in bidirectionally violent compared to perpetrationonly relationships illicit drug users are more likely to engage in perpetration only than no violence this relationship may perhaps be attributed to the view of substance use as a social disinhibitor or a rationalization for violence but because we do not know whether these controlled substances were used during the violent incidents these findings should be interpreted with caution relationship status and demographic factors are also associated with the different forms of violence compared to those in cohabiting relationships dating couples are less likely to experience bidirectional perpetration only and victimization only compared to no violence as such cohabiters are at higher risk for partner violence when compared to individuals in dating relationships which is consistent with previous research cohabiting couples may be at higher risk for ipv due to more isolation from social network members and lower relationship investment andor commitment gender is also associated with the different partner violence categories females are more likely to be perpetrators only and less likely to be victims only when compared to nonviolent relationships when in violent relationships females are less likely to be in bidirectionally violent compared to perpetrationonly relationships and more likely to be in bidirectionally violent compared to victimizationonly relationships these results are consistent with previous research that finds that women are more likely to be the perpetrators of ipv than men furthermore these findings could be attributed to the contention that women may be more willing to admit to using violence compared to males as men may be afraid of the negative stigma associated with victimizing a woman finally age is a protective factor against relationship violence as the odds of bidirectional violence and perpetration only compared to no violence are reduced with age which is perhaps because individuals acquire more effective conflict resolution skills as they mature different types of ipv are also associated with certain racialethnic and educational groups consistent with previous research there are some differences in the type of partner violence experienced among racial and ethnic groups when compared to white individuals those who are black asian or native americanother are more likely to be in bidirectionally violent compared to nonviolent relationships additionally black individuals are more likely than whites to report being perpetrators or victims only compared to nonviolent relationships these differences may reflect varied experiences of ipv andor the propensity for respondents from these divergent racial and ethnic groups to perceive and report their partners and own behavior as abusive it is difficult however to make any substantive interpretations of these findings regarding race given the racial and ethnic heterogeneity of the people within the asian category for example although parent education is not associated with ipv respondent education was differentially associated with partner violence for example when in a violent relationship respondents with some college experience were less likely to report bidirectional violence whereas those with 4 or more years of college were more likely to report bidirectional violence when compared to those reporting victimization only partner education is also linked to aggression having a partner with less than a high school education is associated with bidirectional violence compared to nonviolence and perpetration only whereas being in a relationship with a partner with 4 or more years of college was a protective factor from both bidirectional violence and perpetration only compared to no violence individuals with lower educational attainment are more likely to perpetrate ipv and if one or both partners have lower educational levels this will perhaps increase the likelihood of relationship violence overall the current findings provide some support for johnsons contention that there are different types of violence experienced among intimate couples according to this typology of ipv the types of violence that are experienced within relationships vary depending upon the degree of violence and control that are present in the relationship although the present study could not include direct measures of control or broader measures of violence there is evidence that some of the predictors of bidirectional violence diverge from those associated with unidirectional aggression as such this provides support for the notion that these types of violence are distinct and should be treated separately understanding more about the unique predictors of these different types of relationship violence could provide guidance for clinicians designing intervention efforts there are some limitations to the present study first the data are based on selfreports of both partner violence perpetration and victimization which may be biased without knowing the partners report a second limitation is that the reports of child maltreatment are retrospective and based upon the recall of adult respondents these reports could be unreliable due to memory loss or an unwillingness to report sensitive experiences third add health only includes two questions on ipv that combine physical and psychological aggression which does not distinguish between these types of violence or capture the range of abusive incidents that may be experienced such as stalking furthermore respondents were only asked to reflect on ipv that occurred within the past year as such the results may be underestimating the actual prevalence of ipv occurring within these intimate relationships finally the sample consists solely of young adults thus the findings cannot be generalized to individuals outside this age group notwithstanding these limitations there are several strengths of this study first a longitudinal survey design was used that incorporates data from both males and females second although causality cannot be inferred from the findings using a large nationally representative sample allows for both generalizability of results and confidence in the significant differences found third this study makes an important contribution to the body of literature on partner violence by specifically focusing on bidirectional violence and comparing it to both unidirectional and no violence instead of merely combining the violence groups into a single ipv measure or just comparing bidirectional to nonviolence partner violence affects millions of people each year and understanding some of the early life risk factors is important for interventions that could prevent bidirectional violence in adulthood based on findings from this study services related to the treatment of child physical abuse and adolescent controlled substance use and depression are especially needed for the prevention of bidirectional violence in young adulthood future research should explore other potential predictors of bidirectional violence such as the amount of time a respondent reports being in a marital cohabiting or dating relationship and the role of gender among a variety of violent relationships using couplelevel data note 1 many contemporary studies refer to what is defined as bidirectional violence in the literature review with a variety of phrases including mutual violence for the purposes of the current study the authors retained the terminology used by the researchers cited

in order to understand more fully the context and impact of intimate partner violence ipv it is important to make distinctions between different types of relationship aggression as such the current study longitudinally examines the differential effects of childhood adolescent and demographic factors on three different partner violence groups those who experience bidirectional ipv those who experience unidirectional ipv and those who do not experience either form of ipv multinomial logistic regression results reveal that depressive symptoms and lower partner education predict bidirectional when compared to unidirectional ipv and nonviolence in contrast other risk factors such as illicit drug use are found to be predictors of unidirectional violence only which reveals that the correlates of violence vary depending upon the type of ipv examined

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introduction in the era of growing globalization the demand for training in multicultural awareness is anticipated to increase chappell and utomo et al maintained that studies regarding multicultural counseling competence reflect the effectiveness of multicultural training in preparing counselors to meet the challenges of diverse societies in the 21st century multicultural training helps prepare counselors with multicultural counseling competence to lower racial and ethnic inequalities in mental health services practice counseling ethically facilitate counselor trainees to deal with legal and ethical issues in counseling confidently and reduce the risk of adverse effects from culturally inappropriate conceptualization of client issues despite its importance in multicultural training multicultural counseling competence research suffers from criticism regarding its lack of focus see and ng claimed that training in multicultural counseling competence is lacking in most counseling training programs moreover aga mohd jaladin et al asserted that the multicultural focus is limited which leads to a lack of infusion of multicultural components into the overall teaching and learning processes which results in a lack of exposure to and experience with diverse cultures thus this could hinder the contribution of multicultural training to the development of multicultural counseling competence in addition hays maintained that most research on perceived changes in multicultural andor social justice counseling competency focused on how trainees curricular experiencesparticularly their involvement in multicultural counseling courses or other discrete learning experienceshave affected those perceptions therefore the call to explore the counselor trainees experiences during multicultural training is pertinent multicultural experience is conceptualized by vora et al as the degree to which someone has knowledge of identification with and internalization of more than one societal culture recently maddux et al defined multicultural experiences as exposure to or interactions with elements andor members of a different culture based on their newly developed model multicultural experiences will impact intrapersonal interpersonal and organizational outcomes such as creativity psychological adjustment and individualfirm performance in this paper two types of multicultural experiences are studied personal and academic multicultural experiences the personal multicultural experience refers to counselor trainees multicultural encounters during their formative years that come with lived experience in their community meanwhile the academic multicultural experience is the multicultural exposure and interaction counselor trainees experience during multicultural counseling courses the multicultural counseling course attended by counselor trainees is expected to allow them to enrich their multicultural experience as they come from different backgrounds and have various personal multicultural experiences while most multicultural counseling courses focus on the three components of multicultural counseling competence counselor trainees should be provided with more multicultural exposure and interactions during classes to develop skills to work with diverse clients literature review experience as a variable in multicultural counseling research has a specific connotation based on its name for example there are cultural immersion experiences multicultural training experiences and multicultural experiences compared to other forms of experience studies about multicultural experiences are limited in multicultural counseling research this experience has only been found in chaichanasakuls work meanwhile guzman et al barden et al johnson and williams harris et al andkuo et al studied different forms of experiences as they are related to multicultural counseling competence however their studies will still be included in this paper to support the hypothesis regarding the relationship between multicultural experiences and multicultural counseling competence chaichanasakul hypothesized that multicultural experiences cognitive flexibility cultural flexibility and personality would predict multicultural counseling competence the researcher used the california brief multicultural competence scale to assess the counselor trainees multicultural counseling competence structural equation modelling was done to examine his proposed model the findings showed that multicultural experiences did predict multicultural counseling competence with cognitive and cultural flexibility as mediators in his study chaichanasakul also found a relationship between the number of years in a training program and multicultural counseling competence this finding implied that more extended training and greater multicultural experiences did relate to the development of multicultural counseling competence guzman et al observed that school counselors with fewer teaching and counseling experiences scored higher levels in demonstrated multicultural counseling competence but not in selfreported multicultural counseling competence their findings suggested that ongoing practice in a persons formative years which comes with lived experience in a society that values diversity and works towards racial equality influences demonstrated multicultural counseling competence therefore this underscores the importance of measuring multicultural experience in understanding the development of multicultural counseling competence to examine differences in multicultural selfefficacy and multicultural counseling competence between counselor trainees based on involvement in an international immersion experience barden et al undertook an empirical quasiexperimental study the trainee counselors were enrolled in a university in southeast americas fulltime counselor training curriculum which cacrep approved they were split into two groups for the experiment and two for comparison participants in cultural immersion programs had the opportunity to interact directly with individuals from various backgrounds and engage in crosscultural learning the participants abilities selfefficacy and capacity to think critically and conceptualize the cultural contexts of others all improved because of this exposure and engagement according to barden et als findings the outcomes had no significant differences between groups the fact that participants had little to no opportunity for actual counseling practice due to cultural immersion may account for the lack of a discernible difference in this regard according to barden et al this result may also highlight the possible obstacles to evaluating competence and the potential difficulties associated with growing competence over relatively short periods johnson and williams in terms of specific forms of experience this study suggested that multicultural training experience was a significant predictor of increased multicultural awareness knowledge and skills on the other hand the number of months of practicum experience received was a significant predictor of multicultural skills and knowledge but not awareness in a study by harris et al the multicultural counseling knowledge and awareness scale was used to assess the impact of an abroad experience on students multicultural competence in two study abroad courses throughout four distinct yearly excursions the inaugural study abroad plan included two courses taught over five weeks in germany and cultural immersion the second fiveweek study abroad programs main topics were nongovernmental organizations indian development and multiculturalism the results of the effect size analysis showed that exposing students to various immersive multicultural perspectives norms rituals and practices can be accomplished through both direct and indirect methods of enhancing multicultural competence all these studies suggested that continuous involvement in multicultural activities or attending multicultural counseling courses will be beneficial in improving counselor trainees multicultural counseling competence in addition these studies proposed that a more extended period may be needed to develop multicultural counseling competence as less counseling experience and months of practicum experience resulted in lower multicultural counseling competence for both practicing counselors and counselor trainees however certain forms of experience react differently to multicultural counseling competence depending on how multicultural counseling competence is measured for example those with less teaching and counseling experience scored higher in demonstrated multicultural counseling competence but not in selfreported multicultural counseling competence multicultural experience through interaction and tasks related to multicultural counseling roleplay and experience from a persons formative years may allow counselor trainees to nurture their multicultural knowledge awareness and skills this strengthens the need for multicultural experience to be further investigated as part of counselor trainees multicultural experience to understand better its role in developing multicultural counseling competence only guzman et al conducted a correlational study to measure selfreported and demonstrated multicultural counseling competence guzman et al hypothesized that selfreported multicultural counseling competence may predict school counselors demonstrated multicultural competence they also hypothesized that prior training in multicultural issues age race and professional experience in a school setting might be associated with selfreported and demonstrated multicultural counseling competence the selfreported multicultural counseling competence was measured using multicultural counseling competence training and skillsrevised in contrast multicultural counseling competence was measured using the multicultural critical incident vignette marlowecrowne social desirability scale was also used as a control for biased responses in the mcctsr a total of 227 questionnaires were completed and analyzed multiple linear regression results showed that selfreported multicultural counseling competence did not predict demonstrated multicultural counseling competence age race and professional experience in a school setting reacted differently toward selfreported multicultural counseling competence and demonstrated multicultural counseling competence age race and professional experience in a school setting were not found to be related to selfreported multicultural counseling competence in contrast age race and professional experience in school significantly predicted the demonstrated multicultural counseling competence thus this finding can be interpreted as for the counselors multicultural counseling competence to be visible more experience is needed in conclusion multicultural training should be the medium through which the counselor trainees can experience multicultural exposure and interaction especially in the malaysian context where counselors graduate with their first degree at a young age purpose of study counseling is a facetoface communication process where counselors face cultural challenges such as maintaining eye contact and verbal and nonverbal language connotations conventional theoretical paradigms might need to be adapted to reconsider counseling practice from a onetoone relationship between a counselor and client to a more inclusive community perspective in fulfilling clients needs otherwise the counselor fails to perform his or her duties ethically therefore counselors must have the knowledge sensitivity and skills to conduct counseling sessions efficiently with clients from various cultures multiculturalism in counseling has long been embedded across the curriculum and established as a subject known as multicultural training to develop counselor trainees multicultural counseling competence to ensure they work effectively with diverse clients studies measuring counselors multicultural counseling competence reported that the participants scored high however there is an open question of whether these findings reflect the current generation of counselors in line with the passage of time and technology the current generation of counselors is born from the generation known as digital natives who are believed to be more comfortable communicating through technology especially smartphones and social media networks it is expected that trainee counselors today have limited personal multicultural experience likely related to identifying academic multicultural experiences in multicultural training and developing their multicultural knowledge awareness and skills for instance a study by garcía et al reported that some therapists in online sessions mentioned how challenging it is to sustain moments of silence as in a psychotherapy session silence can be clinically beneficial mishandling this situation due to a lack of multicultural experience may backfire on the counselor trainees and harm the clients therefore this study sought to explore the relationship between multicultural experiences and multicultural counseling competencies among malaysian counselor trainees this study outlines two research objectives that are to identify the level of multicultural experiences and multicultural counseling competencies among malaysian counselor trainees and explore the relationship between multicultural experiences and multicultural counseling competencies among malaysian counselor trainees methodology population and sample size in this correlational study the population of interest is the local undergraduate counselor trainees completing their internship training the total number of people in the population was 265 counselor trainees for structural equation modelling there was no consensus on the best formula to determine the sample size iacobucci recommended a minimum of 50 participants meanwhile kline maintained that sem required a substantial sample size and as a rule of thumb most studies involved 200 cases on the other hand the statistical power analysis recommended 166 respondents at a statistical significance of 05 statistical power rejecting the null hypothesis of 95 and an effect size of 30 nevertheless this study cautiously took into consideration the assertions by yung and bentler byrne and koopman et al of a moderate sample size of 100 to 200 for bootstrapping thus the final sample size used in this study was 208 after considering the suggestion by mitchell and jolley for 25 more participants to ensure the returned questionnaires are sufficient for analysis instruments the questionnaire used in the present study is a combination of four measurements and a demographic sheet as described below  multicultural experience inventory the mei was used to measure participants degree of multicultural experience the items were then divided into type a and type b according to two types of scoring this study used type a items which comprised 17 items in this study the mei was translated adapted and validated to fit its use in the malaysian context the confirmatory factor analysis confirmed seven items in the adapted mei the ratings ranged from 1 to 5 on a fivepoint likert scale the responses to the questions were scored as follows 1 or 5 received one point 2 or 4 received two points and 3 received three points the aggregate of all item scores yielded a multicultural experience score which ranged from 7 to 21 reflecting an individuals level of multicultural experience the adapted mei possessed fair psychometric properties and had high internal consistency α 875 and sufficient convergent validity ave 520 to be completed by trained observers or counseling supervisors in this study the cccir was translated adapted and validated to fit its use in the malaysian context 16 items in the adapted cccir were confirmed through cfa the overall score range is 13 to 48 with each item represented by a 6point likerttype scale ranging from 1 to 6 the overall score reflected the counselors level of multicultural counseling competency and the extent to which they could effectively counsel clients from varied cultural backgrounds the adapted cccir possessed fair psychometric properties and had excellent internal consistency α 944 and convergent validity ave 909 the adapted cccir possessed fair psychometric properties and had excellent internal consistency α 944 and convergent validity ave 909  demographic data information on the respondents age gender ethnicity and religion was provided on a demographic sheet attached to the questionnaires final page procedure data collection commenced after the grant of ethical clearance from universiti putra malaysias ethical committee and permission from the deputy vicechancellor of selected universities to conduct the study involving their counselor trainees additionally formal letters were addressed to the department head dean and internship coordinators to request help accessing the supervisors and counselor trainees data the relevant data were the total number of counselor trainees counselor trainees names student numbers email addresses and addresses of internship locations as well as the supervisors names and email addresses a sampling frame was built with a code for each counselor trainee based on the information collected the code was written on folded paper and placed in a bowl the researcher drew upon it until the total number of samples reached 208 participants a cover letter and consent form were attached to the questionnaire booklets questionnaire set a was for the counselor trainees and set b was for the supervisor and they were mailed individually to the respondents in addition the questionnaires for counselor trainees and supervisors were coded to maintain confidentiality the code represented a counselor trainee under their supervision if a particular supervisor had three counselor trainees under supervision the supervisor would receive three sets of coded questionnaires the supervisors cover letter featured the code for each trainee counselor five weeks before the internship period ended the questionnaires were emailed out 205 trainee counselors and 38 supervisors successfully responded data analysis the data was analyzed by computing and organizing the scores based on the specific variables studied the 205 usable responses were analyzed using descriptive analysis and inferential statistics the descriptive statistics were calculated using spss then amos was used to assess the hypothesized and interrelationships between the studied variables results level of multicultural experiences and multicultural counseling competencies as presented in table 1 the mean score of personal multicultural experience was 187 lower than midpoint 2 therefore the counselor trainees overall level of personal multicultural experience was low meanwhile counselor trainees overall academic multicultural experience level was high as the mean score was 387 and higher than the midpoint of 3 similarly the counselor trainees overall level of selfperceived multicultural counseling competence was moderate with a mean score of 255 equivalent to the midpoint of 25 in addition the mean score of observed multicultural counseling competence was 485 higher than the midpoint of 35 this finding evidenced the counselor trainees overall level of observed multicultural counseling competence was high relationship between multicultural experiences and multicultural counseling competencies as illustrated in table 2 both personal and academic multicultural experiences were found to have no significant relationships with observed multicultural counseling competence similarly the results indicated that selfperceived multicultural counseling competence was found to have no significant relationship with observed multicultural counseling competence discussion in this study personal multicultural experience referred to counselor trainees multicultural encounters during formative years which came with lived experience in their community the descriptive analysis results showed that the counselor trainees obtained low scores for items on their personal multicultural experience this finding indicated that the counselor trainees had low multicultural exposure and interactions during their formative years this result was inconsistent with chaichanasakul who found that the counselor trainees scored highly for their personal multicultural experience this contradictory finding can be explained by the different demographic backgrounds of the counselor trainees involved in the two studies the respondents in chaichanasakuls study were mainly europeans or americans who were studying for their phd in counseling psychology and clinical psychology at the time of the study the respondents were in the fourth year of their studies and aged between 21 to 53 years old these characteristics of his sample especially in terms of age and the fact that they were phd students may have contributed to the high scores in their multicultural experience the more comprehensive age ranges implied higher cognitive maturity and more cultural resources on the other hand the respondents in this study were undergraduate counselor trainees from a predominantly homogenous background they came from a homogenous group of 22 to 24yearolds one would expect older doctoral candidates to have more life experience and more chances for multicultural exposure and interactions academic multicultural experience measured in this study referred to counselor trainees multicultural experience during a multicultural counseling course the descriptive analysis results proved that counselor trainees scored highly for items on their academic multicultural experience this implied that counselor trainees had had high multicultural exposure and interactions in the multicultural counseling course established studies on multicultural training or multicultural counseling course experiences such as johnson and williams and pieterse et al involved counselor education students they believed that experience during the multicultural counseling course or training reflected the activities in the multicultural counseling course and the various aspects of student experiences while attending the course these activities triggered more multicultural exposure and interaction increasing the counselor trainees multicultural experience which could lead to personal change despite their low personal multicultural experience the counselor trainees showed high academic multicultural experience after attending the multicultural counseling course this suggested that the current multicultural counseling course has sufficient content and activities that provide a medium for counselor trainees to experience multicultural exposure and interactions earlier studies like johnson and williams and pieterse et al maintained that activities in multicultural courses are essential in developing multicultural awareness knowledge and skills perceived multicultural counseling competence refers to how one sees oneself as competent in multicultural counseling this study used a selfreport measurement that covered two components of multicultural counseling competence multicultural knowledge and multicultural awareness in this study the counselor trainees obtained moderate scores for items on selfperceived multicultural counseling competence this implied that the counselor trainees perceived themselves as having moderate multicultural knowledge and awareness of collaborating with multicultural clients abdul malek et al reported similar findings their study involved counseling teachers in schools and found that the respondents obtained moderate scores for items on perceived multicultural counseling competence in this regard the school counseling teachers might have had the same level of exposure to cultural resources as the counselor trainees in this study school counseling teachers have limited opportunities to widen their cultural resources due to the homogenous working setting where most clients come from the same age group thus their cultural resources may have been limited to what they gained from the multicultural counseling course they attended during the counselor education program even when they might have had more working experience most studies focused on measuring selfperceived multicultural counseling competence on the other hand guzman et al owen et al anddillon et al were some of the studies that measured observed multicultural counseling competence for instance owen et al and dillon et al used the cccir in their studies they measured the counselors observed multicultural counseling competence from the clients perspective however neither study reported their respondents observed multicultural counseling competence level furthermore only guzman et al used a similar type of multicultural counseling competence measurement procedure where they measured their participants multicultural counseling competence based on experts evaluation of participants responses to the multicultural critical incident vignettes their findings showed that younger respondents and people of color responded better and scored higher on observed multicultural counseling competence similarly in this study the supervisors gave the counselor trainees a high rating on observed multicultural counseling competence and they dealt with clients from a younger age group and different ethnic groups the supervisors rated them highly as the counselor trainees had more opportunities to practice multicultural counseling competence during ongoing counseling sessions in their respective internship locations and everyday experiences as they adjusted to their new environment some of the counselor trainees had undergone their internship in a setting and location different from their home environment for example a counselor trainee from a state in east malaysia did his internship training at a school in one of the states in peninsular malaysia the counselor trainee needed to adapt his behavior or skills while attending to younger clients from different ethnic groups this behavior adaptation translated into skills during the counseling sessions was observable to the supervisors besides personal and academic multicultural experiences counselor trainees selfperceived multicultural counseling competence which comprises multicultural knowledge and multicultural awareness is essential for counselor trainees to develop and sharpen their multicultural skills a multicultural skill scan is not acquired without a good knowledge of the culture moreover shah maintained that multicultural knowledge without multicultural awareness might lead to unhealthy behaviors such as stereotypes and discrimination multicultural knowledge multicultural awareness and multicultural skills are interdependent as sue et al maintained that an effective counselor requires all three domains however the findings revealed no significant relationships between personal multicultural experience academic multicultural experience and selfperceived multicultural counseling competence with observed multicultural counseling competence these findings were supported by studies conducted by dillon et al and owen et al to date the study by guzman et al measured a similar perspective of multicultural counseling competence through supervisors observation and rating of the manifest multicultural counseling skills nevertheless the current findings contradicted guzman et al in terms of the relationship between personal multicultural experience and observed multicultural counseling competence guzman et al reported the opposite findings they found that experience has a significant relationship with observed multicultural counseling competence this relationship was possible due to ongoing exposure and interaction in a persons formative years that come with lived experience in a society that values diversity which is effective in observed multicultural counseling competence the nature of the findings can also be explained by referring to other related studies for instance the lack of relationships between personal and academic multicultural experience with observed multicultural counseling competence may be related to colorblind racial attitudes chao et al referred to color blindness as the denial of the social significance regarding race and the existence of racism in the united states today this concept may be applicable in this study to explain an individuals tendency to recognize the differences between individuals and their groups this lower tendency may be due to the lack of opportunities to experience different cultures as the counselor trainees grew up in a homogenous environment the homogenous environment in which the counselor trainees grew up could be traced back to the british colonialism era the british adopted a capitalist system that divided economic activities based on ethnicity to create a plural society the british ensured that the ethnic groups did not have much contact with one another hence the malays were present in the unwaged peasant sector and nonmalays in the waged capitalist sector this landscape has shaped the mind and nurtured the tendency to live and socialize within a homogenous group this scenario in turn limited the multicultural exposure and interaction among the counselor trainees even though decades have passed homogenous associations persist in some geographical settings due to the influence of hegemony and social media which often highlight racial matters this has an impact on intergroup relations among malaysians in addition the study sample in their 20s belongs to generation y or the millennials the digital natives who tend to interact virtually rather than physically and they are believed to frequently utilize modern technology like social media and smartphones more than other age groups virtual interaction through social media limits the process of social identification and inhibits the development of diverse cultural experiences in addition donohue maintained that being embedded within ones culture provides scripts and routines for behavior if a person experiences just their own culture they begin to take for granted that their way of life is the way things are however once these experiences occur within a distinct culture or with someone from a different cultural perspective they can be viewed differently unfortunately multicultural counseling competence is impossible without the ability to address race and racism therefore with limited multicultural experience counselor trainees may stay in their comfort zone and be unable to experience some form of cognitive and cultural dissonance which contributes to shifting their worldviews and cultural schemas in other words their multicultural resources were not growing chao et al found that respondents with high colorblind racial attitudes obtained lower scores on multicultural knowledge without appropriate and sufficient knowledge counselor trainees may not be aware or sure whether they portray behaviorsskills that are effective during a counseling session with multicultural clients the lack of relationships between selfperceived and observed multicultural counseling competence is consistent with dillon et al and owen et al they measured observed multicultural counseling competence using the cccir but from the clients perspective dillon et al discovered that counselors selfreportperceived multicultural counseling competence did not correlate with observed multicultural counseling competence as rated by clients owen et al explained that this phenomenon might be related to clients cultural sensitivity in this light the lack of relationship could be explained by the fact that counselor trainees observed multicultural counseling competence had more to do with a specific supervisor than a generalized counselor trainee characteristic the supervisors rating of the counselor trainees observed that multicultural counseling competence was more related to their perceptions of what occurred during the supervision sessions some counselor trainees might have been more accustomed to supervisors than others when cultural approaches were incorporated into a supervised counseling session the supervisors awareness of cultural issues might be related to their ethnic identity or past experiences related to their cultural identity the findings of this study implicated that the multicultural course or training delivered by the counselor educators contained experiential activities allowing the counselor trainees to experience multicultural exposure and interaction during lectures as practical knowledge of multicultural counseling is also essential counselor trainees must be taught how to dissect and infuse cultural information during the session to incorporate it in choosing assessments and planning interventions for the client thus class instructors should enlighten counselor trainees on how knowledge and awareness can be transformed into visible action through experiential learning activities such as case studies roleplays fishbowl exercises problembased learning and fieldwork this effort will then improve the relationship between ones knowledge and awareness of skills in addition counselor educators might maintain or improve selfreflection activities so that counselor trainees become more aware of their personal multicultural experience and can link it to their academic multicultural experience counselor trainees should be encouraged to practice selfreflection as recommended by researchers as one of the methods to improve awareness among mental health practitioners as well as to encourage multicultural counseling competence growth counselor trainees can translate their experience into new knowledge and indepth awareness through selfreflection many class instructors have set selfreflection writing as one of the assignments however it will be more profitable if other subject instructors set up the same assignments at the end of the process counselor trainees will gain a holistic insight into themselves counseling and life according to kim et al consistently reflecting on our cultural values traditions and privileges helps us critically assess our attitudes and ideas about our culture simultaneously it enables an understanding of how many sociocultural variables affect our psychological experiences and behaviors the process of selfreflection should be nurtured so that it becomes a routine that works as active selfcare which benefits counselor trainees professionally and personally in terms of future research this study additionally addresses the need for longitudinal studies to capture the specific training factors such as instructor training and competence cultural immersion experiences and classroom activities that may influence the development of counselor trainees multicultural counseling selfefficacy and multicultural counseling competencies in addition since this study only involved local undergraduate counselor trainees at the end of their internship the findings might not be generalizable to experienced counselors future research should involve other groups of samples from the counseling population such as counselor educators or professional counselors lastly this study recommends further study identifying the underlying variables such as counseling selfefficacy or selfintrospectiveness which may link multicultural experiences and multicultural counseling competencies conclusion this study found that personal and academic multicultural experience and selfperceived multicultural counseling competence had no significant relationship with observed multicultural counseling competence in addition this study also reported that counselor trainees scored low levels of personal multicultural experience high levels of academic multicultural experience moderate levels of selfperceived multicultural counseling competence and high levels of observed multicultural counseling competence all in all based on the findings this study encouraged and supported the continuous efforts of multicultural counseling course instructors to maintain their practice of experiential pedagogy as well as recommended future research to study further the underlying variables such as counseling selfefficacy or selfintrospectiveness that may link multicultural experiences and multicultural counseling competencies

the multicultural counseling course attended by counselor trainees is expected to enrich their multicultural experience through the academic environment as they come from different backgrounds and personal multicultural experiences while most multicultural counseling courses focus on the three components of multicultural counseling competence counselor trainees should be provided with more multicultural exposure and interactions during classes to develop skills to work with diverse clients therefore this descriptivecorrelational study explores the relationship between multicultural experiences personal and academic and multicultural counseling competencies selfreported and observerrated among malaysian counselor trainees all four instruments had been adapted and translated into the malay language before being completed by 208 randomly selected counselor trainees this study reported that counselor trainees scored at low levels of personal multicultural experience high levels of academic multicultural experience moderate levels of selfperceived multicultural counseling competence and high levels of observed multicultural counseling competence the findings showed no significant relationships between personal and academic multicultural experience and selfperceived and observed multicultural counseling competence in conclusion the findings imply that there are practices of experiential pedagogy in delivering multicultural counseling courses in counselor education programs however more research is needed to identify the underlying variables such as counseling selfefficacy or selfintrospectiveness which may link the study variables as this will serve as the most critical aspect in sustaining the counselor trainees multicultural counseling competencies

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introduction since the 90s human activity analysis has been one of the most important topics in computer vision becoming an integral part of many video surveillance systems but also representing a key application in several other everyday scenarios like workplaces hospitals and many others analyzing activities involved to date the recognition of motion patterns and the production of highlevel descriptions of actions and interactions among entities of interest many surveys on activity analysis have been proposed in the literature the first example is 1 where techniques for the tracking and the recognition of human motion are reviewed in 2 methods for the motion of body parts the tracking of human motion using different camera settings and the recognition of activities are reported in 3 hand and body tracking strategies are discussed together with techniques for human activity recognition based on 2d and 3d models a comprehensive review on visionbased human motion analysis spanning the period 20002006 is presented in 4 in 5 statistical models like dynamic bayesian networks are addressed as one of the most suitable tools for activity recognition an essay on the different components of a typical video surveillance system with emphasis on the activity analysis is reported in 6 the definition of activity as a complex and coordinated organization of simple actions is exploited in 7 in the same year a survey on video surveillance systems has been proposed in 8 also discussing about the different public databases available to validate the algorithms in the very recent review on activity recognition approaches 9 the different strategies are organized as hierarchical and nonhierarchical and the last ones are further divided in spacetime and sequential methods all the above mentioned surveys addressed the modeling of the human activities mainly stressing the technological computer vision aspects in particular all of them focus on detecting and recognizing explicit actions in the sense of gestures performed voluntarily by humans like running walking stopping seating etc vitalized by addressing the socalled social signals 10 which are nonverbal cues inspired by the social affective and psychological literature 11 this allows a more principled encoding of how humans act and react to other people and environmental conditions social signal processing also named social signaling represents the scientific field aimed at a systematic algorithmic and computational analysis of social signals that is deeply rooted in anthropology and social psychology 12 more properly ssp goes beyond the mere human activity modeling aiming at coding and decoding the human behavior in other words it focuses to unveil the underlying hidden states that drive one to act in a determined way with particular actions this challenge is motivated by decades of investigation in human sciences that showed how humans use nonverbal behavioral cues like facial expressions vocalizations gestures or postures to convey often outside conscious awareness their attitude towards other people and social environments as well as emotions 13 the understanding of these cues is thus paramount in order to understand the social meaning of the activities as we will see later only a minority of works adopted the ssp perspective in a video surveillance setting but recently this trend has rapidly grown actually in surveillance the main goal is to detect threatening actions as soon as possible therefore the possibility of doing this by observing the human behavior as a phenomenon subjected to rigorous principles that produces predictable patterns of activities turns out to be incredibly important the aim of this paper is to review the early years of the social signaling oriented approaches for human behavior analysis in a surveillance context individuating what are the contact points between surveillance and social signalling how social signalling may improve the human behavior analysis envisaging and delineating future perspectives the rest of the paper is organized as follows section 2 illustrates the processing scheme of a typical video surveillance system the aim of the section is that of contextualizing which modules of a video surveillance strategy may benefit from the intervention of social signaling findings section 3 is a short overview of the recent advances in the activity analysis aimed at defining what is achieved with pure computer vision and pattern recognition methods section 4 is the core of the paper reviewing the most significant contributions that represent the intersection between video surveillance and ssp section 5 addresses the analysis of crowd behavior that recently has become a welldefined trend in surveillance discussing the importance of embedding social signals in such studies finally section 6 draws the conclusions and presents the envisaged future perspectives a basic video surveillance system overview a typical surveillance system scheme is composed by two parts a lowlevel and a highlevel part each part is composed by different stages explained in the following analysis output video input activity analysis object tracking object detection background subtraction object segmentation the lowlevel stages the lowlevel stages are the background subtractionobject segmentation and the object detection such stages preprocess the raw images in order to discover areas of interest background subtractionobject segmentation background subtraction is a fundamental lowlevel operation that applies on raw videos captured by cctvs 14 it aims at learning the expected chromatic aspect of the scene and how it evolves in time highlighting moving objects ideally under a 247 policy object segmentation follows the background subtraction and aims at individuating connected regions pruning away small fg objects filling holes of large regions adopting temporal continuity to obtain consistent smooth regions across time 15 object detection this stage serves to highlight particular classes of targets in the images it may be applied on the output of the background subtractionobject segmentation step or in a dense way over the entire image 16 these two stage cannot benefit of an intervention of ssp principles since the processing here is focused on entities the pixels carrying very low semantics the highlevel stages the high level stages are the object tracking and the activity analysis object tracking tracking is undoubtedly the paramount aspect of any videosurveillance approach and is very important for the human behavior analysis for a comprehensive review on tracking for surveillance please read 17 tracking aims at computing the trajectory of each distinct object of interest in the scene associating a id label and keeping it across occlusions and multiple cameras a general tracker can be characterized by three main phases 1 the initialization phase localizes the target that needs to be tracked it usually relies on heuristic mechanisms combined with some object detector 2 the dynamic phase predicts where target is more likely to move and it is based usually on a firstor secondorder autoregressive model 3 the observation phase finds the region of the image that is more similar to the target assuming as prior the hypothesis given in the dynamical phase tracking and especially the dynamic module may benefit from social signal processing methods such module simply does not take into account that people whenever free to move in a large environment respect patterns and trajectories largely dominated by social mechanisms 18 therefore the design of a socially driven dynamic model for tracking may be the key ingredient to overcome the current limitations of the current algorithms as already shown in some recent approaches exploiting the social force model 1920 when the scenario is too crowded so that tracking approaches become ineffective motion flow estimation techniques are usually preferred 21 activity analysis activity analysis and recognition1 is the last module added in the typical scheme of a surveillance system it usually takes the trajectories of the targets and the object detections results as input and provides a description of the activities carried out in the scene under the form of parametric models or natural language expressions 22 the general idea is to segment the trajectories and the detections of each subject into simple actions by means of actions classifiers that work on few consecutive frames then higherlevel reasoning is applied to combine the simple actions through statistical pattern recognition paradigms or methods that exploit temporal logics it is very important to note that almost all the behavioractivity recognition modules are strongly context dependent the definition of the plausible simple actions and activities are tightly linked to the kind of monitored environment in all the cases the activity recognition approaches ignore that the human behavior is a process subject to laws rigorous enough to produce stable patterns corresponding to social emotional and psychological phenomena it turns out that this module is the one where social signal processing applies mostly for this reason we will now give a short overview of what has been done so far for this stage in the classical computer vision sense highlighting later the main limitations where social signaling may help the most classical activity analysis a short review this overview is not exhaustive and wants only to give an idea on the kind of activities considered so far in surveillance for more detailed overviews please consider the surveys referred in the introduction approaches that follow the scheme of sec 2 for individuating singleagent activities based on tracking trajectories are 23242526 one of the most known classical system for automated surveillance is vsam 23 where individual activities like entering vehicles entering buildings etc are encoded as simple markov models another masterpiece is 24 where expected trajectories are quantized and learnt by neural networks and the goal is that of finding abnormal events as outliers in 25 the clustering is hierarchical producing a hierarchical binary tree a finer use of trajectory data is presented in 2726 where semantic zones like entryexit zones junctions paths routes sink sources and stop zones are located in the monitored scene the use of spatiotemporal features instead of trajectories is gaining more popularity for finely analyzing individual human behavior 28293031 such features overcome the limitations of trackingbased schemes by exhibiting robustness to noise small camera movements and changes in lighting conditions allowing to encode activities as walking jumping bending turning around kicking etc moving to activities involving more than a person dynamic bayesian networks 32 such as hidden markov models 33 and more complex models which build upon hmms are the most used tools 343536 in 34 a total of three kinds of activities on a public square are modeled by means of coupled hidden markov models operating on trajectories semimarkov reasoning for encoding long term activities is proposed in 35 simple events are temporally composed in order to define complex events interactions are modeled by logic operators that assemble together singlethread complex events into a multithread complex event in 36 video sequences are represented at different scales in terms of different motion details related to trajectory silhouette body parts etc then these scales are combined using a hierarchical directionalstate dynamic bayesian network to perform recognition of activities like two people walking in the same or opposite direction people interaction dropping and picking up of an object a marriage between syntactical and statistical pattern recognition paradigms has been proposed in 37 a lowlevel module detects by tracking simple events these events are then fed into a stochastic contextfree parser that connects atomic events by exploiting longer range temporal constraints more recently the same principle is adopted and developed in 38 to deal with interactive activities as greeting fighting concerning the approaches based on spatiotemporal features twoagents interactions are modeled in 39 employing spatial and temporal logic for the classification of activities like shaking hands hugging punching pointing all the above approaches focus on activities performed by 12 people under the form of sequences of explicit actions interesting aspects as personality traits or intentions which could be useful for predicting activities are not taken into account the following methods bring into the analysis the concept of group of objects in 40 groups are represented by a geometrical shape in which vertices are the locations assumed by the moving persons along time the idea is that a mean shape represents a particular group activity and variations with respect to it indicate abnormal events the variations can be spatial or temporal this system has been applied in an airport scenario where the interacting people were passengers moving from the airplane to the terminals airport cargo loadingunloading activities structured as multiple interactions between vehicles with actions like moving truck moving cargo are modeled in 41 with dynamic bayesian networks whose structure was learnt in an automatic fashion more recently in 42 group activities are encoded with three types of localized causalities namely selfcausality paircausality and groupcausality which characterize the local interactionreasoning relations within between and among motion trajectories of different humans respectively six different human group activities are considered ie walkingroup runingroup standandtalk gathering fighting and ignoring the same authors improved their framework in 43 employing gaussian processes for describing motion trajectories in 44 group interactions with a varying number of subjects are investigated employing an asynchronous hmm as a hierarchical activity model they distinguish symmetric and asymmetric dynamics activities in particular they focus on ingroup approach walktogether split ignore chase fight and runtogether activities another generative model is presented in 21 where interacting events in crowded scene are modeled in an unsupervised way and interactions are modeled as cooccurrences of atomic events no tracking is performed due to the high density of people and local motions are considered as lowlevel features instead after collecting such motion patterns atomic events can be defined as distributions over these lowlevel features and in the same way interactions are modeled as distributions over atomic events all the distributions are modeled with dual hierarchical dirichlet process which decides in an automatic fashion both the number of atomic events and interactions the system works very well in detecting interactions in traffic scenes with cars and pedestrian but it seems less expressive in modeling human interactions the discriminative approach in 45 encodes the context as a mean for inferring individual activities in a more robust way two types of contextual information are used the first captures the main activity performed by a group of people the second evaluates the close neighborhood of a person five actions are considered in order to understand the state of the art at a glance we organize the approaches discussed so far by considering three aspects the first is the degree of environmental supervision that focuses on how much the monitored scenario is constrained highly constrained scenarios correspond to small ambients possibly monitored by several multimodal sensors viceversa unconstrained situations occur when large outdoor scenes are captured by a single camera the second aspect is the level of detail of the interaction which refers to the level of detail with which an interaction is modeled from one side we have highly specific interactions where body gestures are needed on the other side we have generic interactions where each individual is represented as a simple point whose only position and motion are considered the third aspect is the number of subjects that takes into account the number of people involved in an activity in table 1 we organize the surveyed papers accordingly to the des ldi and nos characteristics from a pure technical point of view another possible taxonomy can be defined according with the type of methodology employed to this end the techniques can be partitioned into three classes namely 1 the graphical modelsbased approaches or more simply generative models 2 the discriminative approaches 3 the syntactical approaches the generative models include markov models 23 bayesian networks 40 dynamic bayesian networks 3435364421412726 non parametric models 2528 generic bayesian models 30 the discriminative approaches usually adopt support vector machines 2942 with different kinds of kernels 39 relevance vector machines 31 latent svms 45 gaussian processes 43 neural networks 24 the syntactic approaches dictate the construction of grammars which are then used to express the structure of a process using a set of production rules 3738 summarizing the last generation of surveillance systems witnesses a certain maturity in managing the lower levels of the data processing ie dealing with multiple visual entities capturing their positions in a given possibly sparse environment however considering the activity analysis level much more can be done in the following we list different problems where the lack of social knowledge clearly emerges • problem 1definition of threatening behavior all the surveillance systems aims at promptly identifying threatening behaviors but it turns that most of them provides unusual activities considering a previously learned statistics especially when this statistics collected is scarce this will cause huge amounts of false positives making the system unusable for practical purposes therefore a different definition of threatening behavior has to be forged • problem 2modeling of groups what is a group in the surveillance literature this usually corresponds to having a set of individuals exhibiting similar characteristics ie close in space with the same oriented motion this description fails to distinguish a situation where space constraints force people to wander close from standard proximity given by personal relationships therefore a more expressive definition of group has to be designed • problem 3modeling of interactions in outdoor scenarios all the above quoted studies face the problem of the interaction modelling in very constrained scenarios where interacting activities are foreseen or expected in outdoor scenarios the simple spatial proximity is usually assumed as warrantee for interaction this is intuitively false in crowded situations like cocktail parties therefore a more precise definition of interaction has to be provided as we will see in the following social signal processing may help in answering the above questions providing novel cues that can be exploited by standard surveillance algorithms 4 social signal processing for activity recognition toward the analysis of the behavior social signal processing aims at developing theories and algorithms that codify how human beings behave while involved in social interactions putting together perspectives from sociology psychology and computer science 1011 here the main tools for the analysis are the social signals 11 ie temporal cooccurences of social or behavioral cues 46 that can be basically defined as a set of temporally sequenced changes in neuromuscular neurocognitive and neurophysiological activity behavioral cues have been organized into five categories in 11 that are heterogeneous multimodal aspects of a social interplay 1 physical appearance 2 gesture and posture 3 face and eyes behavior 4 vocal behavior and 5 space and environment the interaction of social signal processing and automated surveillance is to our opinion at its infancy actually the most ssp approaches deal with wellconstrained scenarios as smart or meeting rooms where the sensor machinery is massive and pervasive in this way fine behavioral cues can be captured especially the ones focusing on the gesture and posture the face and eyes behavior and the vocal behavior such capabilities cannot be exploited in a typical surveillance scenario actually smart sensors cannot be placed in the environment because of 1 privacy protection measures and 2 scarce effectiveness in wide open scenes mutual gaze it turns out that few ssp works are concerned with surveillance 11 and they involve primarily the category of cues related to the space and the environment that in our opinion represents the most intuitive connection actually from the ssp side this category has been extensively investigated in human sciences where the spatial arrangement of people in social encounters has been shown to be a reliable evidence of the social phenomena taking place among interacting individuals 4718 from a surveillance perspective the encoding of proxemics aspects comes along with the tracking and classification technologies that provide the relative position of people at each frame in the rest of the section the five categories of behavioral cues are detailed reviewing the surveillance approaches that explicitly use them and envisaging possible future perspectives of crosspollination physical appearance physical appearance of a person codifies attributes like attraction height and somatotype attractiveness is an important physical factor as it pushes one to interact attractive people have a high probability of getting in contact with other people 13 research in the area of facial perception has identified many different factors that contribute to a face being considered attractive and it is generally accepted that beauty cannot be defined by one single principle 48 the second important physical attribute is height people tend to attribute high social status to taller people finally somatotypes tend to draw some attributes of personality traits for example thin people are considered to express less emotion while fat people tend to be more talkative to the best of our knowledge this class of cues has not been exploited in any surveillance approach and is also absent in the more general literature of the automated analysis of behavior therefore its use for surveillance seems unlikely gesture and posture gestures are used to regulate the human interaction and they often performed consciously or unconsciously to convey some specific meaning furthermore gestures as in figure 3 can also express an emotion and hence capable of convey the social signals for the most complicated human behaviors like shame and embarrassment 11 the usage of the gestures in a social signalingdriven surveillance sense is hard the goal is not only capturing intentional gestures that are voluntarily expressed by the subjects for communicating something but it is also capturing unintentional movements subtle andor rapid oscillations of the limbs casual touching of the noseear hair twisting and self protection gesture like closing the arms these cues are very hard to be modeled since they are inherently affected by noise and occlusions while the former attempt has been pursued by a huge quantity of works the goal of capturing subtle gestures is a big challenge with no traces in the literature in 49 gesturing is used to infer who is talking when in a surveillance scenario realizing through statistical analysis a simple form of diarization actually cognitive scientists showed that speech and gestures are so tightly intertwined that every important investigation of language has taken gestures into account 51 while the multimodal diarization is common in the literature the unimodal diarization exploiting visual information is rare 52 unrelated to surveillance we think that this is a direction worth to be investigated because this allows to capture turn taking patterns indicating ongoing conversations and thus genuine social interactions as it can be seen in figure 3 the posture is an aspect of the human behavior which is unconsciously regulated and thus can be considered as the most reliable nonverbal social cue in general posture conveys social signals in three different ways 11 namely inclusive vs no inclusive facetoface vs parallel body orientation and congruent vs noncongruent these cues may help to distinguish extrovert and introvert individuals suggesting a mean to individuate threatening behaviors only few and very recent surveillance approaches deal with posture information 53545556 they will be explained in the following since they exploit mostly cues coming from other behavioral categories face and gaze behavior these are termed as the best efficient social signals that can describe the human behavior and also have an impact on our perception about others affect 57 figure 4 shows the example of facial expressions and gaze direction that can be termed as strong social signals nonverbal facial cues includes fear sad happiness anger disgust surprise psychological states like suicidal and depression and also social behavior like rapport and accord in surveillance the goal of capturing fine visual cues from the face is very hard since we are in a noncollaborative scenario and the sensors usually capture the faces at a low resolution a different matter holds for the gaze orientation since objects are foveated for visual acuity gaze direction generally provides precise information regarding the spatial localization of ones attentional focus 58 also called visual focus of attention concerning social aspects vfoa is a fundamental mean of nonverbal communication 596061 so that its modeling is very attractive in surveillance the problem is that measuring the vfoa by using eye gaze is often difficult or impossible in standard surveillance scenarios either the movement of the subject has to be constrained or highresolution images of the eyes are required 62 therefore the viewing direction has been reasonably approximated by just measuring the head pose 5963 in such scenario the work of 61 estimates pan and tilt parameters of the head and the vfoa is represented as a vector normal to the persons face the application purpose is to understand if a person is looking at an advertisement located on a vertical glass or not since the specific setup is very constrained this model works pretty well however as observed by the authors more general setups impose more complex models that consider camera position people location and scene structure similar considerations hold for the work presented in 60 where an active appearance model models the face and pose of a person in order to discover which portion of a mallshelf is observed following this claim and considering a general unrestricted scenario where people can enter leave and move freely the vfoa can be approximated by the threedimensional visual field of an individual more precisely according to biological evidence 64 the vfoa can be described as a 3d polyhedron delimiting the portion of the scene that the subject is looking at the use of the gaze approximation as a 3d polyhedron in surveillance brought a radical change of perspective for the behavior analysis we moved from a objective point of view ie the point of view of the surveillance camera toward a subjective point of view ie that of each single individual the gaze approximation allows to understand what a person is looking at building a set of highlevel inferences for example in 65 and independently in 66 the idea was to infer what part of the scene is seen more frequently by people thus creating a sort of interest maps this may serve to highlight individuals that are focused on particular portions of the environment for a long time if the observed target is critical a threatening behavior could be inferred later on the subjective perspective has been proposed in 53 where group interactions are discovered by estimating the visual focus of attention using a head orientation detector while exploiting proxemic cues the idea is that close people whose vfoa is intersecting are interacting similarly in 54 a set of two and oneperson activities are formed by sequences of actions and then modeled by hmms whose parameters are manually set the importance of the subjective point of view for surveillance encourage scientists in ameliorating the vfoa extraction phase most recently in 67 an approach for the joint tracking in surveillance videos of pose behavioral cues is presented given the tracks generated by a multiperson tracker they first localize the head and extract body and head pose features then these features are used to jointly estimate the pose cues in a 3d space using a particle filtering approach that exploits the conditional coupling between body position and body pose together with the soft coupling between body pose and head pose to summarize we report the table of all the reviewed approaches exploiting face and gaze behavior cues considering the three aspects previously described in sec3 ie des ldi and nos vocal behavior the vocal behavior class comprehends all the spoken cues that define the verbal message and influence its actual meaning such class includes five major components 11 prosody that can provide social signals like competence linguistic vocalization that can communicate hesitation non linguistic vocalization that can provide strong emotional states or tight social bonds silence that can express hesitation and turn taking patterns this last component is the most investigated in this category since it appears the most reliable when the goal is to recognize people personality 68 predict the outcome of negotiations 69 recognize the roles interaction participants play 70 or modeling the type of interactions as turnorganization cannot be fully understood without taking into account its sequential aspects 71 the application of probabilistic sequential models is widespread in 72 a twolayer hmm was employed to model individual and group actions in 73 the purpose was to detect the dominant interlocutor through social cues of mimicking the authors employed an observed influence model ie an aggregate of firstorder markov processes each one addressing an interlocutor more recently 7475 a generative framework has been proposed aimed at classifying conversation intervals of variable length considering the nature of the people involved within and the main mood in surveillance approaches that face monitoring scenarios considering vocal behavior cues are absent since the audio modality is hard to be captured in wide areas and most importantly it is usually forbidden for privacy issues the problem lies in the fact that audio processing is usually associated with speech recognition while in the case of ssp the content of a conversation is ignored an interesting topic for surveillance is that of the modeling of conflicts as they may degenerate in threatening events conflicts have been studied extensively in a wide spectrum of disciplines including sociology and social psychology an approach that could be instantiated in a surveillance context is that of 78 that proposes a semiautomatic generative model for the detection of conflicts in conversations the approach is based on the fact that during conflictual conversations overlapping speech becomes both longer and more frequent 79 the consequence of a competition for holding the floor and preventing others from speaking in summary vocal behavior appears to be a very expressive category of social cues that should be exploited in the surveillance realm since it can be handled in a completely privacyrespectful fashion space and environment the study of the space and environment cues is tightly connected with the concept of proxemics that can be defined as the the study of mans transactions as he perceives and uses intimate personal social and public space in various settings quoting hall 18 the anthropologist who first introduced this term in 1966 in other words proxemics investigates how people use and organize the space they share with others to communicate this happens typically outside conscious awareness socially relevant information such as personality traits attitudes etc from a social point of view two aspects of proxemic behavior appear to be particularly important namely interpersonal distances and spatial arrangement of interactants interpersonal distances have been the subject of the earliest investigations on proxemics and one of the main and seminal findings is that people tend to organize the space around them in terms of four concentric zones associated to different degrees of intimacy intimate zone distances for unmistakable involvement with another body this zone is typically forbidden to other nonintimate persons except in those situations where intrusion cannot be avoided casualpersonal zone distances established when interacting with familiar people such as colleagues or friends this zone is suitable for having personal conversations without feeling hassled it also reflects mutual sympathy socioconsultive zone distances for formal and impersonal relationships in this zone body contact is not possible anymore it is typical for business conversations consultation with professionals or sellercustomer interactions public zone distances for nonpersonal interaction with others it is a zone typical for teachers speakers in front of a large audience theater actors or interpersonal interactions in presence of some physical barrier in the case of northern americans the four zones above correspond to the following ranges less than 45 cm between 45 and 120 cm between 120 and 200 cm and beyond 200 cm while the actual distances characterizing the zones depend on a large number of factors as we will see in the following the partition of the space into concentric areas seems to be common to all situations the spatial arrangement during social interactions addresses two main needs the first is to give all people involved the possibility of participating the second is to separate the group of interactants from other individuals the result are the fformations stable patterns that people tend to form during social interactions an fformation arises whenever two or more people sustain a spatial and orientational relationship in which the space between them is one to which they have equal direct and exclusive access 82 in practice an fformation is the proper organization of three social spaces ospace pspace and rspace the ospace is a convex empty space surrounded by the people involved in a social interaction every participant looks inward into it and no external people are allowed in this region the pspace is a narrow stripe that surrounds the ospace and that contains the bodies of the interactants the rspace is the area beyond the pspace there can be different fformations visàvis an fformation in which the absolute value of the angle between participants is approximately 180 o and both participants share an ospace lshape an fformation in which the absolute value of the angle between participants is approximately 90 o and both participants share an ospace sidebyside an fformation in which the absolute value of the angle between participants is approximately 0 o and both participants share an ospace circle an fformation where people is organized in a circle so that the configuration between adjacent participants can be considered as a hybrid between a lshape and a sidebyside fformation the proxemic behavior intended as the use of the interpersonal distances is affected by a large number of factors and culture seems to be one of the most important ones especially when it comes to the size of the four concentric zones described above in particular cultures seem to distribute along a continuum ranging from contact to noncontact 18 the effect of culture seems to change when interaction participants have seats at disposition in this case people from supposedly noncontact cultures tend to seat closer than the others 83 interesting effects have been observed considering the size and the illumination of the interaction site people allow others to come closer in larger rooms 84 in bright ambients 85 when the ceiling is higher 86 and in outdoor spaces 87 the effects of crowding have been studied as well 88 social density was increased in a constant size environment for a limited period of time and participants of larger groups reported greater degrees of discomfort and manifested other forms of stress to the best of our knowledge only a few works have tried to apply proxemics in computing one probable reason is that current works on analysis of human behavior have focused on scenarios where proxemics do not play a major role or have relied on laboratory settings that impose too many constraints for spontaneous proxemic behavior to emerge 89 most of the computing works that can be said to deal with proxemics concern the dynamics of people moving through public spaces the keystone model for the interaction modeling of moving people ie a basic form of behavior is given in the social force model 90 that applies a gaskinetic analogy to the dynamics of pedestrians it is not a interaction detection system rather it is a physical model for simulating pedestrian interactions while they are moving pedestrians are assumed to react to energy potentials caused by other pedestrians and static obstacles through a repulsive or an attractive force while trying to keep a desired speed and motion direction this model can be thought as explaining group formations and obstacle avoidance strategies ie basic and generic form of human interactions the social force model has been modified in 19 where sfm is embedded in a tracking framework substituting the actual position of the pedestrian of the sfm with a prediction of the location made by a constant velocity model which is then revised considering repulsive effects due to pedestrians or static obstacles no mention about attractive factors are cited in the paper at the same time independently a variational learning strategy is proposed in 20 to train a dynamic model for predicting the position of moving subjects employing the sfm even in this case the attraction factor of the sfm is ignored in 91 a versatile synergistic framework for the analysis of multiperson interactions and activities in heterogeneous situations is presented an adaptive context switching mechanism is designed to mediate between two stages one where the body of an individual can be segmented into parts and the other facing the case where persons are assumed as simple points the concept of spatiotemporal personal space is also introduced to explain the grouping behavior of people they extend the notion of personal space to that of spatiotemporal personal space personal space is the region surrounding each person that is considered personal domain or territory spatiotemporal personal space takes into account the motion of each person modifying the geometry of the personal space into a sort of cone such cone is narrowed down proportionally with the motion of the subject so as the faster the subject the narrower the area an interaction is then defined as caused by intersections of such volumes in 55 fformations are found in a cocktail party scenario by employing proxemics elements and head orientation estimates the approach is based on a hough voting strategy and represents an accurate modeling of the formal definition of fformation the main characteristics are that people have to be reasonably close to each other have to be oriented toward the ospace and that the ospace has to be empty to allow the individuals to look at each other another approach for the fformation is that of 56 they define an fformation as a set of focused encounters and this distinction serves to discriminate a group where people is willing to stay to those group formations resulting from environmental constraints the authors use a graph clustering algorithm by formulating the problem in terms of identifying dominant sets a dominant set is a form of maximal clique which occurs in edge weighted graphs as well as using the proximity between people body orientation information is used these two last approaches seem to be particularly indicated to highlight genuine group formations and interactions where proxemic cues and postural cues go beyond the mere spatial proximity exploited in most of the cases in 92 the authors propose a system that could track and discover groups of interacting people estimating the trajectories of people and employing the modularity cut algorithm 93 a limitation of the work was that of considering solely staged social activities one of the first attempts to interpret the movement of people in social terms has been presented in 94 where nine subjects were left free to move in a 3m × 3m area for 30 minutes the subjects had to speak among themselves about specific themes an analysis of mutual distances in terms of the zones described in section 45 allowed to discriminate between people who did interact and people who did not in a similar way mutual distances have been used to infer personality traits of people left free to move in a room 95 the results show that it is possible to predict extraversion and neuroticism ratings based on velocity and number of intimatepersonalsocial contacts between pairs of individuals looking at one other the approach of 96 studies social relations in fformation calculating pairwise distances between people lying in the pspace and clustering them in different classes the number of classes is chosen automatically by the algorithm following a information theory principle the main finding of the approach is that each of the classes actually represent welldefined social bonds in addiction the approach adapts to different environmental conditions namely the size of the space where people can move the last three approaches are very close to a modelling of social roles in unconstrained scenarios that in turn may serve to the detection of threatening behavior finally we report a concise scheme of the reviewed approaches in table 3 exploiting space and environment cues in a social signaling sense for surveillance purposes still considering the three aspects of des ldi and nos crowd behavior analysis analyzing a crowd represents without doubts a new dimension for the automated surveillance the idea is to monitor huge masses of people categorizing how they move and looking for normal and abnormal situations due for example to incidents panic attacks etc this mission is intriguing because it requires to revise the whole surveillance flowchart previously described in section 2 actually each single individual here cannot be characterized as finely as in the case of 510 people occlusions are very strong and the classical object classification and tracking approaches have shown to be scarcely effective 97 the idea is that there are no more many entities to model but instead a single one the crowd the underlying hypotheses are that a crowd has an own appearance to be modeled it moves with a very complex dynamics that can be learned and behaves following sociological principles crowd analysis was born in the field of transportation and public safety 9798 considering three main applications density estimation tracking some individuals in crowded scene crowd behavior understanding the most studied model in crowd behavior analysis is the social force model already introduced in the previous section 4 about proxemics many variants have been proposed still for simulation targets but recently some works suggest to invert this model to detect and localize the abnormalities present in the crowd 99 the use of sfm in fact avoids individual person tracking and this is the key aspect of its success other methods have been subsequently proposed having this same characteristic in 99 grid of particles is placed over the image and these particles are advected with the spacetime average of optical flow then the interaction force for each particle is estimated using sfm these interaction forces are then mapped onto the image plane to obtain a force flow for every pixel in every frame the resulting vector field is used to model the normal behavior using a bag of words approach in 98 an individual target tracking strategy for unstructured crowded scenes is presented here the crowd is modeled using correlation topic model the idea is that the dynamics of the crowd is learned by quantized local features correlated together with the use of topic models given the observed measurements of the object to be tracked the next position is obtained by incorporating in the object state hypothesis the learned highlevel scene dynamics in 100 a tracking scheme based on local spatiotemporal motion patterns is presented to track an individual in an extremely crowded scene spatiotemporal variations of the crowd motion are learned from regularly spaced small subvolumes of the considered video sequence using a battery of hmms these hmms are subsequently used to predict the motion patterns of a given subject when deviating from the main crowd flow a new scheme to detect the motion patterns in the crowded scenarios is presented in 101 this scheme utilizes the instantaneous motion flow estimating the optical flow field the typical motion patterns are then detected by clustering the flow vectors from the motion flow recently another approach has been proposed still inspired by the sfm and its variants 99 these works utilize a set of particles over each frame and the sfm formulation to estimate the force of each particle subsequently the set of particles forces has been optimised using a swarm optimization technique so that abnormal situations can be detected in a faster and more reliable way also localizing the anomalies 102103 at the best of our knowledge current methods are still far from coupling surveillance and social signal processing in the field of crowd analysis under a genuine sociologic point of view an important survey that deal with the modelling of crowd particularly suited for the field of public transportation and safety is 104 here different theories like predisposition theory emergent norm theory model of disorder social identity theory and elaborate social identity theory are discussed this could be a point where computer vision may draw on the idea is that the coupling of sociological notions and computer vision algorithms may originate novel applications for example in the following we foresee the development of two possible activities • design of public spaces simple architectural elements are known to influence significantly the collective behavior of large crowds in public spaces 105 socially intelligent surveillance technologies can help to analyze this phenomenon and improve the design of public spaces like train stations airports squares etc that are typically populated by a large number of interacting individuals • learning spaces the effectiveness of a learning space is heavily influenced by its physical setup especially when the learning process requires the collaboration of many individuals 106 socially and emotionally intelligent surveillance technologies can help the design of effective learning environments by understanding those behavioral processes that help or compound effective collaboration between people conclusions and future research the technical quality of the classical modules that compose a surveillance system allows nowadays to face very complex scenarios the goal of this review is to support the argument that a social perspective is fundamental to deal with the highest level module ie the analysis of human activities in a principled and fruitful way we discussed how the use of social signals may be valuable toward a robust encoding of social events that otherwise cannot be captured in particular we indicate three problems that is the definition of threatening behavior the modeling of groups and the modeling of interactions in outdoor situations that are very frequent in video surveillance and that can be faced with more effectiveness under a social signal processing perspective in short computer vision and pattern recognition furnish the analysis tools to be exploited following social science findings we are convinced that this is the way surveillance expressiveness may be boosted leaning toward a finer investigation of overt and covert also subtle human behavioral aspects in addition importing social models into crowd analysis represents a very fertile and still unexplored area where many contributions could be provided

the analysis of human activities is one of the most intriguing and important open issues for the automated video surveillance community since few years ago it has been handled following a mere computer vision and pattern recognition perspective where an activity corresponded to a temporal sequence of explicit actions run stop sit walk etc even under this simplistic assumption the issue is hard due to the strong diversity of the people appearance the number of individuals considered we may monitor single individuals groups crowd the variability of the environmental conditions indooroutdoor different weather conditions and the kinds of sensors employed more recently the automated surveillance of human activities has been faced considering a new perspective that brings in notions and principles from the social affective and psychological literature and that is called social signal processing ssp ssp employs primarily nonverbal cues most of them are outside of conscious awareness like face expressions and gazing body posture and gestures vocal characteristics relative distances in the space and the like this paper is the first review analyzing this new trend proposing a structured snapshot of the state of the art and envisaging novel challenges in the surveillance domain where the crosspollination of computer science technologies and sociology theories may offer valid investigation strategies

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background globally modern contraceptive use is fast increasing but continues to be low in subsaharan africa 1 the latest 2014 demographic and housing survey in ghana reports that the prevalence of modern contraceptive use among women of reproductive ages is 22 family planning has been identified as the key measure to help nations achieve the sustainable development goal five which aims at achieving gender equality and empowering all women and girls 2 a number of researches have been done in ghana and other countries to identify factors associated with the low uptake of modern contraceptives their findings indicate that contraceptives use is the cause of the high fertility rates in subsaharan african countries resulting in early childbearing high infant mortality and many other negative effects on the socioeconomic situation in a country 3 according to the gdhs 2014 the use of modern contraceptive is low among women aged 1519 and women age 4549 4 in a study done in vietnam the researcher describes the relationship between womens age and modern contraceptive methods as an inverted ushape while the likelihood of contraceptive use was low among women aged 1524 it was lower among the those 35 and above and highest among women aged 2535 5 the educational level of a woman can also influence her acceptance and use of modern contraceptive methods a study conducted in bangladesh on prevalence and determinants of contraceptive use among employed and unemployed women revealed that employed women with higher educational levels had a marked increased probability of contraceptive use compared to illiterates 6 a study done in nigeria by igbodkwe reveals that women with higher education were four times more likely to use modern contraceptives compared to those with lower educational level attainment 7 in the same vein women whose husbands have attained higher educational statuses were more likely to accept and approve the use of modern contraceptives methods 89 type of residence has also been found by many researchers to be significantly associated with the use of modern contraceptive methods even though the majority of people reside in rural areas women in the urban areas have higher odds of using modern contraceptive methods than women in rural areas 710 wealth index and type of earnings of a woman determines her income status as well as her affordability and accessibility status in connection with modern contraceptives 1112 marital status of a woman can influence her acceptance and use of a modern contraceptive 5713 cultural factors religion and source of information have all links to the beliefs of the women and have been identified to have an influence on choice and use of modern contraceptive methods 11 14 15 16 17 the purpose of this analysis is to assess the trends and determinants of the use of modern contraceptives among ghanaian women of reproductive age it is also to determine whether clustering has an influence on the use of modern contraceptives in ghana clustering is considered in this study in order to access and control for heterogeneity if found to be present between participants from different areas or localities with different characteristics due to the multistage nature of the survey there is a high probability of overestimation of the standard errors if all participants are treated as if they come from the same locality and with similar characteristics this study seeks to determine and identify consistent determinants and others of modern contraceptive use from 2003 to 2014 among the currently nonpregnant married ghanaian women population the most influencing and consistent determinants that will be identified based on these findings will serve as priority intervention areas that the ghana ministry of health and other health partners can concentrate on to improve on the use of modern contraceptives in ghana methods data source the secondary data were obtained from the ghana demographic and household surveys from 2003 to 2014 through the dhs programme data access portal these nationally representative surveys have all studied participants representatively selected from the ten regions of ghana stratified according to urban and rural areas a review of all the survey reports state that a two stage sampling design was used for all the selected periods based on this technique the first stage has to do with the selection of enumeration areas referred to in this paper as clusters from an updated master sampling frame constructed from previous surveys this is usually done using systematic sampling with a probability proportional to the population size and number of households within the cluster this is then followed by the listing of all households within the selected clusters to provide a sample frame for the second stage in the second stage households are systematically selected from all the clusters to provide adequate estimates for key indicators with acceptable precision the variables for this analysis were extracted from the 2003 2008 and 2014 ghana demographic and health surveys structured questionnaires the inclusion criteria were women who slept in the selected households the night before the day of the interview the total number of eligible women interviewed in 2003 2008 and 2014 were 5691 4916 and 9396 respectively in our analysis only participants who provided responses to all variables were used all error entries and missing values for at least an observation or a variable were dropped the sample sizes that was finally used for the analysis were 2229 2356 and 4469 respectively for 2003 2008 and 2014 written informed consent was obtained during the data collection process by the dhs for all participants within the ages of 15 to 49 details can be found at ghana statistical service 4 study outcome modern contraceptive use among currently married nonpregnant women of reproductive ages 1549 years is the outcome variable as was capture in the dhs women within the ages 1549 years were asked if they used any contraceptive to delay or avoid conception those who responded yes were further asked of the type of contraceptive method they used the different types of fertility control methods used in this analysis were categorized into two traditional methods referred to as nonuse and modern contraceptives methods according to ghana statistical service 4 statistical analysis the analysis focused on the use of modern contraceptives and all the analyses were done using stataic version 141 the chisquared test statistics was used to determine whether there was a statistical significant difference among women who use modern contraceptives over the years in order to select and include variables in our multivariable analysis all the variables were assessed at the bivariate level variables were therefore included after having showed some significance at this level of analysis the simple cox proportional hazards model was used for this purpose statistical significance of explanatory variables were considered under an alphalevel of 005 with a confidence level of 95 even though the data sets were obtained by cross sectional surveys a cox proportional hazards model was used for the analysis this because it has been showed by breslow that by imposing a condition of constant follow up time the coxs model can be adapted for the estimation of prevalence rate ratios in cross sectional studies it is therefore a better alternative to logistic regression when equal times of followups are assigned to all individuals in order to ensure that the variance of the coefficients was not overestimated to result in wider confidence intervals compared to those in the binomial distribution a robust variance estimator was used hence a cox regression model with the same follow up time for each participant via a robust variance estimator was implemented the hierarchical nature of the data demanded that a multilevel regression model be used in order to obtain a more accurate and reliable coefficient estimate of the model parameters and their standard errors modelling at the household level did not show any significant association with modern contraceptive use it was therefore omitted from the entire model but cluster was adjusted for in accounting for unobserved variations that may exist between clusters where individuals are nested cluster was considered as a level2 variable while that of individual observations was assigned level1 in the absence of any significant unobserved cluster effect this model reduces to an ordinary cox proportional hazards model results the total number of observations identified based on the variables of interest over the period was 9054 the percentages of modern contraceptives use in ghana was 2153 in 2014 1575 in 2008 and 1875 in 2003 there was an increase in modern contraceptives use in 2014 compared to 2003 and 2008 in the analysis there was a significant difference among modern contraceptive users over the fifteenyear period with a chisquare value of 3368 and a corresponding pvalue 0001 among the women that used modern contraceptives rural residence accounted for 669 in 2003 and reduced to 642 in 2008 and further dropped to 5630 in 2014 the results also showed that there is low use of modern contraceptives among both rural and urban residence for all the periods the majority of the women had no formal education this increased from 3527 in 2008 to 3630 in 2014 by wealth index ratings the majority of the respondents are always in the poorest category these formed 2737 of all respondents in 2003 slightly increased to 2750 and further increased to 3023 in 2014 christians formed the majority of the respondents with most of the christian women belonging to charismatic denominations their number increased from 497 in 2008 to 5492 in 2014 a lot of the women have children between one and three in 2003 8178 of married women did not use modern contraceptives this increased to 8494 in 2008 and decreased to 7859 in 2014 compared to their colleges who are just living with partners results of the hierarchical modelling for both the crude and adjusted estimates are contained in table 1 women with 13 children in the unadjusted analysis showed a 67 more likely use of modern contraceptives compared to women without children in 2003 and this decreased to 54 in 2008 the 2014 analysis however saw a twofold more likely use of modern contraceptives among this group of women with a significant statistical association after adjusting for all the other predictive variables in 2003 there was a 95 more likely use of modern contraceptives among women with children 13 this decreased to 84 more likely use in 2008 and in 2014 a twofold likely use of modern contraceptives was observed among this category of women all referenced to women without children it was also noticed in the adjusted analysis that women with ten children and above were 315 times more likely to use of modern contraceptives compared to women without children it decreased to 95 more likely use of modern contraceptives among this category of women compared to women without children in 2008 and increased positively in 2014 by observing a twofold use of modern contraceptives among women with ten children and above compared to women without children educational level of women at the unadjusted level of analysis showed high statistical association with modern contraceptive use in 2003 2008 and 2014 the adjusted analysis revealed no statistical association as was the case with the crude analysis the adjusted analysis for 2003 showed that women with a higher educational attainment were 55 secondary education 32 and primary education level 24 s were more likely to use modern contraceptives compared to women with no formal education in 2014 the adjusted analysis revealed that women with a higher educational l attainment level were 48 more likely to use modern contraceptives than those with secondary education and primary education compared to women with no formal education the results show that place of residence is statistically the wealth index was found to be associated with modern contraceptive use in 2003 and 2008 with the exception of 2014 in which year it was not the adjusted analysis for 2003 showed that women from the poorest households were 31 more likely to use modern contraceptives women from richest middle and richer households were 16 12 and 7 more likely to use modern contraceptives all referenced to women from poorer households in 2008 the crude analysis showed that women from richer households were more likely to use modern contraceptives than women from poorest middle and richest households when compared to women categorized poorer households the adjusted analysis also showed a 72 increased use of modern contraceptives among women from richer households with statistical significance this is an increase over what was recorded in the same category in 2003 in 2014 the unadjusted analysis revealed that the higher the household wealth index the lower the likely use of modern contraceptives women from richest households were 25 less likely to use modern contraceptives compared to women from poorer wealth index households religion as one of the independent predictors was associated with modern contraceptive use in 2008 and 2014 the adjusted analysis in 2003 however revealed that modern contraceptive use among women belonging to either orthodox and charismatic denominations were equal with islamic women recording a 34 more likely use of modern contraceptives as against women with no religious faith in 2008 the adjusted analysis showed a general reduction in the use of modern contraceptives in all the religious denominations women within the orthodox churches recorded a 42 more likely use of modern contraceptives and the charismatics recorded a 23 more likely use of modern contraceptives muslim women were 15 less likely to use modern contraceptives than women with no religious faith in 2014 orthodox denominations were 15 more likely to use modern contraceptives this was a reduction from what was recorded in both 2003 and 2008 women within charismatic denominations recorded a 23 more likely use of modern contraceptives a reduction in what was noticed in 2003 and 2008 with reference to women with no religious faith even though women belonging to the islamic faith were 10 less likely to use modern contraceptives compared to women with no religion it was still an improvement over what was recorded in 2008 the cluster variable was included in the dataset and controlled for and found to be significant for some of the variables under study in the bivariate as well as the multivariable analyses for all the periods it was therefore necessary to account for the heterogeneity of participants location in order to generate accurate standard errors estimates more specifically in 2014 a cumulative cluster level variance of 0271 was recorded after adjusting for all covariates under study details of the other variables can be found in table 1 discussion the results of this analysis revealed the prevalence of modern contraceptive use in ghana as 1875 in 2003 1575 in 2008 and 2153 in 2014 the prevalence as observed in this study is similar to that reported in the ghana demographic and health survey study where 2003 recorded 187 2008 recorded 166 and that for 2014 was 222 the prevalence of this study showed a statistically significant difference over the period determined via a chisquared test statistic the results of this analysis revealed in the final adjusted model for all the periods under study that the higher the education level of a woman the higher her likelihood to use modern contraceptives in 2014 women who had primary education as the highest level of education attainment were 27 more likely to use modern contraceptives than women who had no formal education women who attained higher educational levels were 48 more likely to use modern contraceptives than women without formal education this finding though significant is lower than what was observed by balew et al which showed that women with higher education have a six fold higher odds of fp acceptance than those with no education 18 the 2014 results further showed that the higher a womans wealth index the less her likelihood of using modern contraceptives this is seen in the adjusted analysis where the results showed that women from the poorest households were 1 less likely to use modern contraceptives women from the richest households were 35 less likely to use modern contraceptives than women from poorer homes this is in line with a study in nigeria which revealed that there was 74 less likelihood of contraceptive use among women from richest homes compared to a 70 less likely use of contraceptives among women from poorest households 2 a similar study done in ghana revealed that women with high wealth status are less likely to use contraceptives than women with low wealth status 3 place of residence can to a large extent by default influence the type of work a person will most probably be doing for a living it was found that the use of modern contraceptives is increasing among rural residents e in ghana in 2003 adjusting for all the factors under study 22 of rural resident women were less likely to use modern contraceptives compared to urban resident women this decreased to 10 less likely use in 2008 but increased to 21 more likely use of modern contraceptives among rural resident women in 2014 compared to urban resident women this is in line with a study done in ethiopia by worku et al 19 which reported that modern contraceptive use increased from 24 among rural residence to 119 in 2005 and further increased to 289 in 2011 19 this improvement in ghana can be attributed to the priority given to the communitybased health planning services concept by the government of ghana in collaboration with the ministry of health the ghana health service and other reproductive health ngos have brought health care services to the door steps of rural residents that are affordable to families and individuals a study in uganda revealed that there is a downward trend in ruralurban variations in modern contraceptive use reporting an odds of 73 lower rate in 1995 the 2003 and 2008 results of this study are also in line with the results of a study conducted in the asuogyaman district of ghana 20 the study concluded that the use of modern contraceptives was higher in urban areas than in the rural areas 20 a womans type of earning determines her economic independence and her contribution to the household expenses this to a large extent empowers her in partaking in major family decisions including in the use of contraceptives the findings for all the periods revealed that women who are paid in cash compared to women who are not paid at all use more modern contraceptives than women paid only in kind as well as women paid both in cash and kind this is contrary to what was noticed in a study on inequality in the fertility rate and the use of modern contraceptives among ghanaian women from 1988 to 2008 that study revealed that the nonuse of modern contraceptives was 665 or 3 more likely among women with low income than among women with high income 7 the findings of this study are also in line with the findings of a study on trends of modern contraceptive use among young married women based on the 2000 2005 and 2011 ethiopian demographic and health surveys 19 the results revealed a higher use of modern contraceptives among women who are paid in cash for working than among women who are not working and women who are working but not paid 19 the results of this study also revealed that the use of modern contraceptives is lower among women with less than three children for all the periods it was constantly high among women with between four and nine children modern contraceptive use is higher among christians than among muslims there was a sharp decrease in modern contraceptives use among orthodox christians between 2008 and 2014 the use of modern contraceptives is however higher among charismatic christians than among orthodox christians the findings of this study are supported by other studies the results of these findings contradict those of a study conducted in mozambique which showed a higher prevalence of modern contraceptive use among catholics than among traditional protestants 21 in the unadjusted analyses for all the periods it was observed that the very strong and consistent predictors of modern contraceptive use among women of reproductive ages in ghana are place of residence and a womans level of education after accounting for cluster variation presented in either two of the three age periods strong predictors of modern contraceptive use among women of reproductive ages in ghana are wealth index partner educational level television as source of information health education by fp workers and desire for children the results of these findings are in line with the findings of a research done on predictors of modern contraceptive use in ethiopia which identified among other predictors place of residence possession of radio and income as significant predictors of modern contraceptives use 22 the results of this study contradict the findings of tsehaye et al 23 as the results of their findings identified place of residence ethnic groups religion and income as not associated with modern contraceptives 23 however the educational level of women marital status and age were identified to by associated with modern contraceptives use 23 this study also revealed that clustering have an effect on modern contraceptive use in ghana though it varies from year to year and from variable to variable this can be attributed to the empirical reasons that individuals within specific clusters will most likely share similar influencing factors and characteristics the results of these findings are in line with what was identified in a study on family planning promotion contraceptive use and fertility decline in ghana that noticed a cluster level variance of 015 that means that there is considerable variations in contraceptive use rates between clusters 11 study strength and weakness the main strength of this study is the analytic method used that is the multilevel or mixed effects cox proportional hazards model this regression model was used due to its advantage over the logistic model to determine associations between the dependent and the independent variables the representativeness of the participants was guaranteed because the survey was conducted by both national and international experts within the area the analysis done with the ghana demographic health survey stopped at just the univariate level this study went beyond just only that by applying both bivariate and multivariable approaches an important limitation of this study is that strong conclusions could not be drawn with respect to the causes of modern contraceptive use this is due to the crosssectional design of the survey hence causality could not be established conclusion the trend analysis of the 2003 2008 and 2014 gdhs data sets revealed a high use of modern contraceptives among urban resident women however there is a gradual increase in the use of modern contraceptives among rural women the study also found higher use of modern contraceptives among christian women than among muslim women even though it was noticed that there is a gradual increase in use among muslim women some of the factors associated with modern contraceptive use in ghana are place of residence and the educational status of a woman others include wealth index partner educational level television as source of information health education by fp workers and desire for children others include age of the woman type of earnings religion ethnicity radio as source of information and newspapersmagazines as sources of information in order to achieve a higher prevalence of contraceptive use more education is needed especially targeting muslim women family planning workers should be encouraged and motivated to help educate the women to reach a number of women sources such television radio and magazines should be used as a tool to reach the targeted group education on the use of contraceptives should not target only women but also the women partners due to partners influence on their usage more local authorities and men groups need to be targeted establishment of community health committees to help educate the people will also be in the right direction to achieve these the ghana health service with the support of other organizations need to make resources available to the regional health directorates for them to also distribute same to the district health directorates this must be done with an effective monitory and evaluation plan strictly implemented from national to the district levels competing interests the authors declare that they have no competing interests

background contraceptives are used in family planning to space or limit pregnancies and are categorized into modern and traditional methods the modern methods have been proven to be more scientifically effective at preventing unwanted pregnancies than the traditional methods with data from three 3 different demographic and health surveys the aim of this study is to assess the trends and identify factors that consistently influence modern contraceptives use among women of the reproductive age group in ghana methods the study used secondary data from the 2003 2008 and 2014 ghana demographic health surveys gdhs the trends of determinants of modern contraceptives use among women of reproductive age in ghana were determined a bivariate approach was used to select significant predictors the cox proportional hazards model analysis was employed via a multilevel modelling approach results out of the total respondents of 2229 2356 and 4469 1875 1575 and 2153 were modern contraceptives users for 2003 2008 and 2014 respectively the multiple cox proportional hazards model analysis identified place of residence and the educational level of a woman as strong predictors of modern contraceptives use in ghana modern contraceptive use is increasing among rural residence women who are in formal occupations professional clerical services are more likely to use modern contraceptives than their colleagues in less formal occupations manual agricultural sales conclusion this study highlights the trends of determinants on modern contraceptive use in ghana from 2003 to 2014 the most persistent determinants of modern contraceptive use in ghana during this time period are place of residence and a womans educational level women working in agriculture and sales are the least users of modern contraceptives in ghana over the period

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d rinking by young people is associated with an array of problems each year as many as 5000 youths younger than the age of 21 in the united states die as a result of drinkingrelated motor vehicle crashes homicides suicide and other injuries such as falls burns and drowning heavy episodic drinking by youths may be particularly closely associated with problem outcomes early onset of drinking is also associated with an increased likelihood of a broad range of negative consequences later in life such as dependence and abuse drinking and driving unwanted or unplanned sex unintended pregnancy sexually transmitted infections violence and unintentional injury overall the estimated costs of underage drinking in the united states reach 619 billion annually heavy drinking has especially been a public health concern for native american youths although considerable heterogeneity of drinking patterns among native americans has been reported native american youths are typically found to start using alcohol at younger ages than other youths and to drink more and more frequently the native american population experiences greater negative health consequences because of alcohol use and misuse including chronic liver disease alcoholrelated automobile crashes suicide homicide and fetal alcohol syndrome given these statistics it is important to better understand the risk factors related to drinking among native american youths to develop more effective prevention interventions availability of alcohol has been identifi ed as a key environmental risk factor associated with youth drinking and drinkingrelated problems thus drinking and drinking problems have been found to be higher in communities where availability is higher and enforcement of minorinpossession laws is less strict we know that individual characteristics such as age play a role in where youths access alcohol for example older adolescents are more likely than younger adolescents to obtain alcohol from parties friends and adult purchasers overall commercial sources are less frequently used to access alcohol than social sources for alcohol but become more important with age conversely family sources are used more frequently by younger adolescents and become less important with age in general older adolescents are less likely than younger adolescents to drink at home or in the presence of parents or other adults however the relationship between how alcohol is accessed and other individual characteristicssuch as race ethnicity and genderhas not been explored in detail studies have also investigated how community environmental factors relate to youth access to alcohol and to their drinking behaviors for example proximity of alcohol outlets and outlet density have been related to youth drinking and drinking problems and to the likelihood of using social and commercial sources of alcohol likewise neighborhood characteristicssuch as residential instability percentage in poverty and overall disadvantagehave been found to be related to increased adolescent drug and alcohol use few studies however have specifi cally examined racial and ethnic differences related to where and how youths access alcohol one study found that african american hispaniclatino asian and native american youths were less likely to obtain alcohol from social sources than their white counterparts another study conducted in wisconsin found that youths accessed alcohol primarily through social sources but the specifi c social sources differed for native american and white youths native american youths were more likely to have obtained alcohol from an adult or from someone younger than age 21 than were white youths whereas white youths were more likely to have obtained alcohol from their parents native american and white youths however did not differ in access to alcohol from other social sources the purpose of this current study is to examine differences in drinking behaviors and sources of alcohol among native american and white youths and to explore individual and environmental factors that are related to drinking and access to alcohol for these groups the present study fi lls a gap in our knowledge by investigating whether native american and white youths differ in their drinking behaviors and where they obtain alcohol using a large survey sample of adolescents from montana going beyond previous research the present study considers not only differences in drinking patterns and in how native american and white youths access alcohol but also environmental factors that may be related to youth access to alcohol and to drinking such information is crucial to understanding how youths in different racial and ethnic groups obtain alcohol and to designing effective policies and environmental interventions to reduce access to alcohol and ultimately drinking and drinking problems among youths method survey data the survey data were collected using the 2008 prevention needs assessment community student survey which is conducted by the montana department of public health and human services addictive and mental disorders division this voluntary and anonymous survey is administered every other year with youths in grades 8 10 and 12 the survey is designed to measure adolescent substance use antisocial behavior and risk and protective factors in 2008 data were collected using selfadministered surveys given by teachers and other school staff in 193 of 338 eligible schools of all eligible students in grades 8 10 and 12 across all schools 66 participated in the 2008 survey school boards were responsible for deciding whether to require active or passive consent from parents sample of the 21225 youths who participated in the 2008 survey 18916 had complete data on the variables of interest and reported being either native american or white of the 18916 respondents who comprised the analytic sample 75 were native american and 925 were white because this study focused on a comparison of native american and white youths drinking behavior and alcohol sources multiracial youths were excluded from the analysis as were youths who were neither native american nor white the native american youths in the sample did not differ in age from white youths overall 499 of the sample was female the gender distribution differed slightly between native american youth and white youths this difference however was not statistically signifi cant youths who identifi ed themselves as native american were not asked about their tribal affi liations youths were also not asked whether they resided on tribal land however seven counties included in the study overlap to a large extent with reservation land measures background variables background variables included gender age and race drinking lifetime drinking was ascertained by asking respondents on how many occasions they had ever had more than just a few sips of any alcoholic beverage drinking in the previous month was measured by asking on how many occasions during the last 30 days they had beer wine or distilled spirits to drink lifetime drinking and 30day drinking were recoded to response category midpoints heavy episodic drinking was measured by asking how many times in the last 2 weeks the youths had fi ve or more alcoholic drinks in a row heavy episodic drinking categories were recoded to category midpoints respondents were also asked how old they were the fi rst time they had more than a sip or two of beer wine or distilled spirits and how old they were when they began drinking alcoholic beverages regularly that is at least once or twice a month ease of access to alcohol perceived ease of access to alcohol was measured by asking respondents if you wanted to get some beer wine or hard liquor how easy would it be for you to get some response categories were very hard sort of hard sort of easy and very easy sources of alcohol to obtain information about sources of alcohol drinkers were asked where they usually obtained alcohol in the last year this question required youths to select responses from a list of sources use of each source was coded as a dichotomous variable countylevel variables to account for environmental factors four countylevel variables were included in the analyses density of alcohol outlets median income percentage of singleparent households and percentage of native american population outlet density was based on the average yearly number of licensed retail alcohol outlets in 2001 per square mile median income was based on 2007 us census estimates and was recoded as income in 10000 increments the percentage of singleparent family households was based on data reported by the montana department of commerce the percentage native american population by county was based on 2000 us census data there are 56 counties in montana but because of the low numbers of respondents in some of the counties 49 counties were included in the analyses multilevel regression analyses multilevel logistic and linear regression analyses were conducted to examine the relationships between individual and countylevel factors and drinking and alcohol sources these analyses were conducted with hlm version 604 to account for clustering of observations within counties the intraclass correlation coeffi cients for past30day alcohol use and lifetime drinking were both 02 in addition sudaan was used for bivariate tests that adjusted for clustering within counties individuallevel models included participants race gender and age the countylevel model included alcoholoutlet density per square mile median income percentage of singleparent households and percentage native american population population density was initially included in the models but was ultimately dropped because it was highly correlated with the percentage of native americans in the county results drinking descriptive statistics for the sample are provided in table 1 more native american youths had consumed alcohol in their lifetime consumed alcohol in the past 30 days and engaged in heavy episodic drinking in the past 30 days than white youths on average native american drinkers had their fi rst sip of alcohol at a younger age than white youths regular drinking also began at an earlier age for native american drinkers than for white drinkers when asked about how easy or diffi cult it was to access alcohol native americans and white youths considered it sort of easy with white youths considering it easier than native american youths sources for alcohol the most common source of alcohol for native american and white youths was someone age 21 or older more than half of native americans and 44 of whites reported getting alcohol from someone age 21 or older this source was followed by someone younger than age 21 commercial sources were not commonly used slightly more than 8 of native american and white youths reported getting alcohol from such sources buying alcohol without a fake id was reported by approximately 4 of native american and 3 of white youths stealing alcohol from a shop was reported by approximately 3 of native american and white youths about 2 of native american youths and white youths reported using a fake id to purchase alcohol almost 12 of native american youths and fewer than 7 of white youths obtained alcohol from strangers twice as many white as native american youths reported getting alcohol from home twice as many native americans as white youths reported getting alcohol from another relative about 10 of native american and white youths reported getting alcohol from a sibling countylevel variables alcohol retail outlet density ranged from 0013 to 3134 with a mean of 031 median income ranged from 28 to 55 with a mean of 38 percentage of singleparent households in the county ranged from 70 to 350 with a mean of 164 percentage of native americans in the county ranged from 04 to 612 with a mean of 79 the seven counties with the highest percentage of native americans were also the counties that are primarily native american reservation land drinking behaviors results of these analyses indicated that native american youths were more likely than white youths to have used alcohol in their lifetime and in the last 30 days after controlling for age and gender native american youths were also more likely to have engaged in heavy episodic drinking in the past 2 weeks signifi cant positive relationships were found for gender and age with lifetime use 30day use and heavy episodic drinking with males reporting more frequent and heavier drinking age at fi rst drink and initiation of regular consumption of alcohol showed the same trend native american youths reported fi rst alcohol consumption at younger ages than white youths males also reported their fi rst alcohol consumption at younger ages when compared with females not surprisingly current age was positively related with age at fi rst alcohol consumption because these variables are confounded there were also differences in youths perception of how easy it was to access alcohol overall native americans reported that it was more diffi cult to obtain alcohol than did white youths and males perceived it to be more diffi cult than did females age was positively related to ease of access with older youths reporting easier access to alcohol at the county level the density of alcohol outlets was not related to drinking behavior we found that median income was negatively related to lifetime use and perceptions of ease of access to alcohol the percentage of singleparent households in the county was positively related to lifetime use 30day use and heavy episodic drinking the percentage of native americans in the county was negatively related to lifetime use 30day use and heavy episodic drinking to further explore these fi ndings we looked at the interactions between the percentage of native american population and race none of these interactions was signifi cant indicating that similar effects were found for white and native american youths that is in both cases those living in counties with higher populations of native americans drank less sources of alcohol the results in table 3 indicate that native american drinkers were less likely than white drinkers to obtain alcohol from home with or without permission and were less likely to obtain it from someone younger than age 21 after controlling for background and countylevel factors native american youths however were more likely to obtain alcohol from siblings from other relatives from someone age 21 or older from a stranger or through theft from a store native american and white youths did not differ in their access to alcohol through purchases with or without a fake id gender and age were also related to the sources through which youths accessed alcohol male drinkers were less likely than female drinkers to obtain alcohol from home with or without permission from someone younger than age 21 or from someone age 21 or older males were more likely to access alcohol through strangers purchase it with or without a fake id or steal it from a shop males and females did not differ in accessing alcohol through siblings or other relatives age was positively related to accessing alcohol through siblings someone younger than 21 someone age 21 or older a stranger and buying it with or without a fake id age was negatively related to accessing alcohol from home without permission age did not play a role in accessing alcohol from home with permission through other relatives or through theft at the county level the density of alcohol retail outlets was not related to where and how youths accessed alcohol youths in counties with a higher median income were more likely to report getting alcohol from home without permission buying alcohol with a fake id and stealing alcohol from a shop youths in counties with a higher percentage of singleparent households were more likely to report getting alcohol from a stranger and someone younger than age 21 youths in counties with a higher percentage of native americans were less likely to report getting alcohol from home without permission from a sibling and from someone younger than age 21 these effects however were small discussion this study is consistent with previous research in fi nding that native american youths were more likely than white youths to have consumed alcohol in their lifetime and in the past 30 days and to report heavy episodic drinking retail alcoholoutlet density was not signifi cantly related to drinking in any of the analyses this lack of fi ndings contrasts with previous research the lack of effects in the present study may in part be the result of the county being too large a geographical unit to adequately capture the relation between alcoholoutlet density and drinking to the extent that alcohol outlets are concentrated in smaller geographical areas any relation between density and youth drinking may have been attenuated in our study unfortunately the available data do not identify outlet locations more specifi cally than the county level median income was negatively related to lifetime drinking and how easy it is to obtain alcohol it may be that counties with a lower median income have other factors that lead to increased alcohol use among youths for example family income is often used as an indicator of community disorganization with communities with higher rates of poverty having an increased risk for youth drinking median income was however positively related to stealing alcohol from a store indicating that youths from higher income counties were more likely to steal alcohol than those from lower income counties this may be a result of it being more diffi cult to access alcohol from other sources in higher income communities median income was also positively related to getting alcohol from home without permission and buying alcohol with a fake id the percentage of singleparent households was positively related to lifetime drinking 30day use and heavy episodic drinking as well as getting alcohol through strangers or someone younger than age 21 one potential explanation of this pattern may be that youths in oneparent households are monitored less closely than youths in twoparent households which has been shown to be related to adolescent risk behaviors living in a county with a greater percentage of native americans was negatively related to youth access to alcohol through home without permission siblings and someone younger than age 21 the percentage of native americans in the county was also negatively related to lifetime use 30day use and heavy episodic drinking these relations held for both native american and white youths this pattern suggests that youths in counties with higher proportions of native americans drink less it may be that communities with a higher proportion of native americans provide an environment for youths that has a protective effect for example studies have shown that native american youths who feel cultural pride and a stronger cultural orientation may exhibit fewer alcohol problems in contrast however other studies have found that identifi cation with native american culture living on reservations and participation in native american traditions may increase substance and alcohol use in some cases these relations may be dependent on the particular tribe or cultural traditions involved however we found that living in a county with a higher proportion of native americans was also protective for white youths as well as native american youths this suggests that there may be other social and environmental factors that are protective in the native american communities in our sample this study cannot determine exactly what aspect of montanas native american communities may be related to reduced alcohol use and access to alcohol among both native american and white youths our study suggests that the role of the family may be a particularly important factor that needs further exploration it has been hypothesized that native american parents may support youth drinking and use alcohol as a way to maintain family bonds our data do not support this hypothesis among the native americans included in this study rather our data show that the native american youths in our sample do not have the same access to alcohol at home as do white youths a similar pattern was found in our previous study of native american and white youths in wisconsin it may be that native american parents are more proactive about preventing youth access to alcohol in the home for example a study examining antismoking socialization found that native american parents were less likely than white parents to believe that schools are better than parents in teaching children about the dangers of smoking cigarettes this belief may be related to preventative steps taken by parents in addition tribal norms regarding alcohol may infl uence parental behavior findings from this study indicate that other adults should be targeted for prevention efforts for native american youths because adults other than parents are the primary providers of alcohol to them educating adults about the risks and legal liability of providing adolescents with alcohol as well as law enforcement strategies may be a useful starting point the focus for white youths should be on parents and other underage drinkers who provide alcohol in particular family interventions should focus on providing parents with guidelines about how to prevent youths from accessing alcohol at home in addition social host ordinances may prevent some parents or other adults from providing alcohol to youths in summary the data presented here indicate that strategies that aim to limit access to alcohol only through commercial sources may not be enough to prevent or reduce youth alcohol use furthermore racial and ethnic differences in the means by which youths access to alcohol are important considerations when selecting interventions such interventions need to be tailored to specifi c populations one of the strengths of this study is that the data set is unique in including a large number of native american youths however there are several limitations one of the limitations of data used for this and the majority of other studies that include native americans is that typically only a small number of tribes are represented this is an important consideration because alcohol use may vary in social acceptability among tribes and access to alcohol may be infl uenced by tribal norms and availability of alcohol for specifi c reservations and in specifi c communities further research should address how underage drinking norms and access to alcohol may differ among different native american communities in addition the study fi ndings based on montana data may not generalize to youths in other parts of the united states the studys crosssectional design also precludes causal interpretations of the observed relations we do not know if drinking is infl uenced by the source of alcohol or if the source of alcohol infl uences drinking behavior for example it is unclear whether youths obtaining alcohol from a certain source drink more alcohol or whether drinking behaviors lead to accessing alcohol from specifi c sources it may be that youths who drink frequently are more reliant on certain sources or are more likely to access alcohol through multiple sources compared with youths who drink infrequently conversely it may be that greater amounts of alcohol are obtained from certain sources which then leads to heavier drinking longitudinal research is needed to better ascertain the directionality of these relationships in addition the participation rate in the survey was low of all eligible students in grades 8 10 and 12 across all eligible schools in montana 66 participated another shortcoming of a schoolbased survey is that youths who drop out are not represented in montana the dropout rate is higher among native american youths than among white youths however overall the dropout rate is low and likely does not have a signifi cant effect on the fi ndings an additional limitation is that our measures for many of the environmental factors were at the county level the county may be too large a unit to thoroughly investigate such infl uences on youth drinking for example in contrast to some previous research density of alcohol retail outlets was not related to drinking behavior or access to alcohol in this study using data for smaller geographic units such as census blocks may be a more optimal unit of measurement in addition some of the countylevel effects may represent individuallevel effects singlefamily household and median income for example were included at the county level but no equivalent individuallevel variables were available despite these limitations this study highlights the importance of considering different ethnic and racial groups when considering youth drinking behaviors and access to alcohol this study further suggests that environmental interventions to address alcohol access need to be tailored for different populations or communities the evidence presented here indicates that strategies that aim to limit access to alcohol through commercial sources may not be enough to reduce youth alcohol use and that racial differences in access to alcohol are an important consideration when selecting interventions or different populations findings indicate that prevention efforts need to take group and possibly community differences into account to be effective

we investigated drinking behavior and sources of alcohol among native american and white youths as well as how underage drinking behavior and sources of alcohol may be related to environmental factors method survey data from a sample of 18916 youths 8th 10th and 12th grades from montana were analyzed using hierarchical linear modeling survey data were supplemented with countylevel economic and census data results native american youths were more likely than white youths to report drinking and heavy episodic drinking and initiate drinking at a younger age native americans were less likely than whites to get alcohol from home or from someone younger than age 21 but were more likely to get it from other social sources or through theft from a store living in a county with more native americans was inversely related to access to alcohol for both white and native american youths as well as reduced lifetime 30day and heavy episodic drinking living in a county with more singleparent households was positively related to lifetime drinking 30day drinking heavy episodic drinking and increased access to alcohol through someone younger than age 21 or a stranger median income was negatively related to lifetime drinking and ease of access to alcohol and was positively related to accessing alcohol from home without permission theft or purchase with a fake id conclusions because native american and white youths have different drinking patterns and obtain alcohol from different sources strategies to prevent alcohol problems in these groups should take these differences into consideration j stud

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introduction numbers play a prominent role in the daily life of human beings just as the motto of the pythagorean school goes all is number 1 2 3 the pythagoreans used numbers to describe the world attempted to capture the essence of all existing things and associated social meanings with the numbers for example they believed that odd numbers were masculine even numbers were feminine 4 the number one stood for the origin of everything and the number ten was the number of the universe 5 this kind of mystical worship for numbers became pythagorean numerology which affected many aspects of peoples life in turn up to the present similar numerology or number preference still widely exists in various cultures around the world 6 7 8 9 for example the number eight represents good fortune and wealth while the number four represents bad fortune in china 10 11 12 similarly in a few christian countries the number thirteen is seen as unlucky 1314 however in italy thirteen is considered a lucky number in modern society the preference for numbers has a profound influence on peoples decision making and it has been extensively studied in the field of consumer research 15 16 17 18 19 20 21 22 23 24 with the rapid development of the internet and the increasing popularity of intelligent terminals global online social media represented by facebook twitter wechat weibo and tiktok have formed a new transnational transethnic and transcultural online community with more than billions of people 25 26 27 28 29 these social media platforms play an indispensable role in daily life a large amount of data on user interaction behavior provides a solid foundation for studying the online presentation of human behavior based on the data generated by social media we can infer users characteristics 3031 and design a more accurate recommendation system 32 in addition users social profiles can reflect their personality 33 34 35 and their preferences for different ways of information consumption 36 in terms of specific applications the data of user interaction on social media can be applied for event prediction 3738 robot detection 3940 and fake news detection 41 further social media also provides us a largescale data of network topology and information transmission trajectory thus we can analyze the evolution of users attention 42 and discourse power in the network 43 in this present research we focus on the preference for numbers in the online social network sina weibo especially the choice for the number of friends we find that the distribution of users friend number has a very significant peak near 200 weibos network structure formation mechanism is the same as that of twitter users are free to decide who and how many to follow however they cannot determine who follows themselves and the corresponding number in this system the numbers of users followers are usually heterogeneous 4445 in other words most users often have a quite limited number of followers while a minority of users have a large number of followers such as social celebrities and entertainment stars however due to the limited time and attention of the users they can only maintain effective social relationships with a certain number of friends therefore the numbers of effective friends of the users are generally homogeneous 46 such as dunbar number 47 in this paper we mainly study users in sina weibo who have a particular preference for 200 friends and investigate their important social properties such as activity popularity attention tendency portraits evolution regional difference economic and educational development level related work number preference is a phenomenon that exists in different countries fields and cultures in 10 the authors studied price ending strategies in asia and found that people prefer prices ending with eight in asian cultures for four main reasons luck market norm appeal and value image in 11 the authors analyzed superstitions and price clustering in the taiwan stock exchange results showed the prevalence of price concentrates in the chinese lucky number group rather than the unlucky number group in 48 the authors analyzed companies listed on the taiwan stock market results revealed that firms could gain return premiums on the stock market if their listing codes include lucky numbers the authors in 12 studied the value of superstition in the number eight by using car plate auction data in malaysia they found that the number eight is considered lucky by ethnic chinese people the authors in 23 compared the effects of integers and nonintegers on consumers evaluation and judgment of related target entities results revealed using nonround numbers would increase attention to numerical values in 49 the authors used nigerian lottery games to analyze players number preferences they found that the two most popular numbers are one and nine and players tried to avoid multiples of seven and numbers containing seven the authors in 24 explored the degree to which voters can translate their ideological predispositions into numerical policy preferences and found that their ideological differences are reflected in numerical preferences with the rise of social media people have become more and more involved in their current online life a large amount of user behavior data has facilitated research in related fields based on social media user attributes researchers focus on predicting users personalities and analyzing their online behavior characteristics in 33 the authors proposed a machine learning approach to predict the users personality based on their social profile the authors in 36 studied users attention economy in news consumption by analyzing users portraits the authors in 30 identified the similarities and differences in personality characteristics of internet and social media addiction profiles in 34 the authors found extraversion is highly related to facebook usage similarly the authors in 35 found a positive relation between big five personality traits of user activity in 42 the authors examined the effects of follower number and comment tone on judgments about opinion leaders there are also some specific applications based on analyzing user attributes such as optimizing recommendation system 32 modeling information dissemination 4350 event detection 3751 and bot detection 3940 however for users with specific personalities offline there are few studies about how their online portraits would be as described before most studies about number preferences were conducted in a certain field offline to the best of our knowledge nobody has verified whether this phenomenon exists on social media moreover if it exists what numbers will it be and how would the attributes of users with these numbers preferences be this paper will bridge the gap between research on number preferences and how it presents on social media datasets and methods datasets as one of the most popular online social media platforms in china sina weibo 52 plays an important role in spreading popular topics entertainment gossip and celebrity anecdotes the collective behavior of users engaging in sina weibo makes it possible to study how traditional chinese culture is reflected on social media we collected users attribute information at three different times on weibo and included users nickname number of friends number of followers number of posts gender and city in addition we also collected data from chinas sixth census including the level of economic development population distribution gender composition age composition urbanization and education level of different regions methods based on the data collected in 2012 weibo users exhibit distinct preferences for the number 200 from both the national and regional levels to verify whether this phenomenon is stable and longstanding we randomly selected 68655 users whose number of friends was less than 200 in 2012 and then analyzed their distribution of the number of friends in 2021 meanwhile to justify this phenomenon as normal human behaviors rather than caused by robots we randomly selected 6620 users whose number of friends is near 200 and then analyzed their posts type after confirming this phenomenon is stable and has research significance we systematically compare the characteristics of users with and without 200 preferences from the static dynamic and regional levels the following are the definitions of variables used in this paper corresponding measurement and combination of using data variables description and definition here we describe the variables used in this paper the number of friends of a user is how many users heshe follows the number of followers of a user is how many users follow himher the number of posts is how many posts heshe has created since registration the post content is the content generated by users it may contain hyperlinks hashtags or mentions according to whether it is an original post or not the post content could be classified into two categories tweet or retweet the proportion of original posts is the percentage of tweets a user has tweeted since registration in section 42 we use m and k o to represent the users activity and popularity respectively the follower count of friends is the number of followers a users friends have based on the friends list we crawled the number of followers of each of hisher friends it directly reflects the users attention tendency especially the users preference on the popularity of their friends measuring portraits evolution in section 43 we explore the evolution of users portraits from 2012 to 2018 for each user we define δ the fluctuation of number of friends followers or posts of himher as δ x x x where x represents the number of friends followers or posts in year t then we calculate the fraction of δ ≤ 5 of two user groups similarly we calculate the fraction of users whose locations remain unchanged preference intensity in section 44 we study the preference intensity for number 200 in different regions we define the preference intensity of number 200 as pi p g 1 p g 2 g 3 where p g 1 ∑ 202 k i 200 p k i 3 and p g 2 g 3 ∑ 199 k i 193 p k i ∑ 209 k i 203 p k i 14 4 here p k i denotes the proportion of users whose number of friends is k i 3 and 14 denote the number of different k i in the user groups with and without the preference for the number 200 respectively linking user portraits to regional gdp and education in section 45 we study the correlations between preference intensity and regional characteristics the location information in user portraits can be used to identify which province heshe belongs to the census data records each provinces information about gdp education genderage composition etc we link province information to census data and get the corresponding regions gdp and education information results we crawled 6836935 users attribute information of sina weibo using a random walk sampling method 53 in 2012 when calculating the distribution of the number of friends we observe that there exists a very sharp peak at 200 in figure 1aj we demonstrate this phenomenon in different provinces in detail meanwhile figure 1l indicates that there is a peak between 200 to 202 this phenomenon reveals users preference for the number 200 to better analyze the statistical characteristics of the users with the preference of the number 200 we investigate the differences among various aspects of three user groups based on their number of friends group 1 whose number of friends is 200 201 or 202 which includes 48960 users group 2 whose number of friends is between 193 and 199 which consists of 88573 users group 3 whose number of friends is between 203 and 209 which includes 76954 users the number of friends for these three user groups is very close which can exclude other factors impact on subsequent analysis as much as possible and reflect the characteristics of users with the preference for the number 200 better we can observe that the distribution of the number of friends in sina weibo is homogeneous while the distribution of the number of followers is heterogeneous meanwhile we found a sharp peak at 200 in different regions which indicates this is a ubiquitous phenomenon note that the peak at the number of 2000 is caused by sina weibos system setting of the maximum number of friends for normal users and vip users are not subject to this restriction evolution of the number of friends in order to study the evolution of the distribution of the number of friends we randomly selected 22604 22936 and 23115 users whose number of friends in 2012 was in the range between 120 and 130 145 and 155 and 170 and 180 respectively and then crawled their attribute information in 2021 in figure 2a the histogram and the corresponding solid line represent the distribution of the number of friends for these three user groups in 2012 and 2021 respectively we can observe that the distribution of the number of friends in 2021 also has a peak at 200 meanwhile we used resampling methods 54 to estimate the bias here we used uniform sampling with a replacement method to investigate the effects of sampling bias from figure 2a we can see that the discrepancies between resampled dataset and the original dataset are minimal in all corresponding solid lines these results suggest that the sampling bias is not significant for verifying this is a stable phenomenon that is to say when a users number of friends evolved up to 200 the evolution speed will slow down in other words the number of friends of users will stay at 200 for a relatively long time this phenomenon reflects from another aspect that the preference for 200 friends is not robots behavior moreover we randomly selected 1302 users with the preference of the number 200 and 5318 users without the preference of the number 200 in 2012 in 2018 we crawled all posts of these users published since registration and counted the proportions of the original posts for each user figure 2b shows the distribution of proportions of original posts and we can see that the two distributions are almost the same specifically there are 4601 users with the preference for the number 200 whose proportion of the original post is more than half which is similar with users without the preference for the number 200 that indicates the posting behavior of users with the preference for the number 200 is consistent with that of normal users this further illustrates that the preference for number 200 is not robots behavior user activity popularity and attention tendency we start by studying the activity popularity and attention tendency of users whose number of friends is 200 201 and 202 from figure 3ab we can see that users with the preference for the number 200 have fewer posts and followers than users without the preference for the number 200 which means the former users are less active and popular for instance for the users with the preference for the number 200 3312 of users posted less than 10 posts and 2611 of users have less than 20 followers moreover the behavior of the two groups of users without the preference for the number 200 is almost the same further we analyzed the attention tendency of these users figure 3c shows users with a preference for the number 200 are relatively more inclined to follow popular users compared with users without the preference for the number 200 for instance there are 4342 of users with a preference for the number 200 would follow popular users while only 2651 of them would follow normal users however among users without the preference for the number 200 the corresponding percentages are 3613 and 3275 respectively three different color lines represent three user groups whose number of friends is between 193 and 199 between 200 and 202 and between 203 and 209 in 2012 respectively cumulative distribution of the follower count of friends the two dash lines corresponding to the abscissa are 5 × 10 2 and 10 5 respectively we can see that users with the preference for the number 200 have lower activity fewer followers and tend to follow popular users note that combined with the friends list and crawled the number of followers of each of the users friends then calculated the average follower count of these friends user portrait evolution in order to further investigate the activity of users with the preference for the number 200 we next focus on the evolution of users portraits over time in 2018 we have also collected the attribute information of users whose number of friends in 2012 was between 193 and 209 we obtained valid data consisting of 43198 users with the preference for the number 200 and 146404 users without the preference for the number 200 for users whose number of friends was k in 2012 we count the proportion of the users whose number of friends followers and total posts are fluctuated within 5 by 2018 ie the corresponding number changes were less than 5 compared to 2012 from figure 4ac we can see that compared to users without the preference for the number 200 the changes of the number of friends followers and total posts are smaller in users with the preference for the number 200 for instance in figure 4ac only about 10 of users without the preference for the number 200 change less than 5 while the corresponding proportions exceed 40 in users with the preference for the number 200 similarly we count the proportion of the users whose geographical position remains unchanged from 2012 to 2018 as figure 4d shows although both these two kinds of users rarely changed during this period the change of those users with the preference for the number 200 is even less regional difference next we discuss users preference intensity of the number 200 in different regions as defined in section 32 pi will be approximately equal to 1 if all users have no preference for the number 200 because there will be no peak at 200 in this case additionally a higher value indicates a stronger preference figure 5a shows that the preference for the number 200 intensity in northwest china is much stronger than the one in southeast china whose degree of difference can be separated well by hu line 55 a line dividing the population urbanization level and culture transformation moreover the preference intensity of number 200 in taiwan tibet and ningxia is highest while shanghai beijing and guangdong are relatively lower further we rank 34 regions preference intensity of number 200 as figure 5b shows we can see that the preference intensity in the northwest region is significantly higher than the national average while the southeast region is far below the national average for instance tibet and ningxia are 47 and 33 higher than the national average respectively while shanghai and fujian are below 28 and 23 respectively the relationship between the preference intensity of the number 200 and the average years of education in the region each point represents a province and the black line represents the fitted line of the least squares method with a confidence of 95 r 2 are 056 and 032 respectively from this figure we can see that there exist obvious differences in regions for preference intensity the northwestern region is relatively strong while the southeastern coastal region is weak moreover there is a significant negative correlation between preference intensity and the level of regional economiceducational development economic and educational level figure 5a shows the 200 preference intensity roughly decreases from northwest to southeast china which is consistent with the regional economic and educational level that prompted us to further study their correlations we collected relevant data from the official website of the national bureau of statistics 56 including the regional gdp of 31 provincesmunicipalities in mainland china and the average years of education in each province in the sixth population census in 2011 figure 5cd exhibit the negative correlation between the economic level the educational level and the preference intensity of the number 200 which implies regions where the economic and educational levels are more undeveloped the preference intensity for number 200 is more strong conclusions in this work we studied 68 million sina weibo users systematically and found that a significant fraction of users have a special preference for number 200 ie they prefer to follow 200 friends we comparatively portrayed users with the preference for the number 200 from several different perspectives such as user activity popularity attention tendency regional distribution economic and education level the results show that users with a 200 preference have lower social activity and fewer followers compared with users without the preference for the number 200 we found that they are more inclined to pay attention to users with higher popularity and their social portraits change relatively slowly moreover we also found the preference intensity of number 200 is stronger in regions with relatively undeveloped economic and educational levels further analysis revealed that there exists a significant negative correlation between the preference intensity and the development of regions that indicates users with the preference for the number 200 are likely to be vulnerable groups in society and influenced by opinion leaders in the network we argue that people have a special preference for 200 friends for a few reasons on the one hand in traditional chinese culture people have a special preference for some numbers such as 6 8 10 100 200 etc on the other hand due to the limits of brain capacity people can only maintain effective social relationships with a certain number of friends however online social networks make information exchange among people more convenient than ever which is the most likely reason why the number of friends is a little higher than the dunbar number 47 in online social networks discussion this paper systematically studied the phenomenon of number preferences on one of chinas most popular online social media nevertheless two questions need to be seriously considered when evaluating its universality around the world firstly whether there is a similar phenomenon of number preference on other social networks secondly if so whether the exact number is still 200 or another number that depends on its cultural background yet it is difficult to verify the above two questions affected by the facebookcambridge analytica data breach 5758 the worlds mainstream social media such as twitter facebook and wechat have strengthened user privacy protection through the restricted apis and anticrawler mechanism 59 it is now almost impossible to collect large amounts of user data in a short time besides collecting and using data correctly is another issue that cannot be ignored 60 however verifying its universality will be still possible in the future on the one hand suppose other social media reopen their previous apis to access more user data or researchers collaborate with the social media to get the required data in that case it will be possible to examine this phenomenon on different social network platforms in china and beyond on the other hand largescale offline experimental investigations which take more time and effort might also help validate the above findings data availability statement data associated with this study will be available on the website of corresponding author after publication author contributions yh designed the study fm and hs performed the study and analyzed the results jx jw and cw discussed and analyzed the results fm and yh wrote the manuscript all authors have read and agreed to the published version of the manuscript abbreviations the following abbreviations are used in this manuscript mathematical symbols the following mathematical symbols are used in this manuscript δ fluctuation of user portraits p k i distribution of number of friends ∑ p k i sum of distribution of number of friends p gi average of distribution of number of friends in g i

preferences or dislikes for specific numbers are ubiquitous in human society in traditional chinese culture people show special preference for some numbers such as 6 8 10 100 200 etc by analyzing the data of 68 million users of sina weibo one of the largest online social media platforms in china we discover that users exhibit a distinct preference for the number 200 ie a significant fraction of users prefer to follow 200 friends this number which is very close to the dunbar number that predicts the cognitive limit on the number of stable social relationships motivates us to investigate how the preference for numbers in traditional chinese culture is reflected on social media we systematically portray users who prefer 200 friends and analyze their several important social features including activity popularity attention tendency regional distribution economic level and education level we find that the activity and popularity of users with the preference for the number 200 are relatively lower than others they are more inclined to follow popular users and their social portraits change relatively slowly besides users who have a stronger preference for the number 200 are more likely to be located in regions with underdeveloped economies and education that indicates users with the preference for the number 200 are likely to be vulnerable groups in society and are easily affected by opinion leaders

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introduction globally an estimated one in ten individuals are now obese 1 between 1980 and 2008 the agestandardized prevalence of obesity rose from 48 to 98 in men and from 79 to 138 in women worldwide 1 as has been well documented overweight and obesity have been linked to several major chronic diseases including type ii diabetes selected cancers cardiovascular disease asthma gallbladder disease osteoarthritis and chronic back pain 2 an estimated 26 million people die each year from noncommunicable disease as a result of being overweight or obese the large majority of deaths occurring in resourcepoor countries 3 several risk factors for overweight and obesity have been identified during different periods of the life course with special attention given to those occurring early in life a review of the effects of earlylife socioeconomic status based on 30 studies almost all from highincome countries found that low childhood ses was typically associated with an elevated risk of adult obesity particularly in women 4 there have been conflicting reports as to the direction of the sesadiposity relation in lowand middleincome countries some investigators report that higher ses is associated with higher adiposity 5 6 7 and others that higher ses is associated with lower adiposity 89 this may be due to methodological limitations including the ses indicator used in addition most populations comprise only women yet there may be differential sesadiposity effects according to gender as evident in a cohort from china 10 however longitudinal data from lmics are scarce this is in part because of the high loss to followup resulting from rudimentary administrative tracking systems and internal migration in these societies herein we address these methodological shortcomings and paucity of data by examining the association between earlylife ses and adult adiposity gender differentials social mobility and the effect of mediators including adult ses and behavioural risk factors in the ribeirao preto cohort the earliest established cohort study in brazil 11 materials and methods sample and participants in the present analyses we use data collected between 1978 and 2004 as part of the ribeirao preto cohort study ribeirao preto is a city of over halfamillion inhabitants in the south east of brazil the rpcs was designed specifically to investigate the contribution of earlylife exposures to adult risk of noncommunicable disease a full description of the study member characteristics and methodology has been published elsewhere 12 in brief a total of 9067 newborn babies were recruited through their mothers from 1 june 1978 to 31 may 1979 babies of mothers who were not from ribeira ˜o preto and did not reside in the city at the time of delivery were excluded the additional exclusion of twins resulted in 6827 single liveborns in the cohort in 2004 when the study members were aged 2325 years the procedures used to identify surviving study members included accessing the original birth charts which held addresses of the liveborns and updating this information from a series of registers the latter included the unified health system electronic database lists of users of private health plans school charts and military recruitment charts from the original cohort of 6827 liveborns 343 participants were found to be deceased and 819 could not be traced leaving 5665 singletons attempts were then made to invite for medical examination a nonrandom sample based on oneinthree of this group the first of every three names was selected from a list sorted by birth date in each geographic region and if unavailable the next name down was selected in this traced group losses to followup occurred because of refusal to participate imprisonment death after 20 years of age or failure to attend interview losses were replaced using the same sampling frame resulting in 2063 young adults 1112 figure 1 illustrates the flow of participants over 25 years of followup outcomes three indices of adiposity were used body mass index waist circumference and waisttohip ratio these were calculated from anthropometric measurements obtained at followup trained doctors and nurse technicians took these measurements from individuals in light clothing without shoes based on a standard protocol using a precision scale that was periodically calibrated and a nonstretch metric tape height was measured to the nearest 01 cm using a freestanding wooden stadiometer made at the university of sao paulo brazil based on the harpenden model weight was measured to the nearest 50 g using mechanical scales wc was measured as the smallest circumference between the ribs and the iliac crest while the participant was standing with the abdomen relaxed at the end of a normal expiration where there was no natural waistline the measurement was taken at the level of the umbilicus hip circumference was measured at the maximum circumference between the iliac crest and the crotch while the participant was standing all the circumference measures were recorded to the nearest 01 cm bmi was calculated as weight in kilograms divided by height in metres squared ses and other variables total family income was recorded at birth and then again at followup participants were asked to report their family income using the question how much did you and all the members of your family earn last month interviewers specified that sources of income should include salaries money earned from investments including interest property rentals pensions donations from parents and any other source absolute income values were converted into multiples of the brazilian minimum wage in each period and categorised into tertiles for the purposes of the present analyses this overcame issues of inflation changes in the minimum wage and the fact that brazil changed currency during the course of the study to examine the effect of social mobility on adiposity a variable comprising the four different permutations of childhood and adult ses categories was created lowlow was the reference group the role of a number of adult health behaviours as key mediators was also investigated total caloric intake percent fat intake and physical activity current smoking and current alcohol consumption total caloric intake and percent dietary fat were calculated by the dietsys software version 40 based on the information derived from a food frequency questionnaire validated for the brazilian population 13 physical activity was measured by the short version of the international physical activity questionnaire 14 these data were then classified as low moderate and high based on the metabolic cost or unit of resting metabolic rate study members had been weighed at birth within 30 min of delivery naked using mechanical scales that were calibrated weekly and with a measurement accuracy of 10 g statistical analysis the sample characteristics were examined by ses and by gender linear regression was used to estimate the coefficients and 95 confidence intervals for the association between childhood ses and the three markers of adiposity in model 1 the unadjusted sesadiposity relationship was estimated in model 2 adult ses was added model 3 builds on model 2 by adding the potentially mediating health behaviour variables as well as birthweight a path diagram of the association between childhood ses and adult adiposity based on known associations in developed countries is shown in figure 2 the regression results were examined in the light of the expected associations depicted in this diagram in preliminary analyses it became apparent that gender was an effect modifier in the sesadiposity relationship the pvalues for a gender interaction for childhood and adulthood ses in relation to wc and whr wereo002 in all models for bmi the equivalent pvalue was o0001 in the crude model on this basis analyses were performed separately for men and women all the analyses were conducted using the stata 10 statistical package results table 1 shows the distribution of cohort characteristics by childhood and adult ses higher ses in childhood and adulthood was associated with higher birthweight for men and women birthweight was normally distributed in all income groups higher ses in both men and women was associated with lower current caloric intake while higher ses was associated with a higher frequency of alcohol consumption and smoking table 2 shows the unadjusted and adjusted linear regression coefficients for the association between ses and adult adiposity as measured by bmi as described there was some evidence of a difference in these associations in men and women thus higher childhood ses was associated with lower adult bmi in women whereas men from a more affluent background had an elevated adult bmi relative to their lower ses counterparts after adjustment for adult ses the association was attenuated in women further adjustment for health behaviours and birthweight did not markedly change the association between childhood ses and bmi in either women or men table 3 shows the results of the analyses with wc and whr as the outcomes of interest the pattern of association with ses was similar to that for bmi except that the association between childhood ses and whr remained significant after adjustment for the covariates a model adjusting the childhood ses estimates for health behaviours and birthweight was run but did not result in any important differences for example the coefficient comparing high with low childhood ses in relation to bmi 95 ci was à 149 à 229 à 069 before adjustment and à 150 à 233 067 after adjustment controlling for each individual health behaviour separately did not have any further impact on the sesadiposity estimates table 4 shows the relationship of social mobility with the three markers of adiposity among men there was some suggestion that upward mobility might be associated with protection against increased adiposity vs no mobility for bmi 95 ci à 048 à 135 039 both downward mobility and remaining in the high ses group appeared to be associated with higher adiposity compared with remaining in the low ses group in men among women the coefficients showed that upward mobility was protective against adult adiposity compared with remaining in the low ses group remaining in the high ses group was also protective compared with remaining in the low ses group nb the relationships are based on known associations in high income countries low childhood ses ↑ adiposity ↑ caloric intake ↑ fat intake ↓ physical activity ↑ alcohol consumption ↓ smoking low adult ses adult health behaviors discussion in the present study we examine the relation of ses in childhood and early adulthood with adult adiposity in a country in economic transition by using data from the ribeirao preto cohort the main finding was that in women higher ses is associated with lower adiposity whereas in men higher ses is associated with higher adiposity upward mobility and retaining a high ses were found to be protective against adult adiposity in women with the results generally consistent across the adiposity measures comparison with prior studies in relation to the conflicting reports as to whether excess adiposity is becoming a problem of the poor or remains a problem of the higher social groups this study contributes by using a different measure of ses most other studies are based on data for women and use education or wealth to represent ses 56891516 the findings presented in this study show that excess adiposity is a greater problem for low rather than high ses women as found in highincome countries the findings concur with the predictions from the monteiro model 8 that in countries with a gross national income per capita greater than us 2500 higher ses is associated with lower adiposity in women the opposite is true for men where data for men are available evidence suggests that higher ses men become protected from excess adiposity much later than higher ses women in the process of economic development 17 which could explain the gender differences observed in this study among men in the uk whitehall ii cohort a negative association between ses and whr appears to have emerged suggesting men of higher ses may eventually become protected compared with men of lower ses at very high levels of gross national income per capita in terms of the relative importance of childhood vs adult ses the findings in this study differ from those in hics where childhood ses appears to be important in determining adult adiposity in women 18 19 20 and less so in men 421 there are however comparable gender differences in the childhood sesadiposity relationship in hics higher childhood ses is associated with lower adiposity in women while a less consistent direction of association is reported in men data from chinaanother lmicshow an independent association between earlyadulthood ses and metabolic risk after adjustment for childhood ses and health behaviours in women as reported in this study 22 we also found that upward mobility reduces the risk of excess adiposity in women as reported in some of the cohorts from hics 2021 but not others such as the whitehall ii cohort 23 and the british birth cohort 18 this may be a result of differences in cohort maturity the much more mature uk cohorts may be subject to an attenuation of the protective effect of upward mobility due to the increased risk of overweight associated with ageing in addition mobility effects may be much more pronounced in rapidly changing economies plausible mechanisms socially patterned childhood exposures are thought to influence later life outcomes in a number of ways including biological programming during critical periods of growth and through the early acquisition of unhealthy lifestyles 24 while childhood and adult ses are correlated the importance of adult ses in this study was greater in the sesadiposity relationship in women whereas childhood ses appears to be more important in men one explanation for this gender differential may lie in the rapidly changing environment in the early 1980s when the rpcs cohort participants were children overweight and obesity were not yet a public health problem and awareness of dietary habits and obesity may have been low at that time ensuring children had a sufficient quantity of food and enjoying any new commercial food products were the dietary priority at followup however in 2004 it is likely that women of high ses would have experienced social pressure to lose weight and conform to a slim western body shape preference 25 men on the other hand may not have experienced the pressure of these new norms and may simply have retained the dietary habits and body shape expectations formed in their childhood this explanation is temporally consistent with observed longterm trends of obesity by ses in brazil from 1975 to 1997 a period of significant social and economic change in brazil obesity increased from 24 to 69 among men and from 7 to 125 among women this change however was not observed across all socioeconomic groups in men all groups showed an increase in obesity over time and the gradient remained positive had a higher prevalence of obesity in women obesity more than doubled in the lower ses group while the prevalence in richer women started to drop from 128 in 1989 to 92 in 1997 726 this suggests the social gradient had reversed in brazil in women but not men and is consistent with other reports 11 in further explaining why women who remain in the low ses group are most at risk of increased adiposity a biologyenvironment interaction specific to transition settings may be at play a rapid nutrition transition from a situation of calorie scarcity to one of highenergy density could have caused a mismatch between metabolic programming and the energy available for consumption with a consequent increase in the susceptibility to excess adiposity as formulated in gluckmans matchmismatch hypothesis 27 indeed stunted brazilian children have been found to have impaired oxidative stress which combined with a later life exposure to energydense diets increases the risk of obesity 28 this phenomenon is thought to only be observable in countries undergoing a rapid nutrition and economic transition 29 furthermore intrauterine growth retardation was socially patterned in the rpcs with lower birthweights found among lower ses groups 30 a separate study of the rpcs found that severe intrauterine growth restriction was associated with increased preference for carbohydrate consumption in girls but not boys 13 a study of a chinese cohort has also examined the effect of rapid transition in both genders it compared longterm hong kong residents with residents who had migrated from a relatively undeveloped chinese province and found gender differences in lipid profile and fat distribution 3132 it was postulated that sex hormones in puberty among males experiencing an improved nutrition environment and higher socioeconomic development caused them to be more likely to be at risk other possible explanations for the gender and ses differentials that link social and biological factors include the large scale social changes experienced in brazil particularly by women there has been a dramatic decline in fertility rates especially in wealthier households 3334 where women of higher ses tend to have fewer children 35 36 this may reduce their risk of excess adiposity compared with lower ses women who continue to have a relatively greater number of children in addition the adiposity risk associated with repeated pregnancies may explain why women appear to be generally more susceptible to excess adiposity than men in lmics 37 these initial findings from lmics ¼ model 2 þ health behaviours þ birthweight health behaviours include total calorie intake percent fat in diet alcohol consumption smoking and physical activity socioeconomic status gender and adiposity in brazil including brazil and china begin to illustrate how risk factors that have both critical and cumulative effects differ in salience in men and women and how rapid economic transition can influence this salience 38 strengths and limitations the 197879 rpcs provides unique data for the investigation of cardiovascular risk in transition settings the findings are hypothesis generating for future research in lmics despite any limitations of the samples those followed up had a slightly higher overall education level and occupational status compared with the overall sample 12 in addition individuals of low ses had somewhat lower followup rates compared with those of high ses 30 of women and 25 of men of low ses were followed up compared with 36 of women and men of high ses this may have influenced the variation in the sample and account for the absence of social patterning of some of the important behavioural factors in table 1 in particular the fact that there was a significant difference between the two periods in the prevalence of low childhood ses may have affected the results however the fact that the findings are consistent with other cohorts from brazil and data from chinese cohorts supports their relevance in understanding the social patterning and mechanisms of excess adiposity in lmics a single ses measure was used in the study but the availability of income data provides an alternative to the wealth and education indicators commonly used in analyses of ses and adiposity and contribute to resolving some of the questions surrounding the association in lmics education was not taken into account although it has been shown to mediate between childhood ses and adult smoking and overweight 18 this may have had a role in producing the gender differences observed in the data as the health returns to educational attainment are likely to differ between the populations of men and women in brazil however the majority of participants at followup had similar levels of education 13 the results were largely consistent across the three adiposity measures displaying the same gender patterns the availability of anthropometry at birth strengthens the conclusions regarding ses effects independently of biological factors the investigation incorporated health behaviours and revealed very little role for these in mediating the ses effect in either gender although physical activity remains difficult to assess accurately the international physical activity questionnaire is one of the more reliable questionnaires the cohort was not old enough to yield information about effects at older ages and therefore limits the generalisability of the findings to other age groups finally another possible source of uncertainty around the results comes from the fact that low ses participants were more often found to be heads of their household compared with high ses participants which may have affected the precision of the householdbased ses measurement the most likely explanation is that high ses 24yearolds will have remained in education for longer and be living in their parental homes low ses individuals would more often be classified as head of the household either because they entered employment and started earning greater incomes than their parents or may have started working got married and left the parental home in view of these contextual observations it is unlikely that the precision of the ses measure would be significantly affected particularly in comparing lowand highses groups because the overall aggregate household incomes would have been very different abbreviations bmi body mass index ci confidence interval ses socioeconomic status wc waist circumference whr waisttohip ratio a fully adjusted model health behaviours include total calorie intake percent fat in diet alcohol consumption smoking and physical activity conclusion this study contributes to both the investigation of changing patterns of association between ses and adiposity and the emerging understanding of life course effects of ses in lowand middleincome countries where the burden of excess adiposity is reaching alarming levels 39 it shows that the nature of the association and the effects of earlylife ses on adiposity differ by gender among women high ses is associated with lower adiposity and adult ses appears to be more important than childhood ses in contrast men displayed the opposite pattern with high ses being associated with higher adiposity and adult ses being less important these findings suggest women are experiencing the social transition much faster than men lmics are experiencing social changes affecting obesity risk at a much faster pace than populations in hics hics experienced changes in dietary and physical activity patterns over several decades affording them time for health services and public health systems to adapt to the changing disease profile in the population the luxury of time may not be available for lmics and they may need to adapt much more rapidly to provide adequate prevention and health care delivery for excess adiposity and its complications in terms of research the confounding structure of any given disease outcome in settings experiencing such rapid social and economic transition may differ from those in highincome countries and gender specific effects of ses on adiposity appear to be more salient in lmics 1719 this makes the investigation of the patterns and mechanisms of overweight and obesity in lmics crucial 4041 longitudinal data from lmics can reveal important differences in the role of ses as period effects are captured within single cohorts finally reducing health inequalities gender or otherwise is an important intervention in reducing poverty as set out in the millennium development goals 42 conflict of interest the authors declare no conflict of interest

background longitudinal studies drawn from highincome countries demonstrate longterm associations of early childhood socioeconomic deprivation with increased adiposity in adulthood however there are very few data from resourcepoor countries where there are reasons to anticipate different gradients accordingly we sought to characterise the nature of the socioeconomic status ses adiposity association in brazil methods we use data from the ribeirao preto cohort study in brazil in which 9067 newborns were recruited via their mothers in 197879 and oneinthree followed up in 200204 2325years ses based on family income salaries interest on savings pensions and so on was assessed at birth and early adulthood and three different adiposity measures body mass index bmi waist circumference wc waisttohip ratio whr ascertained at followup the association between childhood ses adult ses and social mobility defined as four permutations of ses in childhood and adulthood lowlow lowhigh highlow highhigh and the adiposity measures was examined using linear regression results there was evidence that the association between ses and the three markers of adiposity was modified by gender in both adulthood po002 for all outcomes and childhood ses po002 for wc and whr thus in an unadjusted model linear regression analyses showed that higher childhood ses was associated with lower adiposity in women coefficient 95 confidence intervals bmi à 149 à 229 à 069 wc à 385 à 573 à 197 whr à 003 à 004 à 002 however in men higher childhood ses was related to higher adiposity bmi 103 028 à 178 wc 315 120 509 whr 0009 à 0001 0019 although statistical significance was not seen in all analyses there was a suggestion that adult ses but not adult health behaviours or birthweight accounted for these relationships in women only upward mobility was associated with protection against greater adiposity in women but not men conclusion in the present study in men there was some evidence that both higher childhood and adulthood ses was related to a higher adiposity risk while the reverse gradient was apparent in women

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prevalence studies such complications may also arise from cultural differences in the understanding of cyberbullying as well as from the rapid developments in technology cyberbullying can lead to various negative emotions patchin and hinduja reported that those who suffered from cyberbullying usually experienced anger frustration and sadness kowalski limber and agatson indicated that cyberbullying victims generally experience isolation loneliness anxiety depression and lowered selfesteem beran and li found that those who have been cyberbullied are more likely to engage in antisocial behaviors such as absenteeism in fact it has been found that cyberbullying may lead to more severe negative outcomes when compared to traditional bullying for instance hay meldrum and mann found that cyberbullying had modestly higher effects in terms of delinquency selfharm and suicidal ideation thus it is important to examine the factors influencing cyberbullying perpetration although there exists extensive research in the field of cyberbullying most studies are lacking in theoretical foundations tokunaga as well as heirman and walrave indicated that it is important to examine cyberbullying based on a theoretical framework although two studies have employed the theory of planned behavior to explore cyberbullying perpetration these studies mainly focused on american college students and european adolescents without considering younger children and those from asian countries in addition some studies have explored the role of parental mediation on cyberbullying victimization however studies examining the association between parental mediation and cyberbullying perpetration especially across different age groups are limited therefore this present study explores cyberbullying perpetration from a theoretical angle with a focus on the extended theory of reasoned action and the parental mediation theory this study focuses on cyberbullying on social media because there are limited studies in this area even though cyberbullying has been found to be the most rampant on social media specifically this study examines the effects of attitude subjective norms descriptive norms injunctive norms and active mediation and restrictive mediation on cyberbullying perpetration on social media among primary and secondary school students in singapore furthermore we also examine age as a potential moderator of parental mediation and cyberbullying perpetration on social media theory of reasoned action the theory of reasoned action can be used to forecast peoples behavioral intention and hence predict their likelihood of engaging in that behavior tra includes two types of beliefs behavioral and normative beliefs first behavioral beliefs are dependent on individuals attitude towards the behavior in other words individuals possessing a more positive attitude towards a certain behavior are more likely to perform the behavior indeed attitude towards cyberbullying was found to be positively associated with cyberbullying perpetration second normative beliefs focus on how subjective norms influence behavioral intention the formation of a subjective norm is dependent on expected social expectation from important others upon engaging in the behavior this includes expectations of individuals friends and family which is positively associated with behaviors several studies have established the significance on the subjective norms induced by important others onto ones behavior for instance heinemann pellander vogelbusch and wojtek found a strong positive correlation between subjective norms and subsequent treatment of physically handicapped individuals and homosexuals furthermore since subjective norms are formed via the perceptions of ones important others these norms may be observed via individuals behavior toward ingroups and outgroups for example group bias is commonly observed among children e especially those with higher levels of group identification when individuals have strong beliefs that the behavior will elicit social understanding they will be more likely to perform the behavior ojala and nesdale found that the frequency of bullying behaviors increases when aggressiveness and bullying attains legitimacy or validity by being considered as a norm in the ingroup furthermore doane et al explored cyberbullying perpetration among american college students and found strong positive correlations between attitude subjective norms and cyberbullying perpetration based on the abovementioned considerations we advance the following hypotheses h1 individuals with less favorable attitude are less likely to engage in cyberbullying perpetration on social media h2 individuals who perceive that significant referent groups would disapprove of them to cyberbully others are less likely to engage in cyberbullying perpetration on social media descriptive norms in general social norms are rules and standards that are understood by members of a group and that guide andor constrain social behavior without the force of laws besides subjective norms the social norms theory postulates the existence of two other normsdescriptive and injunctive normsthat are also associated with behavior these three norms could lead individuals into constructing an inaccurate standard of behavior upon misinterpreting the attitude andor behaviors of family members and peers descriptive norms are formed by observing the actions of others credibility of particular behaviors is boosted when many people engage in them thus making the behaviors more acceptable and correct the perceived social support then helps individuals formulate social heuristics which is a general guideline that leads to correct behavior most of the time in the case of traditional bullying in a classroom environment descriptive norms can come from estimates of the frequency of a behavior within a group where when more students are engaging in bullying behavior the behavior will be more likely to be deemed as the common and correct behavior hence increasing the students behavioral intentions while there is much evidence that descriptive norms are positively associated with traditional bullying studies examining the relationship between descriptive norms and cyberbullying are scarce moreover traditional bullying and cyberbullying take place in different environments therefore we cannot simply assume the same relationship between descriptive norms and cyberbullying hence we propose the following research question rq1 how does perceived prevalence of significant referent groups in cyberbullying relate to individuals likelihood to engage in cyberbullying perpetration on social media injunctive norms injunctive norms indicate the extent of general consensus for socially acceptable behaviors injunctive norms differ from subjective norms in the notion that it considers the perception held by society in general while subjective norms focus on perceptions held by ones important others in forming a perceived injunctive norm individuals will consider expected levels of approval andor punishment from the general public approval can come in the form of popularity while punishment can come in the form of social isolation previous research has found that injunctive norms affected both normative beliefs of aggression and had direct effects on aggressive behavior over time this implies a relationship between injunctive norms and traditional bullying however extant cyberbullying research understudied the association of injunctive norms with cyberbullying perpetration thus we develop the following research question rq2 how does the perception that societal approval of cyberbullying relate to individuals likelihood to engage in cyberbullying perpetration on social media parental mediation according to the parental mediation theory various interpersonal communication strategies are employed by parents to reduce the harmful consequences of their childrens media usage the pmt usually encompasses two types of mediation e active mediation and restrictive mediation active mediation addresses the fact that children are active users of cyberspace and actively engage in activities such as seeking others with the aim of communication for instance parents may discuss issues and provide information about the internet to their children and guide them how to use the internet safely and track their childs internet usage regularly such parental communication has been found to be effective in equipping children with the skills and knowledge on responding to dangerous situations while on the internet on the other hand restrictive mediation serves as a subtler way of influencing the childs internet usage such as by setting rules limiting time spent online and putting restrictions on the types of accessible websites studies have found a strong negative correlation between restrictive mediation and duration of the childs internet usage or the amount of dangers that the child experiences online in general numerous studies have found that parental mediation as a whole is considered to be one of the most effective methods in addressing the risks that children face on the internet for instance restrictive parental mediation strategies such as limiting the time children spent online and restricting the sites children were allowed to access are associated with lowered risk of cyberbullying victimization in addition the presence of positive parentadolescent communication quality a key factor in successful active mediation strategies has been found to have a buffering effect against risks such as cyberbullying that arise from high internet usage however there are still relatively scant studies in the case of parental mediation and cyberbullying perpetration hence we aim to bridge this existing research gap by examining the association between active and restrictive mediation and childrens cyberbullying perpetration as such we advanced the following hypotheses h3 individuals under active parental mediation are less likely to engage in cyberbullying perpetration on social media h4 individuals under restrictive parental mediation are less likely to engage in cyberbullying perpetration on social media maccoby indicated that the significance of the parents influence in socializing their children generally decreases as the childs age increases in general parents exert more influence onto the growth of children when the children are at a younger age however in the case of adolescents the proportion of time spent with other agents such as peers and teachers increases while the time spent with family members decreases this indicates that as compared to younger children the norms values and beliefs possessed by adolescents are likely to be more influenced by these external characters age as a moderator additionally it has been found that children of different ages generally have differing reactions to parental mediation strategies for instance younger children tend to be more responsive and accepting of parental mediation as compared to adolescents besides results from some studies revealed that parental mediation may be ineffective in protecting adolescents from mediarelated risks hence we expect that different parental mediation strategies may have different effects on cyberbullying perpetration among children and adolescents in light of the abovementioned age differences we posit the following research questions rq3 how do active parental mediation strategies differ in preventing cyberbullying perpetration on social media between children and adolescents rq4 how do restrictive parental mediation strategies differ in preventing cyberbullying perpetration on social media between children and adolescents method sample and procedure we conducted a selfadministered paperandpencil survey in four primary schools and four secondary schools in singapore upper primary school students and secondary school students were recruited to participate in this study we applied and received ethical approval from the university institutional review board and the ministry of education in singapore prior to conducting the survey with the students we had obtained written permission from the children and their parents specifically we had asked the teachers in each school to distribute the parental consent forms to the parents one week before the scheduled survey date parents were required to return the parental consent form to the school before the scheduled survey date on the scheduled survey date students were required to complete the childrens minor consent form before filling out the questionnaire multistage cluster sampling was used to ensure that schools from the four singapore regions were equally represented in this survey the survey was conducted from june to december in 2015 out of the initial fifteen primary schools and twelve secondary schools invited to participate in the survey four primary schools and four secondary schools eventually participated the response rates were 267 for primary schools and 333 for secondary schools a total of 1424 students participated in the survey specifically 635 were upper primary school children and 789 were secondary school adolescents the total average response rates were 696 for student participation the margin of error was approximately 3 at the 95 confidence level measures demographic variables demographic variables of students specified in this study included education level age and gender attitude attitude was measured on four dimensions adopted from heirman and walrave participants rated their attitude toward cyberbullying perpetration via the following dimensions disadvantageousadvantageous unpleasantpleasant badgood and harmfulbeneficial on a sevenpoint likert scale the items were averaged to form a composite index it was then reverse coded in which a higher score indicates less favorable attitude toward cyberbullying perpetration subjective norms subjective norms were measured using six items adopted from ajzen where students rated on a scale of 1 to 7 for the following statements most of my friends would not expect me to make rude or mean comments to someone on social media most of my friends would not expect me to spread rumours about someone on social media whether they are true or not most of my friends would not expect me to make aggressive or threatening comments to someone on social media my family members would not expect me to make rude or mean comments to someone on social media my family members would not expect me to spread rumours about someone on social media whether they are true or not and my family members would not expect me to make aggressive or threatening comments to someone on social media the items were averaged to create a composite index in which a higher score indicates a lower level of perceived approval for cyberbullying from individuals referent groups descriptive norms descriptive norms were measured by using six items adopted from ajzen and fishbein where students had to rate on a scale of 1 to 7 for the following statements most of my friends do not make rude or mean comments to someone on social media most of my friends do not spread rumours about someone on social media whether they are true or not most of my friends do not make aggressive or threatening comments to someone on social media my family members do not make rude or mean comments to someone on social media my family members do not spread rumours about someone on social media whether they are true or not and my family members do not make aggressive or threatening comments to someone on social media the items were averaged to create a composite index in which a higher score indicates a lower level of perceived prevalence of cyberbullying among referent groups injunctive norms injunctive norms were measured using six items adopted from ajzen and fishbein where students rated on a scale of 1 to 7 for the following statements most of my friends would not approve of me making rude or mean comments to someone on social media most of my friends would not approve of me spreading rumours about someone on social media whether they are true or not most of my friends would not approve of me making aggressive or threatening comments to someone on social media my family members would not approve of me making rude or mean comments to someone on social media my family members would not approve of me spreading rumours about someone on social media whether they are true or not and my family members would not approve of me making aggressive or threatening comments to someone on social media the items were averaged to create a composite index in which a higher score indicates a lower level of perceived societal approval for cyberbullying active mediation active mediation was measured using four items adopted from lwin et al where parents rated on a scale of 1 to 7 for the following statements tell your child about the information they can disclose on social media remind your child not to give out any personal information on social media tell your child to stop any experience on social media if they feel uncomfortable or scared and explain to your child about the dangers of social media the items were averaged to create a composite index in which a higher score indicates a higher level of active mediation restrictive mediation restrictive mediation was measured using five items adopted from lwin et al where parents rated on a scale of 1 to 7 for the following statements restrict the amount of time your child can use social media set rules regarding your childs access to social media such as facebook twitter youtube instagram whatsapp etc limit the kinds of activities your child can do on social media restrict the type of social media platforms your child can visit and limit your child to using social media only for school work the items were averaged to create a composite index in which a higher score indicates a higher level of active mediation cyberbullying perpetration cyberbullying perpetration was measured using a 3item scale adapted from ybarra dienerwest and leaf students were asked to rate their frequency of cyberbullying perpetration behavior in the last 12 months from 1 to 7 for the following statements made rude or mean comments to someone on social media spread rumours about someone on social media whether they are true or not and made aggressive or threatening comments to someone on social media the items were averaged to create a composite index in which a higher score indicates a higher frequency of cyberbullying perpetration results an ordinary least squares hierarchical regression analysis was conducted to test our hypotheses and research questions the independent variables were entered into the regression model according to their assumed causal order the first block included control variables such as demographic variables trarelated variables were entered in the second block next parental mediation variables were included in the third block the last block included the two interaction terms the main effect variables were centered and standardized before the creation of interaction terms to prevent multicollinearity problems between the interaction term and its components in addition the assumptions of regression were tested first all study variables were normally distributed second according to the scatter plots the relationship between the independent and dependent variables was linear moreover the data was homoscedastic lastly there was no multicollinearity in the data since variance inflation factors for all dependent variables were smaller than 25 the overall regression model explained a total of 2730 of the variance in cyberbullying perpetration first the demographic variables in the first block explained 470 of the variance in cyberbullying perpetration specifically education level was negatively related to cyberbullying perpetration while age was positively associated with cyberbullying perpetration with regard to tra the results demonstrated that attitude was negatively associated with cyberbullying perpetration which supported h1 similarly subjective norms had a negative association with cyberbullying perpetration hence supporting h2 to answer rq1 and rq2 the results revealed that descriptive norms and injunctive norms were not significantly associated with cyberbullying perpetration the tra block explained 1750 of the variance in cyberbullying perpetration next in terms of parental mediation the results showed that both active and restrictive mediation were negatively associated with cyberbullying perpetration which supported h3 and h4 these two parental mediation variables explained 400 of the variance in the dependent variable finally to answer rq3 and rq4 we examined whether age would moderate the negative relationships between parental mediation and cyberbullying perpetration table 1 revealed that the relationship between active mediation and cyberbullying perpetration was significantly moderated by age specifically the results showed that the negative relationship was greater for children than for adolescents notably age was a significant moderator of restrictive mediation and cyberbullying perpetration fig 2 revealed that children who were exposed to high restrictive mediation were less likely to perform cyberbullying perpetration while adolescents who were exposed to high restrictive mediation were more likely to engage in cyberbullying perpetration the interaction block explained 110 of the variance in cyberbullying perpetration discussion the aim of this study was to explore the factors associated with cyberbullying perpetration based on tra and pmt moreover the moderating effects of age on the relationship between parental mediation and cyberbullying perpetration were also examined first this study showed that individuals with less favorable attitude had a lower likelihood to engage in cyberbullying behavior this is consistent with extant research where a positive correlation was found between positive attitude and cyberbullying perpetration in fact heirman and walrave found attitude to be the most crucial predictor of perpetration in terms of social norms our findings revealed that subjective norms had a significant negative association with cyberbullying perpetration some previous studies have also showed similar findings where individuals who perceive an expectation from significant others to not behave offensively are less likely to engage in aggressive behaviors one reason for this finding may be due to the strong pressure exerted from ones peers who are considered to be ones most influential reference group in the presence of peers who cyberbully the social pressure e which manifests itself as subjective norms e imposes a significant influence onto the intention to engage in cyberbullying in order to elicit higher levels of social approval and respect from peers in contrast descriptive norms and injunctive norms were not significantly associated with cyberbullying perpetration in other words individuals who perceive that their significant others cyberbully others or an approval from significant others to cyberbully may not be more likely to engage in cyberbullying perpetration first it is possible that children and adolescents may not be aware of others cyberbullying behaviors according to the thirdperson effect theory they may hence perceive that others are more likely to be involved in cyberbullying on social media than themselves this may result in an overestimation of the number of actual people engaging in cyberbullying perpetration along with an underestimation of their personal likelihood to cyberbully others such personal biases might explain the nonsignificant association between the social norms and cyberbullying perpetration besides in terms of injunctive norms one possible explanation for the null finding as proposed by cialdini is that since salience is a crucial preexisting factor for normative influence on behavior young children may not be aware of injunctive norms which are formed based on social approval of others as compared to descriptive and subjective norms injunctive norms are considerably less salient and more ambiguous and may exert a lesser influence on ones eventual behavior hence injunctive norms generally require more cognitive analyses for individuals to make indirect inferences on the behavior as well as to understand and decipher the ambiguous levels of social acceptability of the behavior furthermore the low salience of injunctive norms in cyberbullying may be further increased due to the anonymity of online behaviors hence lowering the influence of any possible approval andor punishment from the general public next results showed that active mediation strategies and restrictive mediation strategies were negatively associated with cyberbullying perpetration in other words parents who engage in strategies of active mediation and restrictive mediation could be effective in preventing childrens cyberbullying perpetration with an increase in knowledge about the risks of social media upon active mediation strategies children may be more cautious about their behaviors on social media and be more aware of any negative consequences that may arise from deviant behavior on social media in addition the restriction in terms of time and access to certain social media platforms successfully leads to lower opportunities to cyberbully others such findings are consistent with extant studies where parental mediation was found to be effective in reducing childrens engagement in online risks finally age was found to be a significant moderator of parental mediation e both active and restrictive mediation e and cyberbullying perpetration consistent with extant findings the effectiveness of active mediation was greater in reducing cyberbullying perpetration for children than adolescents indeed nonsignificant effects of active mediation on older children have been found in several other studies as well one plausible explanation for such findings is that adolescents are more mature than younger children hence even without enough guidance from their parents adolescents may still possess an understanding of the negative consequences and psychological harm induced by cyberbullying and thus display lower levels of cyberbullying on the other hand younger children may not have attained such levels of emotional maturity and therefore their cyberbullying behaviors are largely affected by active guidance from their parents additionally age is a significant moderator of restrictive mediation on cyberbullying as well our findings revealed that younger children were likely to respond more positively toward restrictive mediation strategies however in line with existing research overly restrictive control was found to increase cyberbullying perpetration in adolescents in fact adolescents exhibited less cyberbullying behaviors when they are exposed to less restrictive strategies for example nathanson found that adolescents under high restrictive mediation displayed more negative attitudes toward their parents as well as more rebellious acts such as viewing forbidden online content with peers nathanson also indicated that adolescents under restrictive mediation might perceive lower levels of trust from their parents and hence invest less time and effort into developing positive relationships with their parents such attitudes may eventually lead to adolescents behaving in the opposite ways that their parents wished them to hence increasing the likelihood of cyberbullying perpetration such opposite behaviors may also be explained by the boomerang effect where older children may be less susceptible to intimidation by representations of authority and that restrictive strategies may lead to older children becoming more tempted to access the forbidden material and engage in antisocial behaviors another possible reason pertains to adolescents becoming more independent they generally spend more time away from home and are more influenced by their peers hence parental restrictions which are usually limited to the home setting may not be effective in addressing cyberbullying perpetration among older children limitations and contributions there are several limitations in this study that should be addressed in future studies first crosssectional data was used in this study while it is useful for correlation purposes causal relations cannot be concluded from such data second instead of investigating cyberbullying risk factors on individual media platforms factors associated with cyberbullying perpetration were examined as a whole instead it is possible that different associations may be present for different social media platforms third this study did not investigate the influence of social media consumption as well as the impact of psychological factors on cyberbullying which might be also crucial factors of cyberbullying fifth while this study explored the influences of active and restrictive mediation on cyberbullying perpetration on social media parents might use many different strategies to manage childrens social media use future research could explore parental mediation strategies of social media use and their effectiveness on cyberbullying moreover this study did not examine how other potential factors such as the perceived estimated risks of being caught by relevant authorities might affect an unethical behavior like cyberbullying perpetration in the case of music piracy for example studies have found that individuals who underestimated the risk of being caught while illegally downloading music still held a positive attitude towards music piracy on the other hand participants who perceived a high risk of prosecution were more likely to classify the act of illegally downloading software as unethical and were subsequently less likely to perform the behavior extending this notion to cyberbullying future studies could investigate the association between perceived estimated risk of being caught and cyberbullying perpetration as well as the strength of the perceived estimated risk of being caught as a potential moderator on the relationship between attitude towards cyberbullying and cyberbullying perpetration on a similar note studies have found that the strength of agreement regarding the social acceptability of illegally downloading software and the fear of social repercussions upon being caught significantly influenced participants decisions to pirate software such information may be derived from the existing descriptive and injunctive norms within the individuals social circle as such although our study did not demonstrate that descriptive and injunctive norms were significantly related to cyberbullying perpetration it might be worthwhile for future studies to investigate the influence of descriptive and injunctive norms in the formation of perceived estimated risks of being caught for engaging in cyberbullying perpetration besides this the current study measured cyberbullying perpetration via specific types of cyberbullying behavior while such constructs have been widely used other widely established aspects of cyberbullying should be included into future studies to improve on the representativeness and coverage of cyberbullying for instance constructs measuring key aspects of cyberbullying such as power imbalance repetition anonymity and intentionality should be included in future studies to provide for a more indepth measure of cyberbullying additionally future studies should also distinguish between cyberbullying from fighting with someone online while the former includes the intent to hurt others the latter involves retaliatory selfprotective behaviors against cyberbullying from others instead lastly slight differences in the classification of the types of behaviors that may be considered as cyberbullying exist among individuals from different cultural backgrounds since this study focused on a singaporean sample the results obtained may not be entirely representative of that in other cultures hence in order to fully understand the relationships between the constructs measured and cyberbullying perpetration future studies should replicate this study in other cultural contexts our study has several theoretical and practical implications as mentioned in the introduction the majority of extant studies investigated cyberbullying from an empirical angle while studies using a theoretical angle are largely limited hence the findings from attitude and subjective norms on cyberbullying perpetration highlight tra to be a promising theoretical framework to examine cyberbullying also limited studies explored the association between parental mediation and cyberbullying with the majority of existing studies focusing on cyberbullying victimization rather than perpetration this study hence contributes to the relatively scant research in this field findings that parental mediation may have differing effectiveness based on the childrens age brings about several practical implications that may benefit educators and parents when addressing their childrens online risk for example active mediation strategies such as direct teachings and guidance would be more appropriate for younger children similarly for restrictive strategies educators and parents must direct more attention and care when applying such strategies to older children restrictive strategies such as website and time restrictions should be set in such a way that the older child does not perceive an infringement on their freedom and autonomy overly restrictive mediation strategies may backfire and lead to an increase in cyberbullying perpetration thereby defeating the purpose of the mediation mediation and intervention strategies should instead be tailored to children of different age groups and specific perceptions for instance mediation and intervention strategies targeted toward children should include elements of both active mediation and restrictive mediation on the other hand due to the possibility of restrictive mediation unintentionally increasing cyberbullying perpetration mediation and intervention strategies for adolescents should include lesser focus on both active and restriction mediation in order to protect them from cyberbullying complementing the above parents and teachers should also undergo educational awareness activities to raise their awareness on the matter of cyberbullying such activities may be implemented in the form of instructional videos or lectures on cyberbullying in addition to increasing awareness on cyberbullying risks and outcomes such activities have been shown to enhance participants efficacy in dealing with cyberbullying cases due to their close proximity and relationship to the children and adolescents experiencing and committing cyberbullying it is imperative that parents and teachers be knowledgeable and competent in the techniques that identify and address cyberbullying

this study aims to explore factors associated with cyberbullying perpetration on social media among children and adolescents in singapore based on the theory of reasoned action and the parental mediation theory more specifically the relationships between attitude subjective norms descriptive norms injunctive norms and active and restrictive parental mediation with cyberbullying perpetration on social media were investigated moreover we examined the moderating effect of age on the relationship between parental mediation and cyberbullying perpetration multistage cluster sampling was used in which 635 upper primary school children ie primary 4 to 6 students and 789 secondary school adolescents participated in our survey the results revealed that attitude subjective norms and the two parental mediationsactive and restrictive mediationwere negatively associated with cyberbullying perpetration on social media age was a significant moderator of both parental mediation strategies and cyberbullying perpetration implications and limitations of this study were discussed

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background the world health organisation has clearly identified the integral role that mental health plays in an individuals overall wellness indeed there can be no health without mental health 1 the colossal growth in the worldwide ageing population has resulted in increasing attention being focused on the mental health of these individuals for older individuals ageing presents not only losses in physiological function but also an increased threat of mental health problems 2 3 4 in recent years increasing mental health problems among this population have led to higher incidences of disability declines in quality of life and increased mortality risk 5 addressing these issues has become a global challenge as one of the most populous countries china is experiencing a rapid population ageing becoming the country with the largest elderly population 6 the latest population data from the national bureau of statistics indicates that the number of people over age 65 in china is estimated to be at 17599 million accounting for 1257 of the countrys total population in 2019 7 it is predicted that the number of people over age 65 in china will increase to about 400 million by 2050 or 269 of the countrys population 8 a report realized by the china ageing development foundation in 2018 shows that 63 of the chinese elderly often feel lonely and 62 of them often feel stressed or depressed 9 suggesting that the situation of the mental health problems among the chinese elderly is not optimistic as early as 2016 the state council issued the outline for the healthy china 2030 plan aimed at improving population health to build a healthy china this outline has proposed a healthy ageing strategy that noted the necessity of developing mental healthcare services for older adults and strengthening effective interventions for mental and psychosocial disabilities 10 however it is difficult to adequately address older adults mental health problems due to the limited professional medical resources 11 according to official figures released by who in 2017 for per 100000 residents in china less than 875 mental health workers are available in chinas mental health system which is far from satisfying peoples high demands for professional medical services 2 moreover with the decline of the filial piety culture and the acceleration of modern industrialisation and urbanisation most adult childrenespecially those from rural areaschoose to leave home for better job opportunities leaving their elderly parents alone this phenomenon has resulted in several problems for the ageing population including declining living standards and increasing suicide incidence 12 13 14 15 therefore it is imperative to develop effective and accessible approaches to address the mental health problems of chinas elderly population given the decline in family support and insufficient medical and endowment resources the chinese government has been working to develop the community care services to promote the health and wellbeing of elderly individuals 16 these services provided by local communities are aimed to satisfy various care service needs in terms of daily life support healthcare recreational and spiritual needs of the chinese elderly living in the home studies on the relationship between community care services and older adults mental health were mainly conducted in developed countries and regions with mixed conclusions jacob et al showed significant improvements in the physical and mental health and quality of life of elderly individuals who participated in communitybased care programs 17 ormsby et al suggested that provision of communitybased mens shed programmes which is an activity option in the community gives more opportunities for older men to demonstrate competence and maintain their social networks thus contributing positively to their physical mental social and occupational health 18 naoko revealed that consistent with stressbuffering or stressmoderating models of formal support home and communitybased services seemed to be effective for mental health among seniors with consistently low or rapidly declining daily functions 19 rodriguezromero concluded that by empowering the elderly and increasing their social support a community intervention could help the lonely older persons stop feeling lonely and improve their health status 20 djernes documented low utilisation of inhome and communitybased programmes among the ageing adults noting that such social support of low quality often increase depression and exacerbate medical symptoms among the elderly 21 similarly chen and hao found that providing basic care services like housekeeping and visiting medical service for ageing adults had a significant positive effect on their mental health while providing psychological health services like spiritual comfort and psychological counselling had no such effect this is because the quality and professional level of these services provided by communities was far from meeting ageing adults mental demands and promoting their mental health 22 however while the development of community care services in china has achieved some progress very few studies have paid attention to the development of these services and the association between using these services and older adults mental health is virtually unknown limited research has been undertaken to evaluate the effects of community care services on chinese seniors health yet only the provision of community care services was examined and the health outcomes of using these services is still unclear 23 existing studies only focused on the rural elderly or the urban elderly in the developed regions in china 24 considering the separate urbanrural structure and regional economic disparity of china it is necessary to compare the community care services utilisation mental health level of the elderly and their associations in the specific rural and urban contexts in the moderately developed regions to improve the validity of findings additionally numerous studies have showed that there were remarkable gender differences in terms of mental health level and social support 2526 while few studies have examined whether there exist gender differences in the utilisation of community care services and their association with the mental health of older people finally given the fact that the development of community care services in china serves as a supplement to family support its surprising that few studies had considered family support as potential confounding factors and therefore calls for further examination 27 to fill these research gaps firstly the current study analysed community care services utilisation mental health level of elderly individuals and their associations in chinas shaanxi province which is a moderately developed province in china secondly considering ruralurban disparity and malefemale difference the results in this study were compared across gender and location groups finally to reduce biases associated with omitted family support variables instrumental support and emotional support provided by family members were controlled in this study these findings could help chinese policy makers understand gaps in community care services development and the association between using such services and the mental health of different groups of elderly people thus developing strategies to improve these services methods study design and sampling the data used in this study were obtained through a crosssectional survey conducted from june to august 2019 see additional file 1 28 this study used a stratified sampling method the survey was conducted in baoji yanan and hanzhong the pilot cities of home and community care services and ranked as moderate in economic development in shaanxi province and in china representing the average level on this basis we selected seven counties and further selected three or four typical communities from each county each of these communities had communityintegrated service facilities that provide care services for the local elderly population data collection this study was approved by the medical ethics committee of health science center of xian jiaotong university the ethics committee approves the procedure for the verbal consent which is allowed for social investigation not involving any biological or medical experiment before the investigation each elderly resident was informed of the details and the purpose of the study only when the respondents confirmed that they were willing to participate in this survey and gave their verbal consent our investigators began the investigation the survey team was composed of more than 20 members including professors and students for each participant in this survey two investigators helped himher finish the questionnaire about the personal sociodemographic characteristics community care services utilization and mental health level one investigator explained the question to the participant as some old adults were illiterate or unable to understand the questions and another investigator filled out the questionnaire on the base of the respondent answers after filtering the data we obtained 687 valid samples measurements dependent variable mental health level the researchers share the whos view that mental health is more than just the absence of mental disorders or disabilities but a state of wellbeing in which an individual realises his or her own abilities can cope with the normal life stresses can work productively and is able to contribute to his or her community 1 therefore in terms of the assessment of mental health in this study the selfrated mental health was assessed using the question in general how do you feel about your mental state with possible answers including very bad bad fair good and very good selfreported health is a common and important indicator that can comprehensively and directly reflect individuals selfperception of their health 2930 for the purposes of this study the researchers constructed the following binary indicator for mental health in which good 1 and poor 0 this method has been applied in other studies examining similar variables 3132 independent variables community care services utilisation in this study utilisation of four categories of community care services was used as the independent variables first 22 specific services were identified from a preliminary survey of available community care services second considering collinearity problems similar services were aggregated into four community care services categories daily care medical care social and recreational and spiritual comfort services 3334 daily care services refer to some basic living support services provided by the government neighbourhoodvillage committees and communities such as housekeeping grocery delivery and community canteen services medical care services refer to some basic healthrelated services for the elderly provided by the government community health centres or local clinics such as health lectures regular medical examinations and visiting medical services social and recreational services refer to entertainment and cultural activities supported by the community such as some interest groups recreation centres and chess and card clubs spiritual comfort services mainly refer to services concerning and consoling elderly peoples spiritual needs like psychological counselling and matrimonial services provided by the community third we examined the samples community care services utilisation for each of the four categories specifically a binary variable was used to indicate utilisation of each service when a respondent reported using one or more specific services the corresponding service category was defined as 1 if no service was used the corresponding category was defined as 0 control variables the demographic variables of age sex marital status chronic diseases and activities of daily living limitations were considered in this study household income location public health insurance oldage insurance and education were included as socioeconomic status variables moreover the potential effect of family support was also considered to achieve this family support was divided into two categories and measured by asking respondents whether they got sufficient economic support and daily care from family members and communicated frequently with family members education was set as a categorical variable age as a continuous variable and the other variables as binary variables a description of these control variables is shown in table 1 statistics analysis descriptive analysis was used to present characteristics of control variables chisquare analysis was used to examine whether there were statistically significant differences in community care services utilisation and mental health level and their relationships of the elderly among urbanrural groups and malefemale groups difference examination was conducted using spss statistical software statistical significance was set at p 005 to evaluate the association between community care services utilisation and the mental health level of the elderly a binary logistic regression analysis model was implemented to ensure the reliability of the results we further conducted the robustness test there are various ways to test the robustness such as changing the testing model changing dependent variables or independent variables and adding or removing control variables in this study we changed the testing model and the linear regression model was used to further examine the association between community care services utilisation and the mental health level of the elderly all regression analyses were conducted in stata version 151 and statistical significance was considered at the alpha level of p 01 p 005 and p 001 results descriptive characteristics table 2 shows the respondents sociodemographic characteristics the sample of 687 valid surveyscompleted by elderly people in shaanxi province with access to community care servicesincluded 266 males and 421 females the average respondent age was 70 42 mental health and community care services utilisation for different groups while there was no significant difference in mental health level between the urban and rural groups there was a noted difference between the male and female groups the percentage of urban respondents with good mental health was only slightly higher than that of the rural respondents in contrast the percentage of older men who claim having a poor mental health is significantly lower than that of older women table 3 shows a comparison of community care services utilisation between urbanrural and malefemale groups data showed that of the 687 respondents 209 used at least one daily care service while 478 never used any daily care service the daily care services utilisation of urban and male older adults was slightly more frequent than those of the rural and female older adults in medical care services utilisation 498 respondents reported using at least one multivariate regression results table 4 shows the multivariable regression results of the binary logistic regression models the results of model 1 showed that daily care services and social and recreational services were significantly and positively associated with mental health level of the 687 elderly individuals the associations between mental health level and medical care services and spiritual comfort services were positive but not significant some sociodemographic characteristics were also significantly related to mental health level of the respondents the elderly reported a better mental health as they got older additionally respondents who graduated from junior middle school reported having a better mental health than those with a primary school degree or lower compared with those with lower household incomes respondents with higher incomes reported having a better mental health as expected having no adl limitations or chronic diseases also predicted a better mental health in terms of family support getting sufficient economic support and daily care and communicating frequently with family were significantly associated with a better mental health the results of model 2 to model 5 showed that the associations between mental health level and community care services utilisation varied between urbanrural groups and malefemale groups specifically using daily care services utilisation had a significantly positive relationship with the mental health level of male and rural respondents while using social and recreational services was positively and significantly associated with the mental health level of female and urban respondents robustness test results table 5 shows the multivariable regression results of the linear regression models to ensure the reliability of the results in table 4 we further changed the testing model to test the robustness of the results the dependent variable was set as a continuous variable and the associations between community care services utilisation and mental health level of older individuals were examined in the linear regression models the results showed that the significance and direction of the coefficient of dependent variables in model 6 to model 10 were consistent with that in model 1 to model 5 which suggested that the estimates and results of the association between dependent and independent variables in this study were robust and reliable discussion survey data collected in the shaanxi province in 2019 were used to examine the associations between four types of community care services utilisation and the mental health level of older individuals including the differences of these associations among urbanrural and malefemale groups data analysis revealed three crucial findings first the mental health level of chinas older population is not optimal especially among women second there were some differences and inequities in community care services utilisation among the elderly in urban and rural areas third while the use of daily care services and social and recreational services was positively related to the mental health level of these respondents the differences of the relationship were observed in ruralurban groups and malefemale groups the results of this study showed that 1878 of the respondents reported having a poor mental health this finding highlights the unoptimistic situation of the mental health problems among chinas ageing citizens additionally the mental health of older women was found to be significantly worse than that of older men a finding consistent with those of other studies 35 in another finding while the mental health of urban older individuals was slightly better than that of those living in rural areas the difference was not significant although the overall mental health of all of chinas ageing population is of concern these results suggested that more attention should be focused on meeting the pressing needs of the rural and female elderly populations interestingly medical care services utilisation was significantly higher in rural areas than in urban areas in fact the unequal development of public health resources and services between urban and rural areas has been a longstanding problem in china 36 as an important part of the chinese healthcare system the development of community care services is worse in terms of both quality and quantity in rural areas especially poorer areas 37 according to official data released by the ministry of civil affairs in 2018 the coverage rate of communityintegrated service facilities in urban areas was 787 but only 453 in rural areas 38 however due to the deficiency of large hospitals and restricted transportation many rural residents have fewer chances to access professional medical resources in bigger medical institutions compared with urban areas therefore the elderly in rural areas might turn to community health centres or local clinics for some basic treatments as they have health problems while those in urban areas are prone to get some professional and advanced medical treatments from large hospitals 39 this might explain the unexpected finding that although there are fewer and worse healthcare facilities and healthcare services in rural areas the rural participants use medical care services provided by communities more frequently than urban participants our results showed that the proportion of the elderly population accessing social and recreational services in rural areas is significantly higher than those in urban areas this finding seemed to be inconsistent with some existing studies which suggested that rural older people were less socially active than urban older people 40 a possible explanation for this is that apart from social and recreational services provided by the community urban older people have plenty of choices of social activities because economy public transportation and entertainment facilities and services are considerably more developed and accessible than are those in rural areas 41 while rural older people have relatively limited entertainment ways thus they might use local community social and recreational services more frequently than urban older people furthermore due to the accelerative urbanization and industrialization in china more and more adult children are flowing from rural areas to urban and developed areas leading to the increase of empty nesters in rural china 42 in this instance some of the rural elderly prefer to seek new channels such as participating in community social activities to extend their social network and social support key findings of this study indicated that after controlling for sociodemographic variables the utilisation of daily care services and social and recreational services was positively associated with the mental health level among older adults to be specific older people who receive daily care services had a higher probability of having good mental health the probable reason for this finding is the fact that individuals receiving daily care from community care centre staff likely feel supported and secure which benefits their mental health 19 43 44 45 furthermore receiving professionally provided services frees older individuals from the burden of housework allowing them to enjoy more leisure time activities that can boost their mood 23 the results among rural and urban respondents had key differences for example while the utilisation of daily care services predicted better mental health among elderly individuals in rural areas this association was not observed in urban areas applying maslows hierarchy of needs theory the underlying reason for this finding might be attributed to the fact that compared with those living in urban areas the care service needs of older individuals living in rural areas are more basic 46 furthermore because rural residents highly value the tradition of hard work they are more likely to continue working as they aged as long as their physical condition allows in this case receiving daily care services could reduce their labour burden to a large extent which may contribute to family wellbeing 24 in terms of malefemale differences the positive association between daily care services utilisation and the mental health level was significant only among the male elderly with the traditional roles of men breadwinners and women homemakers females generally have played the primary role of taking care of families 4748 under the influence of the traditional gender role attitude women might feel lost when they get older and shift into the role of receiving such services instead of providing them 4950 therefore older womens possible feelings of worthlessness from getting daily care services from others may offset the potential benefit of relieving them from the burden of housework this phenomenon may help explain the result that no significant positive association was observed in the female group from receiving such services similar to findings presented in prior studies the results of this study indicated that using social and recreational services was positively and significantly correlated with older adults mental health level 5152 according to the activity theory participating in diverse social activities can refresh and improve selfcognition of ageing adults and reduce their sense of isolation from the everchanging society around them therefore it is beneficial for older adults to expand their social networks and obtain a variety of healthrelated information 53 additionally community social and recreational services create new opportunities for the elderly to get together with kindred spirits which could help make up for deficiencies in interpersonal interactions with their family members and satisfy their demand for a better life 54 regarding ruralurban differences social and recreational services utilisation predicted better mental health among urban residents but not rural residents the researchers speculated that despite some progress in promoting the development of elderly services in rural areas significant gaps remain between urban and rural service content and quality due to restrictions related to economic and policy factors 55 in some cases lower level of community care services and activities may not help increase positive health behaviours among the rural elderly 215657 in addition although social and recreational services utilisation was higher among the rural residents the social networks and social capital they accessed through these services were limited in contrast the urban elderly may be more likely to access beneficial healthrelated information and resources by engaging in community activities and broadening their social circles thus significantly promoting their psychological wellbeing 58 regarding malefemale differences the utilisation of social and recreational services had a positive and significant relationship with womens mental health but not with mens the probable reason for this finding may be that women compared with men spend more time in providing and receiving social support and have more extensive and better social relations therefore they would experience more benefits in health terms from social activities than men do 59 moreover due to gender gaps in family labour division and life habits elderly women tend to shoulder more household chores in such cases participating in community activities can improve elderly womens living environments to a much greater extent making their mental health more sensitive to these social activities than elderly men 60 one unexpected finding was that utilisation of medical care services and spiritual comfort services was not significantly correlated with the mental health of the individuals in our study due the fact that the establishment of community care services in china is still in its infancy the lack of qualified professionals and facilities constrains the provision and utilisation of diverse and highquality care services for older adults especially community medical and psychological care 61 therefore the poor accessibility and low quality may contribute to the result that utilisation of these services did not have a significant correlation with the respondents mental health level 22 we also noticed that getting sufficient economic support and daily care from family members and communicating frequently with family members were positively and significantly associated with good mental health of older adults this finding indicated that family support including instrumental and emotional support still plays an essential and central role in elderly care in china 62 in contrast public health and oldage insurance did not show a significant association with the respondents mental health level as expected as an important component of formal social support adequate and accessible community care services have a more positive relationship with the health of older adults compared with social insurance with extensive coverage 63 these findings also suggested that multigeneration cohabitation should be encouraged to evoke childrens sense of family responsibility and willingness to provide support for their elderly family members the government and local communities also should work together to support the construction of oldage facilities and provide more and higherquality services for the ageing population specifically efforts should be focused on the provision of daily care and social and recreational services medical care and spiritual comfort services should also be strengthened to fully meet the needs and improve the health of communitydwelling older people during this process it is essential to implement effective policy measures to promote the equitable development of these services in both urban and rural areas furthermore to enhance their mental health more attention should focus on the community care services preferences of different population groups in china especially those of older women strength and limitations this study is one of the very few that have examined the association between community care services utilisation and mental health level among chinas ageing population using crosssectional survey data this study also considered disparities and discrepancies between malefemale and ruralurban groups an approach not found in previous studies our results confirmed that the utilisation of daily care services and social and recreational services was associated with better mental health of older people in china the results also revealed the significant malefemale discrepancies and ruralurban disparities in community care services utilisation mental health level and associations between these variables among a sample of ageing adults these findings could help inform the development and implementation of more targeted and effective community care services strategies despite the value of these findings this study did have some limitations that need to be considered first the association between community care services utilisation and respondents mental health level was assessed used the binary logistic regression model with a crosssectional survey therefore the possible time lag between services utilisation and mental health outcomes was not considered and the exact causal relationship still needs further investigation second the survey was conducted only in three cities of the shaanxi province representing an intermediate economy level in china more regions such as xian which has onethird of shaanxis population and represents the welldeveloped economy level in china may be included in future studies to explore the differences between regions having different economic levels third mental health of the older population is a complex issue although some potential variables were controlled for in this study there might be unmeasurable variables that were ignored resulting bias in the results finally while we tried our best to strengthen the normativity and scientificity of the survey process there might be some social desirability bias in this study conclusions in summary this study draws three conclusions first rural and female older individuals suffered worse mental health particularly older women second community care services utilisation was unbalanced among urbanrural groups third community care services had a positive albeit selective association with the mental health level of older adults in china specifically daily care services and social and recreational services were positively associated with good mental health furthermore daily care services utilisation predicted a better mental health of older men and older people living in rural areas while social and recreational services utilisation predicted a better mental health of older women and older people living in urban areas the findings of this study provided some important insights on how to develop more effective community care services for the ageing population in china additional file 1 abbreviations who the world health organisation adl activities of daily living authors information lijian wang born in 1983 in hebei province china received his doctorate in 2012 now he is a professor in public administration at the school of public policy and administration of xian jiaotong university his research interests include elderly health and social security system development competing interests the authors declare that they have no competing interests

background while community care services have been developing rapidly as a new way to meet the growing demands of elderly individuals in china their health benefits are virtually unknown thus the aim of this study was to examine the chinese elderly individuals utilisation of community care services and its association with the mental health with comparing ruralurban and gender differences methods for this 2019 crosssectional study 687 elderly people from 7 counties districts of chinas shaanxi province were enrolled respondents mental health level was assessed using a selfreported mental health measure four categories of community care services utilisation were examined daily care services medical care services social and recreational services and spiritual comfort services the binary logistic regression model was used in examining the association between community care services utilisation and mental health results our results showed that there was a noted difference in mental health level between the male and female groups utilisation of medical care services and social and recreational services was significantly higher in the rural group than that in the urban group regression analysis showed that utilisation of daily care services β 0809 p 0008 and social and recreational service β 0526 p 0035 was significantly and positively associated with elderly individuals mental health level specifically daily care services utilisation predicted a better mental health of the rural elderly β 1051 p 0036 and the male elderly β 1133 p 0053 while social and recreational services utilisation predicted a better mental health of the urban elderly β 0927 p 0008 and the female elderly β 0864 p 0007 conclusions our findings indicated varied levels of community care services utilisation and mental health are common among the elderly people in china community care services utilisation has a positive albeit selective association with elderly individuals mental health further policies should strengthen the equitable development of highquality community care services in urban and rural areas to improve the mental health of elderly individuals and focus more on gender differences in terms of community care services needs

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introduction it was stated in other studies that the prevalence of anxiety depression and anger increased among the general german population throughout the pandemic besides there has been an increase in mental problems among individuals with psychiatric disorders and the immigrant population in society migrants are considered a vulnerable group during the outbreak due to low socioeconomic status job losses and language difficulties objectives this paper aimed to investigate changes in the psychological health of turkish immigrants living in germany during the covid19 pandemic furthermore sociodemographic differences as a key factor were analysed in this study individuals with lower incomes were expected to suffer more from mental health problems methods the participants of this research were mainly first and secondgeneration turkish immigrants they were prescreened for a previous history of mental disorders and screening was performed with scl90r of all 177 participants who completed the questionnaire between october 7 2019 and february 2020 they were recruited again between august 10 2020 and december 10 2020 during the pandemic results according to the findings a significant difference was found for depression anxiety and hostility between the mean scores of the participants before and during covid19 pandemic it was found that the increase in depression and anxiety symptoms during the coronavirus pandemic was higher among participants with lowincome levels conclusions the mental health of our study participants worsened during the current covid19 pandemic turkish immigrants reported having higher depression anxiety and hostility scores in comparison with previous test scores conducted before the outbreak participants with low income were at the highest risk for covid19related depression and anxiety we have already noted in our studies that collective representations about covid19 disease based on its totality the catholicity of its impact on all spheres of peoples lives are socially and culturally conditioned they have their own specifics in different countries associated with many social economic political factors moreover these perceptions change over time objectives to identify the differences in the covid19 representations in residents of different countries and at different stages of the pandemic methods modified questionnaire of the internal picture of the disease consisting of 8 questions about covid19 pandemic all the items were rated using a 0to10 response scale 15 items assess cognitive illness representations items 6 and 8 assess emotional representations item 7 assesses illness comprehensibility results to test of the research hypothesis we used the data accumulated on our platform since april 2020 we selected subsamples russian respondents who took the survey in aprilmay 2020 juneseptember 2020 october december 2020 1st half of 2021 at the same time as sample 4 respondents from azerbaijan and uzbekistan were surveyed finally there was another sample of uzbekistan respondents surveyed in the 1st half of 2022 respondents of both sexes and different ages participated in each sample with a total of 2908 people the table 1 shows the sample means for all items in all samples in all seven samples women are characterized by responses indicating their greater tension stress and psychological fatigue caused by life in a pandemic in almost all samples younger respondents demonstrate greater involvement in the disease and its experiences perhaps this is due to the fact that social restrictions affected young respondents to a greater extent it was shown that with each new wave the indicators for the 2 5 8 grow and 3 4 7 decreases at the same time since no one canceled the pandemic this year along with a decrease in indicators for all items corresponding to stress and anxiety ideas about the possible duration of the pandemic are growing image disclosure of conclusions we can say that people have adapted to coexist with this disease and are ready for its continued presence in the world the average indicators of azerbaijani respondents indicate a more tense attitude towards the pandemic compared to russia and uzbekistan it can be assumed that this is due to longer and more extensive state antiepidemiological measures in azerbaijan disclosure of interest none declared epp0168 positive relationships and academic stressors in the postpandemic context of covid19 in adolescents from a school in córdoba colombia 2013 point out good relationships as a factor that contributes to a good psychological life since they provide emotional and instrumental support in times of stress and challenge indicating in turn normal evolutionary development and the avoidance of psychopathological problems objectives to establish the relationship between positive relationships and the presence of stressors in adolescents methods a crosssectional descriptivecorrelational study was carried out in 109 adolescents the sisco inventory was used to study academic stress as well as the ryff psychological wellbeing scale results a negative magnitude correlation was found between positive relationships and stressors as a secondary result 606 of the evaluated adolescents presented life purpos as the factor with the highest score in the psychological wellbeing variable this points to authors such as erikson who define adolescence as a space characterized by feelings of creativity productivity new ideas and a period of cognitive and social maturation which leads to a definitive commitment to life itself the covid19 pandemic and the measures to control the pandemic adversely affected the mental health of children and adolescents however studies examining the effects of the pandemic on child and adolescent mental health services are scarce objectives our study aims to show how this unexpected pandemic affecting all humanity and the accompanying restrictions affect the admissions to the child psychiatry service methods in this study the diagnoses the treatments used and the length of hospital stay of inpatient child and adolescent psychiatry patients were obtained and compared between the normal period and the pandemic period patients who received inpatient

methods a descriptive and analytical crosssectional study that took place during the period from 1 st march to 15 th may 2021 with 154 patients who were hospitalized at the covid19 unit at hedi chaker hospital sfax we used a preestablished form to record sociodemographic clinical and therapeutic data the posttraumatic stress disorder was assessed by the impact of event scalerevised results the mean age was 6662 ae 1334 years with a male predominance of 604 in our sample 779 of the patients had a somatic history of which hypertension was the most frequent pathology 461 the average length of hospitalization was 95 days ae 63 the form was considered severe in 279 cases according to the iesr scale twentyone patients 136 had posttraumatic stress disorder with a predominance of women 571 a significant association was found between marital status and posttraumatic stress disorder thus married or widowed patients are more likely to develop ptsd in the present study we did not find statistically significant associations between the clinical characteristics of the disease severity of the disease length of hospitalization functional signs and posttraumatic stress disorder conclusions psychological support interventions in surviving patients of covid 19 is necessary aiming to increase resilience manage coping strategies and decrease the deleterious impact of the pandemic on mental health

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introduction human and economic losses from coronavirus disease 2019 since 2019 have been substantial as of may 2 2021 222 countries and international territories have reported over 152 million cases and over 32 million deaths from covid19 1 during this period 122 000 cases and 1800 deaths have been reported in korea other countries that took countermeasures too late or indecisively had to implement rigorous lockdowns in the early phase of the pandemic conversely korea quickly organized intensive mass testing and contact tracing and did effects of social distancing measures not impose a complete lockdown 23 instead the korea disease control and prevention agency promptly introduced nonpharmaceutical interventions such as handwashing covering the mouth with sleeves when coughing avoiding touching the eyes or nose with unwashed hands wearing masks and not visiting crowded places 4 in addition starting in june 2020 the kdca enforced a social distancing system consisting of 5 levels containing differentiated preventive measures in each level the kdca adjusted the grading of levels based on the characteristics and intensity of newly confirmed cases when the second wave of the pandemic began the kdca upgraded the sd level of the capital area to level 2 and strengthened level 2 for mitigation it subsequently downscaled the level to 1 after the end of the second wave during the third wave the sd level of the capital area was increased gradually to level 15 level 2 and level 25 the december 8 2020 increase was coupled with a simultaneous increase in sd to level 2 in noncapital areas nonetheless the third wave was not sufficiently controlled and new cases surged to over 1000 per day in late december 2020 therefore the kdca enacted the no gatherings of more than 5 people policy prohibiting private gatherings of more than 5 people irrespective of region when the number of 7day moving average cases declined to under 400 by january 26 2021 the kdca downscaled the sd level to 2 for the capital area and 15 for noncapital areas 4 the adjustment in sd policies was evaluated as being effective in controlling the number of new cases in korea and other countries 5 6 7 8 9 however fluctuations in the number of new confirmed cases might be a result of a combination of elements such as public compliance with npis the management of highrisk facilities quarantine protocols seasonal effects and vaccination furthermore the success of sd measures thoroughly depends on peoples voluntary participation 1011 previous studies also emphasized the importance of guiding peoples behaviors to prevent and control the spread of covid19 1213 therefore the effectiveness of sd policies should be assessed by judging changes in individuals compliance rather than based on the number of new confirmed cases nonetheless limited data are available regarding how individuals behavior has changed in response to sd levels or the implementation of ngm5 over the past year therefore this study examined the association between compliance with npis and sd policies in korea with repeatedly and representatively surveyed data this study also investigated how sociodemographic characteristics determined compliance with npis its findings and outcomes are expected to provide basic data for planning viable policies with the goal of overcoming covid19 methods data publicly available data from the imperial college londons yougov covid19 behavior tracker data hub were used for this study these data were made accessible for academic research purposes on the github webpage 14 the centre for health policy of the institute of global health innovation took charge of collecting and releasing related reports surveys in korea have been conducted to assess subjective wellbeing 15 perception of danger 16 and life changes 17 in the context of the covid19 pandemic the data in this research were also suitable for assessing peoples compliance with npis given that the data were collected between april 2020 and april 2021 repeatedly using the same questions for compliance with npis since the survey was regularly conducted over the past year it is believed that the data from the survey could shed light on changes in behavior according to sd levels in korea prior studies have also evaluated the strength of the accumulated data from imperial college london 18 19 20 21 a total of 13 300 individuals responded to this survey although the data were collected over 1 year these were crosssectional data as the survey did not follow the same set of people weekly the responses were collected considering demographic characteristics the data contained numerous questions related to covid19 wearing a face mask contact tracing diagnosis of health conditions lifestyle perceptions of vaccination and compliance with npis variables the items used to explain compliance with npis comprised questions on behavioral patterns 7 days prior to responding to the survey for example how often have you taken the following measures to protect yourself or others from covid19 of 20 items 16 were utilized since 4 were not mentioned since january 2021 the answers to each of the items were coded as follows 1 always 2 frequently 3 sometimes 4 rarely 5not at all however we inversely coded answers to ensure that higher compliance was assigned a higher numerical value the factors representing compliance with npis were analyzed using exploratory factor analysis the kaisermeyerolkin test yielded a value of 0930 and the bartletts test of sphericity was significant among the 16 items used 5 were eliminated because they had a low factor loading the results of the rotated principal component analysis were summarized as the following 3 factors personal hygiene wearing a face mask outside home washing ones hands with soap and water using hand sanitizer covering ones nose and mouth when sneezing and coughing and avoiding crowded areas avoiding going out avoiding going out in general avoiding working outside ones home and avoiding going to shops avoiding meeting people avoiding small social gatherings avoiding mediumsized social gatherings and avoiding large social gatherings to calculate the values for each factor the value of the component items was averaged and modified into a binary category if the value was above the average value of all the responses it was marked as high if it was below average it was marked as low these values were used as dependent variables for the chisquare test and binary logistic regression analysis the second factor had 9331 participant records because its component item avoided working outside your home was not relevant to unemployed participants therefore the item did not apply to them we generated the variable of sd level and merged the corresponding sd level into each response in accordance with the date and region of respondents ngm5 was enforced on december 23 2020 in the capital area subsequently it was extended to noncapital areas on january 4 2021 the ngm5 variable was coded into a binary response information on sd level adjustment and the commencement date of ngm5 was gathered from the webpage of the kdca 22 a variable named region was provided in the format of province names and recategorized into 2 categoriesthe capital area and noncapital areas reflecting the dichotomization used by the kdca for sd levels statistical analysis in order to extract dependent variables exploratory factor analysis was conducted the chisquare test was used to compare differences in distributions between categorical variables while binary logistic regression was performed to identify factors associated with a high extent of compliance with npis associations were quantified using odds ratios with 95 confidence intervals all statistical analyses were conducted using ibm spss version 240 ethics statement this study does not have an institutional review board approval number since it uses secondary data results table 1 shows the general characteristics of 13 300 participants according to the 3 preventive factors the mean age of participants was 4320±1426 years participants included 7149 men 7741 fulltime workers and 7086 residents of the capital area furthermore 4919 participants responded during sd stage 1 1289 participants during stage 15 5608 participants during stage 2 and 1484 participants during stage 25 while 8829 participants responded before the enactment of ngm5 all variables except region in the avoiding meeting people factor showed significant differences between high and low compliance table 2 summarizes the associations of the 3 preventive factors and sociodemographic characteristics with and sd policies among men all 3 factors were significantly associated with decreased compliance younger age groups were significantly associated with lower compliance with maintenance of personal hygiene and avoiding meeting people however compliance with avoiding going out was significantly more common among respondents under the age of 30 years than among those over 60 years effects of social distancing measures employment status was significantly associated with avoiding going out and negatively associated with avoiding meeting people in addition residence in the capital area was significantly associated with higher compliance with personal hygiene and avoiding going out as for the policy effects increasing sd stages were positively associated with maintenance of personal hygiene avoiding going out and avoiding meeting other people respectively however the ngm5 policy was not significantly associated with the extent of compliance with antiinfection measures pertaining to covid19 figure 1 shows forest plots for the associations of sociodemographic variables and government policies with the 3 compliance factors the xaxis represents the or which is plotted on a logarithmic scale discussion this study researched associations between compliance with npi and sd policies in korea during the covid19 pandemic values are presented as odds ratio sd social distancing ngm5 no gatherings of more than 5 people effects of social distancing measures all 3 preventive factors maintenance of personal hygiene avoiding going out and avoiding meeting peoplewere associated with sd levels the magnitude of these associations was greater in level 25 than in levels 1 and 15 in particular the probability of compliance with avoiding meeting people was 57 higher in level 25 than in level 1 the reason for this may be the imposition of intensive preventive measures such as prohibiting gatherings at various facilities and limitations or restrictions of opening hours in level 25 conversely the enactment of the ngm5 policy was not significantly associated with compliance toward preventive factors including avoiding meeting people this can be explained by the fact that people did not cancel gatherings to comply with the ngm5 policy instead people kept gathering while complying with gatheringsize guidelines each time they met this interpretation is supported by an announcement from the kdca stating that the rate of infection from individual contacts had increased to 46 as of may 18 2021the highest this year 20 another possible explanation is that the standard of implementation in multiplepurpose facilities may not have been rigorous the kdca reported that mass infections occurred in bars sports facilities karaoke rooms pc rooms and public baths through contact with unknown people among the sociodemographic characteristics men were more likely to have low compliance with respect to every preventive factor significantly men participants were 34 less likely to belong to the highcompliance group for the maintenance of personal hygiene factor than women the result of a previous study also revealed that young men demonstrated low compliance 23 the youngest age group was 37 less likely to belong to the highcompliance group for maintenance of personal hygiene and 32 less likely for avoiding meeting but 20 more likely for avoiding going out these figures seem to reflect sociocultural factors younger people are familiar with the online environment that enables them to telecommute and engage in contactfree living consequently they have fewer reasons to have to go out as part of their regular routines parttime workers showed distinctly higher odds than fulltime workers for compliance with avoiding going out meaning that fulltime workers more frequently went out therefore strategies that help fulltime workers to lessen physical contact regarding work need to be considered including the extension of telecommuting and online meetings as well as adjustments of the commute time to avoid overcrowded public transportation in addition students were more likely to have low compliance with avoiding meeting people than fulltime workers therefore as prior studies have suggested 2425 there is a need for social movements promoting telecommuting and strengthening of the online learning system living in the capital area increased participants chances of belonging to the highcompliance group for maintenance of personal hygiene by 20 as well as the chances of belonging to the high compliance group for avoiding going out by 14 this might have been because the kdca applied an enhanced level of sd in the capital area conversely living in the capital area did not contribute to avoiding meeting people therefore compliance with the measures included in the avoiding meeting people factor should be emphasized this study has several limitations since this study used secondary data there remains the limitation of a lack of information on confounding factors as well as potential issues regarding the validity of selfreported data the possibility of recall bias further we assumed the survey data to be crosssectional however the survey continued for a year therefore the model may have a limited power of explanation for causal relationships among variables and the timevarying effects of prolonged covid19 diffusion moreover the effects of mass media on compliance rates were not fully considered however we tried to take account of timevarying effects by including variables such as sd stages as well as regions where sd stages and the ngm5 policy were applied since each sd stage corresponds to a definite standard of preventive measures sd levels gender age employment status and region had explanatory power for compliance with npis strengthening sd campaigns to inspire the public to voluntarily comply with npis with a particular focus on younger fulltime men workers and residents of the capital area is recommended simultaneously efforts should be made to segment sd measures into substrategies with detailed guidance at each level supplemental materials supplemental material is available at 3961jpmph21139 conflict of interest the authors have no conflicts of interest associated with the material presented in this paper

this study explored changes in individuals behavior in response to social distancing sd levels and the no gatherings of more than 5 people ngm5 rule in korea during the coronavirus disease 2019 covid19 pandemicusing survey data from the covid19 behavior tracker exploratory factor analysis extracted 3 preventive factors maintenance of personal hygiene avoiding going out and avoiding meeting people each factor was used as a dependent variable the chisquare test was used to compare differences in distributions between categorical variables while binary logistic regression was performed to identify factors associated with high compliance with measures to prevent transmissionin men all 3 factors were significantly associated with lower compliance younger age groups were associated with lower compliance with maintenance of personal hygiene and avoiding meeting people employment status was significantly associated with avoiding going out and avoiding meeting people residence in the capital area was significantly associated with higher compliance with personal hygiene and avoiding venturing out increasing sd levels were associated with personal hygiene avoiding going out and avoiding meeting people the ngm5 policy was not significantly associated with compliance conclusions sd levels gender age employment status and region had explanatory power for compliance with nonpharmaceutical interventions npis strengthening social campaigns to inspire voluntary compliance with npis especially focused on men younger people fulltime workers and residents of the capital area is recommended simultaneously efforts need to be made to segment sd measures into substrategies with detailed guidance at each level

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to address these challenges section three presents a comprehensive set of strategies and measures that can guide the preservation and transmission of qinan xiaoqu one essential approach is the documentation of intangible cultural heritage archives providing a systematic and standardized record of this musical heritage preservation initiatives must extend beyond academic institutions and involve local communities through workshops festivals and events such engagement fosters a sense of ownership and pride encouraging active participation in the preservation efforts furthermore transmission strategies emphasize the importance of school family and social education incorporating qinan xiaoqu into school curriculums can help instill cultural awareness and pride among students nurturing the next generation of musicians and enthusiasts family education plays a crucial role as grandparents and elders transmit their knowledge to younger family members ensuring the continuity of tradition within households additionally communitybased social education programs facilitate broader cultural exchange enriching the understanding and appreciation of qinan xiaoqu another crucial aspect of the conservation strategies lies in protecting and supporting the musicians and folk artists ensuring their wellbeing through subsidies and regular health checkups preserves the foundation of qinan xiaoqu moreover fostering a new generation of musicians and promoting their professional growth will ensure the sustainability of the art form in conclusion qinan xiaoqu serves as a priceless cultural heritage that speaks to the rich history and soul of gansu china the preservation and transmission of this intangible cultural heritage require concerted efforts from the government communities musicians and individuals alike by recognizing its historical and cultural significance and implementing a robust set of conservation strategies qinan xiaoqu can transcend time and continue to resonate with generations to come only through collective commitment and unwavering passion can this treasured musical legacy thrive and stand as a testament to the enduring spirit of the chinese people research objective to investigate the current state of transmission and conservation of qinan xiaoqu folk music in gansu china research question what are the existing challenges and barriers in the transmission and conservation of qinan xiaoqu folk music in gansu china and what are the most effective strategies and measures that can be implemented to safeguard and promote its preservation literature review the preservation and transmission of intangible cultural heritage such as traditional folk music is a critical concern for cultural researchers and policymakers around the world qinan xiaoqu a form of traditional folk music in gansu china holds immense historical cultural and spiritual significance making its preservation a matter of great importance in this literature review we will explore the existing research on the challenges and strategies for conserving and transmitting qinan xiaoqu folk music historical significance of qinan xiaoqu qinan xiaoqu is a musical intangible cultural heritage that carries the history and culture of the region and the chinese nation researchers have emphasized its significance in understanding the peoples way of thinking values and emotions within specific historical contexts through the analysis of its musical characteristics lyrics and elements scholars have traced its development in different historical periods providing insights into the cultural evolution of gansu province and the nation as a whole challenges in transmission and conservation several studies have highlighted the challenges faced in preserving qinan xiaoqu folk music one significant obstacle is the weak awareness of transmission and preservation among the local community residents in remote areas like qinan often lack understanding of the importance of safeguarding intangible cultural heritage leading to a passive attitude towards preservation efforts moreover the shortage of preservation funds in economically disadvantaged regions like qinan hinders the implementation of effective preservation programs and infrastructure development deterioration of music cultural environment the impact of modernization and urbanization has led to a gradual erosion of the traditional cultural environment in qinan with more young people leaving their hometowns for work the social atmosphere and daily lifestyle are changing resulting in a decreasing interest in learning and participating in qinan xiaoqu this shift in cultural preferences has the potential to undermine the continuity of this folk music tradition low interest and initiative in learning the dwindling interest in learning qinan xiaoqu is also evident among the younger generation the influence of popular music and the perception that learning traditional music is unprofitable has deterred young individuals from engaging in the art form this lack of interest and initiative poses a significant challenge to the transmission and continuity of qinan xiaoqu strategies and measures for preservation scholars and cultural experts have proposed various strategies to address the challenges faced in preserving and transmitting qinan xiaoqu documentation and archiving of the intangible cultural heritage have been emphasized as essential to preserve its historical and artistic elements the cultivation of new musicians and the establishment of music intangible cultural heritage specialties in music colleges have been recommended to ensure a steady flow of talent in preserving and transmitting the folk music social education transmission and dissemination the role of social education transmission in promoting the preservation of qinan xiaoqu cannot be overlooked emphasizing community involvement and grassroots initiatives can foster a sense of ownership and pride in the local cultural heritage additionally using various dissemination channels such as festival activities performances and media platforms can deepen public understanding and appreciation of qinan xiaoqu in conclusion the literature on the transmission and conservation of qinan xiaoqu folk music highlights the rich historical and cultural significance of this intangible cultural heritage however it also sheds light on the challenges faced in its preservation such as the lack of awareness funding and interest among the younger generation nevertheless the existing research offers valuable insights into potential strategies and measures that can be adopted to safeguard and promote the continuity of qinan xiaoqu ensuring its preservation for future generations research theory the qualitative theory guiding this literature review in ethnomusicology aims to explore the transmission and preservation of qinan xiaoqu folk music in gansu china from a culturally sensitive and holistic perspective qualitative research in ethnomusicology delves into the lived experiences social contexts and cultural meanings associated with musical traditions allowing for a deep understanding of the interplay between music and society through the qualitative lens this literature review seeks to uncover the multifaceted aspects of how qinan xiaoqu is transmitted conserved and valued within its cultural milieu ethnomusicology as a theoretical framework will guide this literature review in examining qinan xiaoqu as a living cultural heritage shaped by historical social and cultural processes ethnomusicology views music as a dynamic and evolving cultural expression intimately intertwined with the communities in which it thrives by employing ethnomusicology theory the review will explore the performative communal and ritualistic dimensions of qinan xiaoqu recognizing its role in shaping identities fostering social cohesion and providing insights into the cultural memory of the region the transmission and preservation theory for this literature review will center on understanding the mechanisms and challenges associated with passing down qinan xiaoqu from one generation to the next while safeguarding its cultural integrity the literature review will draw on concepts such as oral tradition intergenerational learning and the role of master musicians as key transmitters of the tradition preservation efforts including institutional support educational initiatives and community involvement will also be explored to assess their effectiveness in sustaining and revitalizing qinan xiaoqu as an intangible cultural heritage by integrating qualitative theory ethnomusicology theory and a focus on transmission and preservation this literature review aims to provide a comprehensive and nuanced examination of the complexities surrounding qinan xiaoqu folk music the synthesis of these theoretical approaches will contribute to a deeper understanding of how this living musical tradition is embedded within the cultural fabric of gansu china and how it continues to thrive through community participation social practices and the shared experiences of musicians and audiences alike through this multifaceted exploration the review will shed light on the significance of qinan xiaoqu as an enduring and cherished intangible cultural heritage in the region materials and methods for this study a comprehensive research approach is adopted to investigate the transmission and preservation of qinan xiaoqu folk music the research methods encompass a combination of qualitative research techniques fieldwork literature analysis and interviews to provide a holistic understanding of the cultural context and dynamics surrounding this traditional music heritage the following table 1 presents an overview of the research methods utilized in the study research tools to conduct a comprehensive qualitative analysis of the transmission and preservation strategies for qinan xiaoqu folk music in gansu china this research utilized interviews and observations as essential research tools the following research tools were employed interviews structured and semistructured interviews were conducted with key informants including musicians folk artists cultural experts and local residents with knowledge and experience related to qinan xiaoqu these interviews provided valuable firsthand insights into the musical characteristics historical significance cultural relevance and challenges faced in preserving and transmitting qinan xiaoqu observation active observation was carried out during live qinan xiaoqu performances rehearsals and cultural events by immersing in the musical environment and closely observing the singers musicians and audience interactions rich contextual data was collected this observational approach allowed for the documentation of the musical practices traditional elements and cultural dynamics associated with qinan xiaoqu assessing the transmission process and dynamics of qinan xiaoqu from one generation to the next investigating the role of master musicians and their teaching methods in passing down the musical tradition identifying challenges and strategies for preserving qinan xiaoqu in the modern cultural landscape 6 preservation study examining the existing institutional support for the preservation of intangible cultural heritage evaluating the effectiveness of educational initiatives and community involvement in conserving qinan xiaoqu investigating the role of technology and media in promoting and safeguarding the music tradition key informants in this study key informants were individuals who possessed valuable knowledge and expertise related to qinan xiaoqu folk music and its transmission and preservation they included musicians folk artists cultural experts and local residents who had significant insights and experiences with the musical tradition the following table 2 presents the key informants involved in the research these key informants were instrumental in providing valuable data and insights for the qualitative analysis of the transmission and preservation strategies for qinan xiaoqu folk music in gansu china their diverse perspectives and experiences contributed to a comprehensive understanding of the challenges and opportunities in preserving this traditional musical heritage results qinan xiaoqu an intangible cultural heritage of music in the province of gansu china represents a profound musical tradition that holds immense historical cultural and spiritual significance this study aims to present the research findings on three critical aspects related to qinan xiaoqu the importance of its preservation the challenges faced in its transmission and preservation and the strategies and measures proposed to safeguard its continuity for future generations the importance of the preservation of qinan xiaoqu historical significance qinan xiaoqu being an intangible cultural heritage of music serves as a vital repository of history and culture weaving the vibrant tapestry of a region and a nation the musics evolution through different historical periods concentrates within the intangible cultural heritage of music epitomizing the distinct regional characteristics of qinan by delving into its music style lyrics and other preserved elements one can gain profound insights into the thinking values and emotional attitudes of people in specific historical settings this musical heritage predominantly transmitted through oral and hearttoheart teachings offers a simple yet profound pathway for the public to confront history fostering an objective understanding and correct analysis of historical phenomena cultural significance qinan xiaoqu stands as a profound cultural legacy embodying the culmination of cultural elements that have undergone historical and social transformations a treasure trove of historical and cultural resources this musical heritage authentically reflects the essence of the chinese nation its musical expressions encapsulate the collective identity of both the region and the nation showcasing their historical development in an original and captivating manner within the realms of cultural integration and intermingling this intangible cultural heritage stimulates the promotion of cultural diversity reinforcing the cultural selfconfidence of both countries and nations as such it becomes a collective responsibility to actively protect promote and pass down this cherished traditional culture spiritual significance among the chinese nations cherished traditions qinan xiaoqu holds an integral place catering to the spiritual entertainment needs of the masses during times of adversity the unique charm of qinan xiaoqu has served as a source of inspiration uplifting the spirits of people this musical heritage has played a pivotal role in the historical and cultural development instilling a sense of pride and identity among the populace the preservation and transmission of this intangible cultural heritage of music should be a matter of importance for all sectors of society through an analysis of the customs thought patterns and values enshrined within this musical tradition bridges are built connecting people of diverse ethnicities consolidating national unity and fostering a profound sense of collective identity among the people the problems in the transmission and preservation of qin an the preservation and transmission of qinan xiaoqu an esteemed intangible cultural heritage of music in gansu province china has garnered significant attention due to its historical cultural and spiritual significance this cherished folk music carries within its melodies the essence of a region and a nation reflecting the thoughts emotions and values of people across different historical periods however despite its significance the preservation and transmission of qinan xiaoqu face several critical challenges that require immediate attention and strategic measures the preservation and transmission of qinan xiaoqu is a complex endeavor requiring collaborative efforts from government departments musicians folk clubs and individuals the challenges outlined above demand effective strategies and measures to safeguard this cherished musical heritage and ensure its continuity for future generations this study aims to conduct a qualitative analysis to explore the strategies and measures required for the successful transmission and preservation of qinan xiaoqu folk music in gansu china by understanding these challenges and potential solutions we can work towards preserving the cultural legacy of this treasured musical tradition the strategies and measures for transmission and preservation of qin an xiaoqu the preservation and transmission of intangible cultural heritage hold immense importance in safeguarding the history culture and spiritual essence of a region and its people one such treasured cultural heritage is qinan xiaoqu a traditional folk music form that thrives in gansu province china this musical art not only reflects the unique regional characteristics but also encapsulates the historical journey and values of the chinese nation as a significant part of the intangible cultural heritage of music the preservation and transmission of qinan xiaoqu demand utmost attention and concerted efforts in this research we delve into three critical aspects of qinan xiaoqus preservation and transmission first we explore the historical significance of this musical heritage analyzing its music style lyrics and other elements that offer profound insights into the peoples way of thinking emotions and values in specific historical contexts additionally we discuss its cultural significance which stems from the cultural elements embedded in the process of historical and social changes reflecting the true essence of the region and its people lastly we highlight the spiritual significance of qinan xiaoqu as it serves as an integral part of the traditional culture of the chinese nation meeting the spiritual entertainment needs of the masses and inspiring them from a spiritual level however despite its cultural and historical importance qinan xiaoqu faces numerous challenges in its transmission and preservation these challenges warrant immediate attention and effective solutions to ensure its continuity for generations to come one of the primary obstacles is the weak awareness of transmission and preservation among the residents particularly in remote areas like qinan the lack of understanding and involvement of local communities hampers preservation efforts necessitating the promotion of awareness and active participation in protecting this intangible cultural heritage another significant issue is the shortage of preservation funds particularly in economically disadvantaged regions like qinan county the lack of financial support impedes the effective survey preservation and transmission of intangible cultural heritage furthermore the shortage of professional musicians and inheritors poses a significant threat to the continuous transmission of qinan xiaoqu the declining number of skilled musicians coupled with the migration of younger generations to urban areas for better opportunities leaves the heritage vulnerable to extinction additionally the music cultural environment in ethnic areas is deteriorating due to the influx of foreign cultures and changing social attitudes the younger generations declining interest in learning qinan xiaoqu and the absence of a complete cycle in school education add to the preservation challenges moreover the inadequate support for musicians and the lack of a cohesive preservation organization further exacerbates the situation to address these pressing challenges this research focuses on several strategies and measures for the effective transmission and preservation of qinan xiaoqu documentation plays a vital role and efforts must be made to cultivate professional talents in intangible cultural heritage archives preservation measures should be strengthened to prevent damage or loss of precious original archives transmission efforts can be enhanced through school family and social education additionally the protection of musicians through financial support regular medical checkups and professional title evaluation will incentivize their active involvement in preserving this heritage the establishment of a comprehensive training organization will also attract young talent to participate in the transmission of qinan xiaoqu in conclusion application of communication ethnomusicology and sociology in research for better preservation and transmission of qinan xiaoqu discussion and conclusions the objective of this study was to investigate the current state of transmission and conservation of qinan xiaoqu folk music in gansu china through diverse qualitative methodologies from field observations to indepth interviews the study has encapsulated a comprehensive perspective on the cultural context and dynamics that encircle qinan xiaoqu consistent with ethnomusicology theory the study emphasizes exploring qinan xiaoqu as a living cultural heritage shaped by historical social and cultural processes ethnomusicology views music as a dynamic and evolving cultural expression intertwined with the communities in which it thrives by conducting ethnographic observations participant observations and indepth interviews with key informants the research captures the lived experiences social contexts and cultural meanings associated with this musical tradition a significant finding of this research is the confluence between the extant literature and the empirical data gathered the literature delineates qinan xiaoqu as not only a musical reservoir but also a mirror of chinas cultural ethos by synthesizing information from the literature analysis the study contextualizes the preservation and transmission challenges faced by this intangible cultural heritage the research methods utilized in the study including interviews observations and literature analysis align with the research scope and objective by engaging with key informants such as musicians folk artists cultural experts and local residents the study gains valuable insights into the musical characteristics historical significance cultural relevance and preservation challenges of qinan xiaoqu the comprehensive approach ensures a nuanced understanding of the complexities surrounding the transmission and preservation of this treasured musical legacy the research findings demonstrate the historical cultural and spiritual significance of qinan xiaoqu which highlights the importance of its preservation efforts the challenges hindering the successful transmission and preservation of qinan xiaoqu including weak awareness shortage of preservation funds lack of successors changing cultural environment and declining interest among the younger generation have been comprehensively addressed the research identifies strategies and measures that can effectively safeguard and promote the continuity of this cherished intangible cultural heritage conclusively the intricacies surrounding the qinan xiaoqu folk musics transmission and preservation arent just an academic inquiry but hold the promise of an actionable blueprint for future strategies these findings arent merely academic annotations but a clarion call for an integrated approach bringing together governments communities and artists the research stands as both a testament to the inexorable spirit of qinan xiaoqu and a beacon for its sustainable future hoping that the melodies of qinan xiaoqu with the collective endeavor will continue to echo through the annals of time epitomizing the indomitable spirit of the chinese ethos ethical considerations this study included interviews with essential participants who underwent supervision and provided informed consent the informed consent process comprehensively elucidated the studys goals methodologies and confidentiality measures as well as the potential advantages and risks associated with their participation conflict of interest the authors declare no conflicts of interest

folk music serves as a vital bridge that connects people to their cultural heritage reflecting the history values and traditions of a community zheng 2010 nyíri 2011 one such significant treasure of traditional chinese folk music is qinan xiaoqu an intangible cultural heritage rooted in the gansu province of china qinan xiaoqu holds a profound historical cultural and spiritual significance but like many intangible cultural heritages it faces challenges in its transmission and preservation in the modern era

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poor dietary habits during childhood place youth at an increased risk for obesity and dietrelated health conditions later in life including cardiovascular disease and type 2 diabetes 1 one environmental contributor to childrens diet is exposure to food advertising 2 food and beverage companies spend 18 billion annually on youthtargeted marketing 3 which is concerning given laboratory studies have revealed that children who are exposed to food advertisements consume more calories than children who are exposed to nonfood advertisements 2 although television advertising is a major source of food marketing 34 companies have dramatically increased online advertising in response to consumers growing social media use 56 one of the most popular social media sites accessed by adults and youth is youtube 7 a videosharing platform that allows users to post selfgenerated videos on their personal channels as well as view like comment on and share videos posted by others youtube also provides a significant amount of content that is viewed by children 7 more than 80 of parents with a child 12 years of age allow their child to watch youtube and 35 of parents report that their child watches youtube regularly 7 children as young as age 2 to 8 years spend nearly an hour a day using mobile devices and 75 of those children use their devices to watch videos on social media platforms like youtube 8 given that sites like youtube have created a new advertising frontier with the ability to reach large numbers of children and caregivers it is critical to examine the extent to which these social media sites promote unhealthy food and beverage products that could shape children and parents dietary decisions one novel social media advertising tool involves hiring influencers online celebrities with large social media fan bases who shape fans opinions by subtly or overtly endorsing products in their videos 9 in contrast to mainstream celebrities who generate fame from traditional means influencers are everyday people whose primary tool for building fame involves creating entertaining or engaging youtube videos or social media posts that help them attract large numbers of social media followers kid influencers are children whose parents film videos of the child playing with toys or engaging in familyfriendly activities 10 the parents then post those videos on youtube for other children and parents to watch for entertainment burgeoning evidence suggests that consumers increasingly perceive influencers as more relatable and trustworthy than mainstream celebrities 11 recognizing the booming popularity of influencers companies are increasingly hiring these persuasive spokespersons to promote their products 12 hiring kid influencers has the added potential of reaching younger audiences either directly or via their parents 10 the highestpaid youtube influencer in 2018 and 2019 for example was an 8yearold who earned 26 million from advertisements that appeared before the video and sponsored posts 1314 the extent to which companies use kid influencers to market food and beverage products is unknown psychological theories and experimental research studies suggest that kid influencers may influence youtube viewers in multiple ways first product placements build brand awareness and shape product preferences among children 15 such product preferences can lead to increased pester power in which children beg parents for specific products or brands 16 17 18 19 20 in fact pester power results in 190 billion in sales each year 21 second children ages 8 years have limited cognitive abilities to recognize advertising 2122 many children 8 years old cannot distinguish between commercials and cartoons 21 such susceptibility to advertising may be exacerbated by figure 1 a screenshot of foodrelated videos posted on 1 kid influencer channel in the sample influencers because their branded posts are subtly interspersed with their unbranded posts making it more difficult for children or their caregivers to discern persuasive intent 5 finally social norms theory 23 24 25 may inform how kid influencers shape parents behaviors social norms theory suggests that parents may see that a video has millions of views and thousands of likes which may indicate that it is socially acceptable to allow children to watch the videos in addition influencers may generate feelings of trust with viewers because they are both celebrities and everyday people 11 which may influence parents decisions to purchase endorsed products few studies have examined the combined effects of social media influencers and food advertisements 1126 in one study involving adults the authors found that purchase intentions were higher for products promoted by an influencer compared with a celebrity 11 in an experimental study in children researchers found that children who saw a youtube influencer holding unhealthy foods consumed more calories than children who saw a youtube influencer holding nonfood products 26 in another laboratory study researchers randomly assigned 132 adolescents ages 13 to 16 years to view a social media influencer who promoted unhealthy food vegetables or a nonfood item and found that adolescents exposed to the healthy food posts did not consume more vegetables 27 although companies use of kid influencers is growing rapidly no study has examined the extent to which kid influencers include food and beverage product placements in their youtube videos to address this gap in the literature we aimed to determine the number of videos views channel subscribers and likes associated with the 5 mostwatched kid influencer channels on youtube quantify the frequency of product placements for branded and unbranded food andor drinks in those kid influencers youtube videos determine the amount of time food andor drinks appear during the videos and assess the nutritional quality of the food and drinks methods researchers identified kid influencer channels on youtube in july 2019 through the youtube statistics tool maintained by socialbakers a social media analytics program that has been used in other public health research 28 socialbakers staff review the mostviewed channels on youtube and manually sort them into categories on the basis of key words and video content in fig 2 and supplemental table 3 we describe the search process and inclusion and exclusion criteria which yielded a final sample of 5 channels determining the number of videos views subscribers and likes associated with the channels we then visited the youtube home page for each channel in our sample and recorded the following descriptive data the number of videos the channel posted to youtube number of views generated across all videos posted by the channel and number of people who subscribe to the channel to select the sample of videos to examine for product placement we identified 50 videos with the most views and the most recent 50 videos that featured food or drink products or logos in the video thumbnail the thumbnail is critical for increasing viewership because it is designed to attract viewers by showcasing the videos appealing content anyone who creates youtube videos controls which thumbnail appears by selecting an image they want to use as the thumbnail 29 we then recorded each videos publication date and the number of views and likes we also identified the age of children shown in the videos by searching for other videos on their channel in which their date of birth is reported quantifying the frequency of food andor drink product placements we created a content analysis codebook to identify the presence of foods andor drinks food or drink brand logo or food or drink toy whether a child consumed or played with the food or drink item and how many minutes food andor drinks appeared we measured product placements in minutes instead of seconds to convey the deep integration of products in the videos to complete codebook questions 2 researchers began watching each video and paused it whenever a food andor drink item appeared when a food andor drink appeared we assigned 1 subcategory the child consumed the item the child played with the item the logo appeared or the child or caregiver prepared food if the child prepared and ate those cookies we coded it under the consumption subcategory because research reveals exposure to food advertisements leads to increased consumption among children 23 to assess interrater reliability we followed the recommendations of lombard et al 31 determining the amount of time food andor drinks appeared during the videos we then used 3 steps to estimate the number of impressions generated by videos that featured food andor drinks first we recorded the number of minutes the food andor drinks appeared during each video then we multiplied that number by the number of views for that video finally we summed the total number of minutes for all videos assessing the nutritional quality of food and drink products we categorized foods as unhealthy if they received a score 4 on the nutrient profile model a validated nutrition scoring tool 32 we categorized drinks as unhealthy if they contained 25 g of added sugar on the basis of recommendations by the american academy of pediatrics on sugary drink intake among children 33 we conducted all analyses using r results kid influencer channels in the sample collectively generated 482 billion views and 386 million subscribers through 10 058 videos posted on youtube as of july 2019 each channel featured 1 family with 2 or 3 children and video topics included toy reviews playtime or other familyfriendly activities each channel included videos of birthday parties or the birth of the kid influencers which enabled us to calculate their age the average age of the 9 kid influencers was 73 years as of july 2019 the children who starred in the videos ranged in age from 3 to 14 years figure 2 youtube channel and video search flow diagram our search criteria yielded 418 videos because 3 channels had 50 videos featuring food andor drinks in the thumbnail one variable from our codebook did not meet acceptable interrater reliability and was excluded that variable attempted to identify instances when a kid influencer was overtly promoting the brand versus subtly promoting the brand in the story line a total of 179 videos featured food andor drinks and food andor drinks appeared 291 times during those 179 videos the 179 videos that featured food andor drinks were viewed 1 billion times and generated 26 million likes on youtube food andor drink product placements in those kid influencer videos generated ∼165 million impressions for items that were mostly unhealthy branded products the majority of food andor drinks promoted were unhealthy branded items followed by unhealthy unbranded items healthy unbranded items and healthy 34 estimates suggest that companies will spend 15 billion over the next few years on influencerbased marketing 35 these estimates coupled with the current findings figure 4 a sandaroo kids video with 204 000 views demonstrate an urgent need to reduce unhealthy food and drink product placement in videos featuring and targeting young children as online media use increases among young children 8 kid influencers carry the potential to increase childrens exposure to unhealthy food promotions that may increase poor dietary behaviors 226 recognizing the power of media and influencers the federal trade commission issued guidelines regarding social media influencers responsibility to disclose endorsements such written or oral disclosures however may easily be disregarded or not understood by children as identified in a 2019 complaint filed with the ftc against one of the channels in our sample 36 the food industrys selfregulatory efforts also aim to mitigate the harmful effects of childtargeted advertisements but studies have revealed that industry selfregulation is not reducing childtargeted marketing of unhealthy food on television 35 and their guidelines do not mention the role of kid influencers in promoting unhealthy products 37 many kid influencer tactics may qualify as unfair and deceptive acts and practices directed at children under federal and state consumer protection laws the ftc and state attorneys general enforce the ftc act and state consumer protection acts respectively yet the ftcs enforcement on youtube is not consistent with other media for example hostselling is prohibited on television but not on youtube 38 in fact the new youtube kids app has been characterized as hostselling and character marketing on steroids 3638 as kid influencers become more ubiquitous federal and state actions to protect children under existing authorities are necessary simultaneously new regulations and enforcement mechanisms may be necessary to protect children from these evolving marketing strategies these protections are critical given educating parents about deceptive marketing practices may not be effective in reducing their in future studies researchers should examine the extent to which children and adolescents can identify when kid influencers engage in product placement which would inform the extent to which the ftc should strengthen their response to kid influencers endorsements more research is needed to understand whether influencers endorsements of food andor drinks causes increased caloric intake among youth in one study researchers found that adolescents ate more when exposed to the influencer promoting food versus nonfood items but the study lacked a control group that featured food without the influencer 26 given the enormous reach of kid influencers videos on youtube pediatricians can play a critical role in encouraging parents to limit childrens screen time on youtube even on channels that characterize themselves as child friendly or educational pediatricians can also inform parents about the presence of marketing disguised as entertainment on youtube and youtube kids finally the american academy of pediatrics published a report that describes the subtle and interactive features of social mediabased advertising including undisclosed marketing of toys in youtube influencer videos 41 and future american academy of pediatrics publications may benefit from describing the unique role of kid influencers in promoting unhealthy food and beverages this study has some limitations first the sample included a subset of the 10 058 videos posted on these channels so our results underestimate the amount of product placement generated by these kid influencers although we instructed coders to pause the video when food andor beverages appeared they may have missed some appearances in future studies researchers should segment videos to better organize the coding process we also calculated the number of minutes food and beverages appeared in videos but in future studies researchers could be more precise by calculating the number of seconds products appeared although our data suggest that mcdonalds accounts for the most product placement it is possible that our search methods missed other brands second data on how much families were paid for these products placements are not publicly available one family in our sample however has reportedly earned 26 million from their youtube channel including at least 1 million for paid sponsorship videos 1314 finally we did not examine how these product placements may affect dietary choices which is an area of future research our study has several strengths including being the first to analyze a sample of videos to determine the frequency of food and or drink product placements the inclusion of the mostwatched channels that target children and the use of objective nutrition scoring tools conclusions this study is the first to document the wide array of unhealthy food and beverage brands that are promoted through usergenerated youtube videos featuring kid influencers most food advertising research has been focused on television commercials or online advertisements produced by companies 34 this new advertising frontier however has been largely unstudied and underregulated our findings suggest the need for future experimental studies to examine the extent to which viewing these typesof videos increases consumption of unhealthy foods and assess whether kid influencers endorsements increase the preferences for the product among toddlers young children and parents the ftc should enact regulations that more adequately address unhealthy food and beverage brands promoted by kid influencers acknowledgments we thank krystle a financial disclosure the authors have indicated they have no financial relationships relevant to this article to disclose

we aimed to determine the frequency with which kid influencers promote branded and unbranded food and drinks during their youtube videos and assess the nutritional quality of food and drinks shown methods researchers used socialbakers data to identify the 5 mostwatched kid influencers ages 3 to 14 years on youtube in 2019 we searched for 50 of their mostwatched videos and 50 of their videos that featured food andor drinks on the thumbnail image of the video we coded whether kid influencers consumed or played with food or toys quantified the number of minutes food andor drinks appeared and recorded names of branded food andor drinks we assessed the nutritional quality of foods using the nutrient profile model and identified the number of drinks with added sugar results a sample of 418 youtube videos met the search criteria and 179 of those videos featured food andor drinks food andor drinks were featured in those videos 291 times kid influencers youtube videos were collectively viewed 48 billion times and videos featuring food andor drinks were viewed 1 billion times most food andor drinks were unhealthy branded items n 263 9034 eg mcdonalds followed by unhealthy unbranded items n 12 41 eg hot dogs healthy unbranded items n 9 31 eg fruit and healthy branded items n 7 24 eg yoplait yogurt conclusions kid influencers generate millions of impressions for unhealthy food and drink brands through product placement the federal trade commission should strengthen regulations regarding product placement on youtube videos featuring young children whats known on this subject exposure to food advertising is associated with poor diet and food companies have increased online advertising in response to growing social media use young children have limited cognitive abilities to recognize advertising which may be exacerbated by branded influencer poststhis study is the first to document the array of unhealthy branded products promoted through youtube kid influencers most food advertising research has focused on television commercials or online advertisements produced by companies this new frontier has been largely unstudied

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introduction the causes of diabetes disparities are multifactorial and complex and thus solutions need to target different drivers patients need access to care health care must be tailored to the individual needs of each patient and providers have to prescribe the right therapies to get glucose blood pressure and cholesterol under control but diabetes care is largely selfmanagement by patients in their homes and communities healthy lifestyle is crucial including good nutrition physical activity and actively implementing treatment regimens thus diabetes is a classic model for chronic disease management and presents a prime case study of how to integrate care in the health care system with patients lives in their homes and communities there are new incentives to integrate health care and community approaches to diabetes treatments health care policy and market forces are evolving and include population management global payment systems new delivery systems and tax laws requiring nonprofit health care organizations to demonstrate community benefit for example as part of the affordable care act accountable care organizations are responsible for caring for a defined population within a geographic area reaching budgetary goals to share savings and meeting performance standards acos have incentives to partner with communitybased organizations in order to improve chronic care management and prevent costly hospitalizations and emergency department visits background although several initiatives have integrated individual health care and community interventions to reduce diabetes disparities few papers discuss how such projects can expand and spread one comprehensive example is the racial and ethnic approaches to community health programs charleston and georgetown diabetes coalition in south carolina the coalition educated patients providers and community members implemented quality improvement strategies within health systems and promoted sustainability with media and social organizing community health advisors followed up with patients who missed appointments linked them to medication assistance and diabetic supplies and provided grocery store tours and support groups in the community the coalition increased healthy food options developed walking pathways and advocated for policies that promote good health another example is the translation of the diabetes prevention program from academic medical centers into ymcas a modified diabetes prevention program was successfully implemented in ymcas across 46 communities in 23 states at a lower cost per participant compared to the original intervention the investigators attributed this successful translation and expansion to collaboration communitybased delivery health information technology and payment systems that align incentives given the limited number of prior papers and the evolution toward caring for populations such as with acos there is a great need for more case studies of how initiatives that integrate health care and community approaches to reduce diabetes disparities can expand and spread the factors and context that lead to successful expansion and sustainability of integrated diabetes disparities reduction efforts are not well known therefore we describe our experience implementing a collaborative effort to reduce diabetes disparities on the south side of chicago and how we connected with others to expand and sustain these efforts diabetes disparities research at the university of chicagoour investigative team at the university of chicago had previously engaged in multiple lines of research that provided a broad and deep foundation for subsequent ambitious partnerships this research includes quality improvement collaboratives with diabetes such as the health resources and services administrations health disparities collaboratives formative work guiding tailoring of diabetes education and shared decisionmaking programs for african americans and a series of lifestyle modification programs for african americans in addition team members had extensive experience in communitybased participatory research and community collaborations team members had also recently completed a systematic review of interventions to reduce racial and ethnic disparities in diabetes thus the team was poised for the right opportunity the funding opportunity and match with institutional priorities in 2008 the merck foundation released a call for proposals for an alliance to reduce diabetes disparities the foundation would fund five sites that would attempt to reduce diabetes disparities by integrative approaches involving patient provider system and community interventions the cfps goals closely matched the interests of the research team and uhi in addition although the uhi had begun some research projects most notably the south side health and vitality studies it was seeking to support additional projects that combined research service and education also several university research centers have community engagement and disparities reduction as priorities including the institute for translational medicine and national institute of diabetes and digestive and kidney diseases chicago center for diabetes translation research these two centers have subcontracts with the access community health network a network of fqhcs that would eventually participate in the project staff from the uhi helped us identify four clinics from the sshc that were potentially interested in participating in the project along with two clinics at the university of chicago the cfp asked for inkind support and the dean of the biological sciences division supported part of a project manager who would interface with the community as well as uhi staff that would assist the project in addition a newly recruited director of a center for community health and vitality within the uhi had extensive experience with chronic disease quality improvement collaboratives involving clinics and became a member of our team the uhis effort to link patients who did not have regular medical homes to a primary care clinic or provider also fit the project we were awarded the merck foundation grant and later received niddk funding implementation of the initiative we have previously described the early experiences and outcomes of our project in brief we partnered with six clinics and engaged in a quality improvement collaborative with integrative care management some patients received culturally tailored diabetes education and instruction in shared decision making providers received training in cultural competency behavioral change and shared decision making community partnerships were initially the least developed component of the project but rapidly expanded in exciting ways patients taking the culturally tailored diabetes education classes have improved their a1c levels clinics have improved their ability to provide chronic illness care and more persons in the community are aware of healthy lifestyles ongoing evaluations will assess longitudinal clinical outcomes program costs and reach into the community expansion of the initiative integration of health care and communityour community activities have focused on healthy lifestyle and we have connected those efforts to our health care interventions healthy eating is a priority for example we have partnered with the kleo community family life center a communitybased organization that runs a monthly food pantry with the chicago greater food depository we helped expand the pantry incorporate health education health screening and sharing of culturally tailored recipes using food items distributed that day patients in our diabetes education and empowerment classes are encouraged to go to the kleo food pantry and vice versa community residents at the pantry without a regular doctor are referred to the sshc to establish primary care another example of health carecommunity integration is the food rx program a collaboration that we developed with walgreens pharmacy and the 61st street farmers market to increase access to healthy foods on the south side of chicago in food desert areas physicians can prescribe food prescriptions that recommend specific dietary goals and have a redeemable cash value for healthy food at participating walgreens locations or the farmers market in addition our chicago center for diabetes translation research is partnering with the chicago department of public health on collaborative efforts to improve diabetes outcomes in the city the chicago department of public health and our team have developed methods to generate diabetes hospitalization rate estimates at the chicago neighborhood level from data that are geocoded only at the level of us postal zip code these results and the ability to map estimates for small areas will help target interventions to reduce diabetes disparities dissemination media outreach and social mediawe have used multiple venues to inform people about our project and disseminate lessons learned traditional dissemination methods have included academic articles and presentations at national academic meetings as well as community venues such as local community newspapers community presentations and other communitybased health events once we had early successes the university of chicago communications team then used many of its internal publications and websites to get the word out about our project as a strong example of universitycommunity partnership further outreach and word of mouth led to dissemination on local cable television and south side radio stations for example for a modest fee we purchased a time slot for a 13part diabetes education and viewer callin show on chicago cantv a local cable television station that reaches 1 million viewers we invited clinicians from our participating clinics and the university of chicago to give television talks thus getting them more involved we connected with a popular local african american television talk show host jacinda lockett and appeared on her show jacinda subsequently did a feature on one of our events the diabetes cookoff that highlights communitycreated healthy recipes we have appeared numerous times on health interview and callin shows on wvon a popular radio station on the south side in addition we created a website for multiple audiences including patients researchers and new potential partners over the past 12 months our website has had 5229 visits from 3100 unique visitors we also crosslinked the website to our partners to highlight and celebrate the network we helped build and created a project logo and brand to enhance the communitys awareness of our work we also shared information about our project on the chicago center for diabetes translation research website we have used social media including facebook twitter and several blogs our project was recently highlighted in the american diabetes associations diabetes forecast magazine for the lay public sustainability becoming part of standard operating procedurewe have continuously tried to transition the coordination and implementation of successful project components to community members and staff at our participating health centers with the goal of incorporating these resources into their standard operating procedures our clinic sites are assuming increasing administrative responsibility with each round of our patient empowerment classes and one of our sites is now implementing the class without support from our research team one way our team has helped clinics incorporate these programs into standard operating procedure is by using quality improvement methods for example some clinics have tried adding referral to the patient class via their electronic medical record and some have attempted to increase class retention by assigning medical assistants to keep in touch with a small group of patients about attendance we have collaborated with a certified diabetes educator to lead monthly tours at savealot grocery stores on budgetfriendly healthy eating and over the past year we have trained more than 30 community members to lead nutritionfocused educational tours in south side community settings we are also creating infrastructure and protocols to support expansion for example we are collaborating with an alliance of churches on the south side to write a guide that will help them set up food pantry and health education events similar to the ones we created at kleo infusion of new talent and peoplethe project attracts many students and volunteers we have hosted students in nursing public health the culinary arts and medicine including trainees from college students to research fellows they hail from diverse institutions including chicago state university kennedyking community college malcolm x community college the university of illinois at chicago and medical colleges from around the country most of the university of chicago pritzker school of medicine firstyear medical students participate in the national institutes of healthfunded summer research program after their first year of school and many students have been eager to engage in community projects the medical school also requires students to complete a longitudinal scholarly project throughout medical school and community health is represented as one of the five scholarly pathways that students can choose to participate in even the legal team at the university of chicago has been very enthusiastic and helpful using our project to develop legal templates and approaches for other community research and service collaborations synergy with other disparity programsour project shared several staff members with the rwjf finding answers disparities research for change national program office at the university of chicago finding answers has a national scope funding evaluations of disparities interventions performing systematic reviews of the disparities intervention literature and providing technical assistance to organizations attempting to reduce disparities this collaboration allowed our local work to be informed by national trends and findings while also helping the finding answers staff understand better the realworld challenges of implementing disparities interventions finding answers also provided a national venue to disseminate our lessons for example our project was one of the case studies in finding answers training webinars for organizations attempting to reduce disparities during one webinar a group from memphis became intrigued with our food rx program and we helped them contact their local walgreens representative in the summerfall of 2012 finding answers embarked on a media campaign to disseminate information about its roadmap to reduce disparities and the south side diabetes project was highlighted as one example of integrating health care and community approaches to reduce disparities in addition finding answers and members of our diabetes project team collaborated with the american association of medical colleges to provide a workshop on reducing disparities by integrating equity into quality improvement at the national american association of medical colleges integrating quality meeting finding answers and our diabetes project have informed each other and created new opportunities for dissemination and shared learning evolving policy trends and financial incentiveswe focused on population management of a defined catchment area based on community needs assessments scientific evidence and prior experience serendipitously our integration of health care and community approaches dovetailed with increasing national interest in global payment models and acos an article describing our projects early experiences was accepted into a special diabetes issue of health affairs and our projects policy relevance has been one of the themes highlighted in the merck alliances webinars on addressing diabetes disparities we were invited to speak to the commonwealth fund board of directors about our project for this reason like many academic medical centers most of the university of chicagos financial profit has historically come from providing tertiary and quarternary feeforservice care and procedures however senior medical center leadership changed in 2011 subsequently the organizations strategic and operating plans have been updated to prepare for an environment that incentivizes optimization of provider delivery models population health community benefit and care coordination and that will include innovative payment models that promote value in addition consistent with increasing national efforts in the affordable care act and private sector to reduce racial and socioeconomic disparities in care the university of chicago has embarked on an aggressive diversity and inclusion initiative to improve equity in quality of care patient outcomes and experience and workforce diversity our team is actively involved in this local equity initiative the goals and content of our south side diabetes project align well with the university of chicagos new strategic and operating plans for example the six clinics in our project became a focal point of a proposal the university of chicago submitted in response to a request for applications from the state of illinois medicaid agency for care coordination programs the medical director of the participating university primary care group clinic took the lead in writing the proposal and she helped rally the clinics around this common vision medical center leadership chose diabetes as the focus and used our collaborative team structure as the proposals core given the experience relationships infrastructure and groundwork that had been built our project also aligned with the increasing national priority on patientcentered care the university of chicago health plan is a capitated health plan of university and medical center employees and dependents many of whom live on the south side uchp seeks to improve patient satisfaction and thus adopted a component of our project that used mobile phone texting technology to aid patients with diabetes selfmanagement uchp assumed the full financial and administrative responsibility of the texting program after seeing the results of a pilot study involving 18 patients this buyin facilitated true integration of the program into clinical operations increased scale and enhanced sustainability in addition the university is aligning the priorities it identifies through its required community needs assessment with its community benefit and service efforts obesity diabetes and metabolic syndrome are significant health problems on the south side and thus our project fits well with the universitys vision for community benefit programs finally the university of chicago maintains the multifactorial mission of patient care research education and community service our project works in each of these four areas and provides trainees multiple ways to serve and improve their skills mapping project to the rwjf finding answers disparities research for change conceptual model for reducing disparities and the cfir the finding answers reducing disparities model highlights that the causes of disparities are multifactorial and thus the solutions need to address these different areas to be most effective persons with diabetes spend most of their time living in the community therefore we have attempted to increase access to healthy food and safe physical activity and educated the community and engaged in media outreach within the health care system we have implemented culturally tailored diabetes education for patients behavioral change training for providers and a quality improvement collaborative for clinics to improve their care management policy makers will need to implement payment reform to make preventive medicine primary care and public health efforts to reduce disparities financially viable whereas the finding answers model provides targets for intervention the complementary cfir implementation framework has five domains to help identify and understand key drivers that can expand and spread an intervention intervention characteristics outer setting inner setting individuals and process the table also includes the cfir subdomains that are most relevant for our project successful expansion does not follow a simple linear process a framework like cfir helps highlight where a project has strengths for implementation and what gaps need attention discussion our project arose from community needs our prior diabetes disparities reduction efforts the local institutional environment and the priorities of the merck foundation and niddk over time the project expanded particularly in the integration of community partnerships and health care components we designed our project to integrate health care and community because it was the right thing to do in order to effectively tackle diabetes disparities however over time we further aligned our specific interventions with major policy and financial trends in the health care marketplace and the evolving strategic priorities of the university of chicago we also explored multiple ways of expanding the project and invested in partnerships when we received positive feedback and found collaborative partners with shared goals and interests the alignment of interests between community and university of chicago across research education patient care and community service has enabled us to expand and sustain our integrated diabetes disparities reduction initiative with the hopes of significantly improving the health of the south side of chicago we have encountered several challenges the project has required significant investments of time resources and staff from our team for example team members have spent substantial time establishing and cultivating relationships with community organizations local businesses and politicians and participating in university meetings with stakeholders in the medical center and broader university and have expended much effort in overseeing and coordinating volunteers and trainees we were fortunate to receive grant funding and institutional support from the university and our partners and some responsibilities for implementing the project have transitioned to the community and health centers realistically however financial incentives will need to align if integrated health care and community solutions to reduce diabetes disparities are to spread nationally many staff champions and leaders have turned over in clinics and that has required us to rebuild relationships and teams and navigate participants shifting clinical and personal priorities expansion is difficult much of our work is successful because of the many personal touchpoints we have but that limits our expansion regarding depth and breadth we have extended our reach with human capital and technology but it is a challenge nonetheless conclusions we have learned many key lessons 1 take action and do something it is hard to get things going aspirational words are common but actual projects rare people are happy to latch on to a moving train even if it is slow at first it may feel difficult to align so many stakeholders and set things up perfectly but do not let that stop you start something even if on your own expansion can build off small successes we have developed collaborations with local nonprofit organizations such as the 61st street farmers market kleo community family life center and the greater chicago food depository as well as national forprofit companies such as walgreens and the savealot grocery chain we have engaged undergraduates and the legal and communications departments keep an eye out for unlikely partners you might not have imagined and actively search for unanticipated opportunities interests can align around improving community health be inclusive be open to different partners and collaborations 3 include partnerships with established organizations with wide reach for example our partnership with the rwjf finding answers program provided opportunities to disseminate our findings regionally and nationally 4 gain skills in working with media and use local public relations staff researchers usually have no or minimal training in media relations and often want to avoid any perception of selfaggrandizement however it is important to get the word out about your project to highlight key health issues and share your lessons opportunities often develop from there most academic centers have professionally trained public relations staff whose job it is to help researchers craft messages and work with media sources scientific journals are primarily read by scientists expanding the reach of your work to ordinary citizens and policy makers can exponentially increase the realworld impact of your science 5 understand historical policy and economic contexts understanding local and national contexts is critical for recognizing where interests align and what types of tailored programs best fit mutual partners participate on community committees stay in the loop with your organizations strategic planning and connect with policy makers and advisors 6 do not be afraid to create an actionoriented integrated health carecommunity project integrated projects are ambitious and require significant investment but people are enthusiastic to support and work with a project that is doing the right thing such projects are good for the community fit the missions of most organizations and are the types of initiatives that people like to celebrate when an event goes well these projects speak to the heart as well as mind the new health care environment provides tremendously exciting opportunities to reduce disparities in care and improve community and population outcomes go for it research for change conceptual framework for reducing disparities and a model for six levels of intervention patient provider micro system organization community and policy

to reduce racial and ethnic disparities in diabetes care and outcomes it is critical to integrate health care and community approaches however little work describes how to expand and sustain such partnerships and initiatives we outline our experience creating and growing an initiative to improve diabetes care and outcomes in the predominantly african american south side of chicago our project involves patient education and activation a quality improvement collaborative with six clinics provider education and community partnerships we aligned our project with the needs and goals of community residents and organizations the mission and strategic plan of our academic medical center various strengths and resources in chicago and the changing health care marketplace we use the robert wood johnson foundation finding answers disparities research for change conceptual model and the consolidated framework for implementation research to elucidate how we expanded and sustained our project within a shifting environment we recommend taking action to integrate health care with community projects being inclusive building partnerships working with the media and understanding vital historical political and economic contexts

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background mammography screening an xray examination of the breasts is used to diagnose breast cancer at an early stage in order to achieve lower breast cancer mortality sufficiently high attendance in mammography screening is a key factor to obtain the intended effect according to european guidelines an attendance rate of at least 70 is required 1 the swedish populationbased screening programmes have in most parts of the country an attendance rate between 80 and 90 2 but in some parts of the country only 65 attend ie a 35 nonattendance rate 3 it is well established that sociodemographic factors are associated with the risk of nonattendance but previous studies have mainly reported on traditional factors such as low educational level and manual occupation and they are associated with a high rate of nonattendance 4 5 6 theories about social network have been extensively studied using different definitions in both medical and social care research 78 and the importance of support from family and friends on a womens decision to participate in mammography screening has indeed been indicated in some previous studies 8 9 10 attitudes about mammography screening in the womens families and close environment may also affect attendance but only single studies have been performed 11 another factor in close relations that could influence the decision to attend is previous cancer or even previous breast cancer but this aspect has not been widely investigated malmö the third largest city in sweden was the base for a randomised trial on mammography screening in the 1970s 12 a populationbased service screening started in 1991 following this a large populationbased study the malmö diet and cancer study recruited about 17000 women between 1991 and 1996 all participants answered a questionnaire on lifestyle socioeconomic factors and health behaviour the cohort has been reexamined at several occasions and selfreported information on mammography screening is available the aim of the present study was to investigate nonattendance in mammography screening in relation to different aspects of a womens social network family composition social support attitudes and cancer in close relations methods study population and setting the malmö diet and cancer study the malmö diet and cancer study is a populationbased prospective cohort study that recruited women living in malmö sweden between 1991 and 1996 in all 17035 of those invited participated which corresponded to a participation rate of 40 13 a randomised sample of 3531 women was already at baseline included in a subcohort with additional examinations related to cardiovascular risk factors out of these 3531 women the 3045 women who were alive in 2007 were invited to a reexamination when the reexamination was completed in 2012 2212 of all invited women had participated the present study included 1554 women who had been reexamined up until 29 september 2010 and who had completed all parts of the baseline examination and the reexamination at the baseline examination 1554 women were between 45 and 68 years of age and 6184 years at the reexamination the baseline questionnaire included questions on sociodemographic factors and several questions on the social network 14 in the reexamination participants were additionally asked about several aspects of mammography screening the current study was approved by the regional ethics committee in lund mammography screening in the study setting mammography screening was introduced in malmö in 1976 as part of a randomised trial for women between 4569 years of age 12 it was followed by the introduction of a populationbased mammography screening programme in 1990 where all women between 5069 years of age were invited every 18 or 24 months depending on age and parenchyma pattern 3 from 1997 the upper age limit was changed to 74 years and from 2009 and onwards the lower limit was changed to 40 years meaning that currently women aged 4074 years are invited in line with the recommendations from the swedish national board of health and welfare 15 all women in the eligible age groups are invited by letter every 18 months for women aged 4055 years and every 24 months for women 55 years the fee paid by the attendee for a screening mammogram is 120 sek and is not reimbursed for women living in malmö the populationbased screening has been carried out at malmö university hospital now skåne university hospital malmö measures and definitions outcome measure the outcome variable of interest in this study is mammography screening nonattendance based on questions at the reexamination about invitation to mammography screening at malmö university hospital and participation in screening at this hospital the following groups were defined invited participated inviteddid not participate not inviteddid not participate and not invitedparticipated invitedparticipated and not invitedparticipated were classified as attendees as all women in the present age groups from the area ought to have received an invitation correspondingly invitednot participated and not invitednot participated were regarded as nonattendees there were a total of 1452 women who contributed with information on these questions explanatory factors baseline questionnaire the baseline questionnaire included information on country of birth educational level was classified into three different levels occupation was based on the question present or latest job which had been recoded into the swedish socioeconomic classification into employees officialssalaried employees labourers and employers selfemployed 14 information was also available on marital status whether the women were living alone or not and the number of children 14 the social support factors social participation social anchorage and instrumental support have previously been defined by lindström et al 16 social participation was based on 13 different yesno questions about attendance to formal and informal groups in the society during the past year eg a union meeting going to the cinema or a church meeting if three alternatives or fewer were indicated the social participation of that person was considered low 16 social anchorage describes to what extent the person belongs to and is anchored within formal and informal groups and the feeling of membership to these groups familiarity with neighbourhoods sense of belonging to friends and relatives membership or position of trust in organisations or clubs and the feelings of being important to other people it is based on five questions with four possible answers yes i am sure yes probably no probably not and no not at all that were dichotomised to yesno answers the two highest options were set against the two lowest if three or more of the five items denoted low social anchorage the whole variable was regarded as low 16 instrumental support was based on one question with four alternative answers on their ability to get help from people if they fall ill or need help with practical things the women who responded that there is certainly help available were classified as high and the other three alternatives were classified as low 16 reexamination questionnaire planned future participation in mammography screening had three alternative answers yes no and dont know selfrated risk for getting breast cancer was rated as low medium and high attitude on mammography screening was assessed by the question what do you think about mammography screening and had three alternative answers it is goodit improves the chance to recover from breast cancer it makes no differencedoes not affect my health and it does more harm than goodcan be dangerous previous cervical screening was defined from the question have you made a gynaecological health control with pap smear test with alternative answers yes and no cancer in close relationships was based on four different yesno questions about cancer mother hashas had cancer father hashas had cancer siblings have have had cancer and close relatives friends fellow workers havehave had cancer if at least one person in the surrounding has or has had cancer this was classified as a cancer in close relations accordingly breast cancer experience was based on three questions about breast cancer mother hashas had breast cancer sister hashas had breast cancer and close relatives friends follow workers havehad have breast cancer if at least one person in the surrounding has or has had breast cancer this was classified as a breast cancer in close relations previous cancer and previous breast cancer in the respondents medical history were assessed by yesno questions statistical methods the risk of nonattendance in relation to various factors was calculated using logistic regression analysis odds ratios for nonattendance with 95 confidence intervals were calculated all variables were adjusted for age at the time of reexamination in a second model many studies have found nonattendance to be associated with age country of birth educational level and occupation subsequently a final model included these covariates several of the studied factors can be expected to be strongly correlated eg marital status and living alone and it was not considered suitable to perform an analysis including all studied factors in the same model spss 170 was used for all analyses results sociodemographic factors these factors were selected a priori to be included in the final statistical model there were no large differences in age or foreign background between nonattendees and attendees nonattendees had worked to a greater extent as labourers and had a shorter education as compared to attendees family composition and social support women who were unmarried vs married and who had no children vs children were at a statistically significant higher risk for not attending mammography screening nonattendees were more often divorced or widowed and lived alone more often as compared to attendees but these associations were not statistically significant social participation was not associated with nonattendance a low social anchorage and a low instrumental support were positively associated with nonattendance but these estimates did not reach statistical significance health attitudes and screening behaviour in all 952 of nonattendees and 980 of attendees considered mammography screening to be important and that it improves the chance of recovery from breast cancer that is very few women considered that screening makes no difference however the small difference resulted in an about four times higher or concerning nonattendance in these women but with a very wide ci the selfrated risk of breast cancer was not associated with attendance the intention not to participate in mammography screening in the future was strongly associated with the risk of nonattendance and women who had previously abstained from cervical screening were at a statistically significant high risk of being nonattendees in mammography screening cancer in family and close relations the experience of cancer or breast cancer in the own family or in close relations was not associated with the risk of nonattendance women who had themselves experienced a cancer diagnosis had a similar risk of nonattendance as women with no cancer history corresponding to an or of 116 women discussion this study demonstrated that family composition may affect nonattendance in mammography screening virtually all women attendees and nonattendees considered mammography screening to be important nonattendees planned to a lesser degree to attend mammography screening in the future and had relatively often abstained from cervical screening in the past which indicates that their decisions were not a random phenomenon family composition and social support nonattendance was more common in women living alone and in women with no children decisionmaking in a social context was illustrated by willis showing that women felt a responsibility to attend when they got an invitation 17 it is possible to hypothesise that this effect may be more pronounced in women living together with someone else or having children in the present study there were no differences between women who did not attend and those who attend mammography screening with regard to active social participation it might indicate that the decision not to attend cannot directly be linked to how active women are in the society in general on the other hand it may be a result of the mdcs population being a subset of the general population that is more active as indicated by the fact that they decided to take part of the mdcs while the result might have been different in the general population the present study did not show statistically significant results regarding instrumental support and social anchorage there was a tendency towards differences between the groups where the experience of affinity with other people and the ability to get help from someone in the social network may have an impact on attendance in mammography screening the nonsignificant results can be an effect of the small sample size on the other hand there is no data available regarding the extent and the impact of close relations outside the family however previous studies have shown that informal interpersonal aspects like trust to someone in the network can be important and can create good conditions for health 7817 health attitudes and screening behaviour nonattendees in mammography screening planned to abstain from mammography screening in the future and had abstained from cervical screening to a greater extent than women who had attended mammography similar results have also been seen in previous research which shows a clear influence from past screening behaviour on future attendance in mammography screening 11 the fact that almost all women in this study answered that mammography screening improves their possibility of getting cured of breast cancer even those who did not attend mammography screening also suggests that this is a planned action womens intention to attend future mammography screening may also be based on a moral desire to live a healthy life and be a responsible citizen who has done everything possible to detect breast cancer in early stage 17 research on attendees in cervical screening in sweden shows results in the same direction 18 cancer in family and close relations there were no differences between attendees and nonattendees in mammography screening regarding the experience of cancer or breast cancer in the family and the close relationships this is in contrast to previous studies which shows that a history of cancer in the family or among close friends were important for the decision to attend mammography screening 817 the result in the present study can indicate trust to the health care system and experiences of good examples where women have been cured from cancer but this issue needs further attention preferably in qualitative studies strengths and limitations of the study this is a prospective followup of a large populationbased cohort and national population registries make it easy to follow the population over time the study was performed in a population that has been exposed to a general service screening during the last 20 years an additional strength is that the questionnaire contains information that makes it possible to adjust the analyses for potential confounders some aspects of study limitations should be considered in the mdcs the educational level of the participants is slightly higher than that in the general population and the percentage of foreignborn women is lower in this material than that in malmö in general which could limit the representativeness 13 however as there was a wide distribution in the studied sociodemographic factors internal comparisons eg relative risks were probably not affected to any large extent by a potential selection bias a problem in some of the analyses is the low number of individuals hence a low statistical power this may have lead to a type ii error in relation to some of the analysed factors another limitation is that some of the comparisons are crosssectional that is factors only assessed at the reexamination were indeed measured following the decision concerning participation in mammography screening therefore it is difficult to investigate a potential causeeffect relation and these comparisons ought to be regarded as descriptive and explorative conclusions this study indicates that family composition but not necessarily the presence or absence of social support perceived cancer risk or cancer in close relations may affect nonattendance in mammography screening a positive attitude towards mammography screening was found among both attendees and nonattendees although the latter group planned to a lesser degree to attend mammography screening in the future and had relatively often abstained from cervical screening in the past the decision not to attend seems not to be a random phenomenon although our results indicate a complex pattern behind nonattendance which needs to be further elucidated competing interests the authors declare that they have no competing interests

background mammography screening can reduce breast cancer mortality the aim of the present study was to investigate nonattendance in mammography screening in relation to different aspects of a womens social network attitudes and cancer in close relations methods data from the malmö diet and cancer study baseline examination in 19911996 was used a reexamination began in 2007 and 1452 women participated family composition social support sense of belonging attitudes on screening and breast cancer risk and on previous cancer in close relations were investigated in relation to selfreported participation in mammography screening using logistic regression analysis yielding odds ratios with 95 confidence intervals results both attendees 980 and nonattendees 952 considered mammography screening important nonattendance in mammography screening was associated with being unmarried vs married 240130445 and with not having vs having children 177108292 nonattendees planned to abstain from mammography screening in the future more often than attendees 478256890 and they had often abstained from cervical cancer screening 169104275 no other statistically significant association was found conclusions this study indicates that family composition but not necessarily the presence or absence of social support perceived cancer risk or cancer in close relations may affect nonattendance in mammography screening a positive attitude towards mammography screening was found among both attendees and nonattendees although the latter group planned to a lesser degree to attend mammography screening in the future

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introduction there are close to 50 million seniors in the united states an estimate that is expected to nearly double by 2050 among those age 65 years and older approximately 2 million are considered homebound and are characterized by multiple chronic conditions functional impairments and high levels of frailty in addition to being medically complex homebound older adults often require additional supportive services to enable them to maintain their functional independence and remain in their homes and communities where the majority of older adults prefer to reside since its initial implementation in the united states the meals on wheels network has become a major provider of nutrition and social services to homebound older americans with over 2 million paid employees and volunteers nationally mow programs provide homedelivered meals to over 800000 individuals who might otherwise not be able to acquire and prepare their own meals or suffer from hunger and food insecurity america 2017 while clients may pay privately for their meals funding for meals and program operations comes primarily through other sources in addition to the nutritional benefits from the program research has begun to establish the additional benefits that recipients of these programs recognize including decreased rates of depression loneliness falls and hospitalizations recipients of homedelivered meals also report very high levels of satisfaction with mow services and indicate that it helps them to eat healthier foods improves their health and allows them to live independently and remain in their own home as we learn more about the impact of these programs in participants lives it becomes important to understand the mechanisms behind these various beneficial outcomes particularly the role of the drivers who deliver these meals to clients daily despite the network of more than 5000 providers and the many communities served by meal delivery programs across the united states very little is known about the drivers who make programs such as mow possible specifically we do not have a clear insight into the role of drivers in achieving the beneficial outcomes documented in the literature or the needs of clients that drivers are able to meet through their regular interaction furthermore while previous research suggests that volunteerism has both tangible and intangible benefits for volunteers we do not have evidence of the benefits that mow drivers may receive through their service therefore the objective of this article is to describe the interactions of mow drivers and their clients and the perceived benefits of the program to the volunteers who make it possible method as part of the groundwork for a research initiative seeking to expand the scope of the homedelivered meal service we conducted qualitative interviews with mow staff and drivers at six geographically and operationally distinct sites around the country these interviews were part of a larger study aimed to understand the organizational structure and operation of individual mow programs as well as perceptions and experiences of program leaders and drivers this article explores the interview results to illuminate specific ways clients and drivers interact in the program development and testing of interview guides interview questions used with mow staff and drivers were developed into guides through several steps interview questions were developed for each of the four roles interview questions were reviewed by the project team for comprehension and completeness guides were then piloted at two mow programs and by incorporating this feedback were further refined for clarity the project team was comprised of individuals from brown university meals on wheels america and west health institute among the larger team there were two smaller teams a qualitative team and a site visit team the qualitative team designed the data collection instruments and analyzed the site visit data and the site visit team who conducted the site visits and interviews the site visit team was trained by the qualitative team training consisted of an inperson didactic session and participation in the first site visit specifically the qualitative team observed 15 interviews with drivers and mow staff at the end of the first site visit the qualitative team participated in a debrief with the site visit team about how interviews were conducted team members advised and provided suggestions for future site visits as well as discussed impressions of what was learned during the visit the site visit team then conducted site visits and interviews at five additional study sites data collection site visits and semistructured interviews were conducted by the site visit team between july 2016 and october of 2016 with staff and drivers at six mow programs located across the united states our purposive sample of sites was identified by meals on wheels america as part of a selection process for identifying potential sites for a pilot project to develop a mobile application for drivers to track changes in clients conditions in order to ensure diversity sites were selected based on staffing levels volunteer capacity current or potential partnership with healthcare providers and willingness to participate in onsite observations and interviews participating sites included mow programs located in california new jersey north carolina ohio texas and wisconsin the six programs served a mix of clients from different geographical areas four programs delivered in rural areas five programs delivered meals in suburban areas and three programs delivered in urban areas the total annual organizational budget for these programs ranged from us 340000 to us 66 million and the programs served anywhere from an estimated 71000 meals annually to 925000 meals the majority of clients served by these programs was over the age of 60 four of these programs received title iii older americans act funding for the meals five of the programs delivered 5 days a week and one program offered meals six or more days a week one program relied exclusively on paid drivers one program relied only on one paid driver for their rural route and two programs had less than five paid drivers to supplement their primarily volunteerrun programs within these programs mow staff participants were identified based on job descriptions and selected in an effort to understand their respective responsibility for the following job duties overall planning and management of the mow program client intake and assessment and coordination of volunteer recruitment management and training staff filling these positions were invited to participate in the interviews for each site eight to 10 drivers with at least 6 months of experience delivering meals were recruited for participation site visits and interviews occurred across 2 days per site and were led by at least two members of the site visit team the analytic sample consists of 84 participants and includes senior leadership staff and drivers individual interviews took place in a private setting each lasting approximately 30 to 45 minutes written consent to be interviewed and recorded was obtained from participants participants were instructed that they were free to decline to be interviewed andor end the interview at any point following each site visit the site visit team participated in a debrief with the entire project team to review field notes and observations notes and observations were used to develop detailed summaries that were shared and discussed with the qualitative team and incorporated into the study audit trail the study protocol was approved by the western irb and the qualitative data analysis was deemed exempt by the brown university irb analysis interviews from each of the sites were transcribed by an independent party and sent to the qualitative team for review upon receipt each transcript was individually read and coded by at least two of the qualitative team members using a thematic approach suggested by crabtree and miller as part of the pilot testing a thematic coding matrix was developed and vetted by the qualitative team with input from the larger project team refinements of the coding structure were made iteratively as analysis proceeded and codes were added and modified these modifications were recorded in the audit trail upon completion of the initial transcript review two members of the qualitative team met to discuss and reconcile their individual coding these pairs rotated throughout the study discrepancies in coding were discussed until a reconciled agreement was reached discrepancies that could not be reconciled were brought to the qualitative team meeting held at bimonthly intervals coded data were described sorted and managed using nvivo software the steps undertaken to ensure the credibility of the data included the audit trail that outlined ongoing ideas about codes and emerging themes ongoing discussion about themes during the bimonthly meetings of the four qualitative team members seeking and discussing alternative explanations of the data as needed including disconfirming evidence for each potential theme and themes were discussed with the site visit team during monthly project team meetings to vouch for the accuracy of the portrayal results a total of 84 subjects were interviewed across the six sites drivers comprised the majority of respondents while the demographics of participants were not queried we did ask drivers to share about their experience with mow and how long they had been delivering meals interviews with drivers and mow staff across the six sites found that drivers varied significantly in terms of their length of tenure and age for example it was reported that whereas some volunteers have only delivered meals for a short period of time others have been delivering meals for many years one organization stated it provides awards for volunteers who reach 30 and 35 years of service in addition drivers ranged in ages as reported by one individual we have all types of volunteers we have some that are of course retired we have some that are stay at home moms home school moms … people who are employed and and do it at their lunchtime we just have a broad range of different volunteers that we work with on a day to day basis analysis of the interviews with mow staff and drivers revealed the following key themes clients have multiple vulnerabilities clients appear to derive social as well as nutritional benefit from receiving meals drivers report they provide additional support to their clients beyond delivering the meal social bonds between drivers and clients were reported to strengthen over time drivers claim that they too derive validation and personal benefit through their meal delivery each theme is discussed below with representative quotes from participants drivers report clients have multiple vulnerabilities a general theme reported by drivers and staff was discussion about the vulnerabilities of the population of clients who receive services from mow drivers consistently noted that mow clients are homebound lack social support have physical disabilities or decreased functional capabilities suffer from economic hardship are single live alone and are lonely or isolated as indicated by one driver from texas the majority of mow clients cannot drive they cannot go out to eat … even if its not their legs a lot of times they may have arthritis in their hands and cant cook … thats the majority of them others are due to economic hardships they dont have money for groceries things like that according to a driver from wisconsin mow clients comprised a lot of elderly shut ins participants also mentioned the loneliness or isolation that many clients experience as one driver from new jersey said many many many times were the only person some of these people see in a day the following theme describes additional benefits mow clients are considered to obtain from the program interview participants believe clients derive social as well as nutritional benefits from receiving meals interview participants noted that clients received benefits beyond meal delivery from their mow programs benefits included feeling safe the ability to continue to live independently at home companionship from drivers and mow staff and a healthy meal as a mow case manager from north carolina noted clients feel safe knowing that somebody does come and care that they really care and that gives me a reward in knowing that at the end of the day that we really save someone we save them by allowing them to still live independently and their dignity you know is still intact and they might come to the door with a cane but they came to the door and its their door a leadership person at the ohio site reported a lot of people who have not received the service or provided the service thinks its just a simple meal coming to your home … and it is not just a simple meal it is so much more its that health check that safety check … making sure that theyre okay drivers also reinforced the idea that mow allows clients to remain at home as one texas driver suggested a lot of them will tell me i just could not live alone if you werent bringing my meals to me when describing the meal delivery process a driver from new jersey said if youre doing it right its a lifeline for the clients drivers also discussed how clients looked forward to their weekday visit and the companionship that drivers provided as one driver from california said by talking to them i sense that im making their day another driver from wisconsin suggested that because clients probably dont get to see their family often or maybe they dont have family to visit them receiving meals gives them a chance to see someone else … and that makes them happy drivers and mow staff uniformly agree that mow provides more than just nutritional benefits to clients as discussed in the next theme this is largely because drivers do more than just deliver the meal to their clients drivers provide additional support to their clients beyond delivering the meal drivers and mow staff reported that much of the benefit that clients derive from the program is likely attributable to the additional services and support that drivers and the program provide clients while some drivers did express that their role solely consisted of delivering the meal and exchanging brief pleasantries the majority of drivers noted providing additional support to their clients beyond delivering the meal for example according to mow staff drivers do a number of things around the house to help clients a case manager from texas said oh i love our drivers theyre great … and they do stuff that i mean whether its getting the mail or taking out the trash or you know like i have one client the friday driver every week puts him last on the list and cuts his front yard … theres just little things out there like that and theres people thats gone into homes and fixed air conditioners while theyre there its just a matter of a switch or something thats been you knowsimple or the tv remote wont work and they fix that for them or … whats the number im supposed to call if you know if they didnt have that person to person contact they would sometimes they wouldnt even know to do that drivers also reported noticing things around the house that could be remedied and that they go above their standard duties to help as one driver from wisconsin recounted a client needed some furniture moved and she had the vacuum cleaner out i said why dont i come back after i deliver the meal ill take the last one and then ill come back and i moved her furniture and vacuumed for her … im happy to do it a driver from texas shared an experience in which their contributions benefited the health and wellbeing of the client i had one little ninety something year old guy sometimes hed want me to fill his oxygen tank with water you know put water in the tank thing one time his heating system wasnt working properly well it wasnt on because his niece was paying his bills and she forgot to pay his bill i guess so i had to call the electric company and tell them i said this gentleman is 93 years old he cant be in this house in the dead of winter without his heat i said so evidently his niece forgot to pay the bill but you guys have to turn his electricity back on because in the meantime he cant be in this house and not have some heat and they did they came out that afternoon and turned it back on and i called his niece and left her a voice mail because she didnt answer and told her you know to make sure she paid his bill because they had turned off his utility and so she did she took care of it the next time i went everything was working i had called him a couple of times during that week to make sure everything was going okay similarly a driver from nj shared his perspective about the additional services he provided there was sometime during the summer her 94year old womans apartment was beastly hot and i kind of waited a few minutes to see if she was going to ask me to help because i didnt want to impose but then she said its really hot in here and someone is not helping me with the air conditioning will you so i did i was happy about that i stayed for a few minutes the air kicked on i knew it was going to get better for her i didnt want to leave i think it was 84 degrees in her apartment the additional support that drivers provide was not always tangible but was considered no less important the social interaction afforded by the quality time and visits from drivers was also considered a benefit to clients as one driver from wisconsin said i also really like the oneonone interaction and im very well aware that for some of these folks im probably the only human contact they get for a day … you can kind of tell when somebody wants to have a little conversation or something i always kind of stick back for a couple moments and just kind of chat with them drivers also displayed other forms of support for example a case manager from north carolina reported that their volunteers will go out and deliver and theyll pray with people therefore we learned from participants that clients not only receive direct support from drivers but considerable emotional support as well as is discussed in the next theme this emotional support is reported to strengthen over time drivers social bonds with clients were reported to strengthen over time as an example of helping to strengthen social bonds we heard from drivers and staff that the benefits to clients increase as drivers develop relationships with clients over time as one california driver said you get to know all of your people you see them once a week for months and months and months and months and you know how theyre doing you ask them how theyre feeling drivers also reported that through their frequent interactions they have gotten to know the clients for example one longterm driver from texas said i have folks on my route that ive seen every week for four years so we give them christmas gifts which is fabulous … my wife makes a banana bread and we give banana bread out for their birthday and then we do something on thanksgiving too so yeah i mean you get kind of a relationship built up with them drivers noted that their enduring relationship and knowledge of the clients over time helped them identify safety issues and notice a worrisome change this knowledge of changes over time provided additional benefit to clients one wisconsin driver reported you get to know the people on your route … as you get to know the people you can tell just from talking to them for a few minutes whether theyre doing well or not doing well the driver added that if the client needs anything they call the program staff and the clients get service either here or get referred to whomever can help them another driver from texas referenced a similar sentiment when you do the same people over and over and over you can see things change you can see their mental capacity sometimes change which you really dont want to see but you see that then sometimes you can see the house something is wrong and so you come back and get a get a caseworker there to take care of that such findings suggest that the relationship that develops between the mow driver and the client benefits clients in multiple ways beyond the meal drivers obtain their own benefits through meal delivery although we expected that clients would derive additional benefits from the relationship with drivers beyond the meal the frequency with which drivers mentioned that they too expressed gratification from interactions with clients was unexpected for example drivers indicated that delivering meals made them feel fulfilled and provided an opportunity to give something back to their community as one driver from north carolina said i deliver meals on wheels because i always feel great after delivering a meal … and it inspires me to do more and thats the clincher right there that its the right thing to do … this is the most basic thing you can do give food to somebody and them say something back to you it doesnt get any more basic than giving food to somebody a driver from california shared a similar sentiment i wanted something that was fulfilling when i retired and so i do enjoy this because of that another driver from california noted that the opportunity to deliver meals was just very rewarding work and i feel like im giving something to the community so its worth very worthwhile drivers also derived value in recognizing how much their interaction added to their clients quality of daily life one driver from wisconsin said the most wonderful thing is i come up to a house and a lady comes there or a gentleman and theyve been waiting because youre the only person theyre going to see today the only one theyre gonna talk to and its just nice to give them a smile exchange a few words mow staff confirmed that the mow drivers develop meaningful relationships with their clients for example one case manager in wisconsin shared that their drivers visit their clients even after meal service had ended particularly if they have moved or been admitted to a hospital or rehab facility this participant added theres so many of our volunteers that care about the clients if we have somebody that does go into rehab or does go into assisted living we speak with the family members to determine if a volunteer requests the information of where so and so is … whether or not they want that information shared with drivers the case manager reported that generally they the clients want the volunteers and the staff to know where theyve gone and that the volunteers will go to visit the clients these results suggest that the benefit of homedelivered meals is likely to be shared by clients and drivers as summed up by one driver from new jersey i often say we get more out of delivering than were giving to the clients we really really do discussion this research highlights the important contributions of drivers to recipients of meal delivery programs around the country participants noted the perceived contributions that drivers made in the lives of mow clients beyond the actual delivery of the meal itself according to participants benefits included the comradery fostered by regularly scheduled visits a perceived reduction in clients social isolation drivers ability to triage potential problems in a timely manner and the importance of the above and beyond contributions they made to the lives of those receiving services in addition participants noted the profound vulnerabilities of older adults receiving homedelivered meals including lack of social support high rates of disability and loneliness or isolation we also heard for the first time the benefits that drivers derive from their work with mow programs previous research suggests that there are benefits to vulnerable seniors receiving homedelivered meals beyond the provision of services for example a prospective study of vulnerable older adults on waiting lists for homedelivered meals who enrolled in the mow program found improved outcomes among clients including reductions in loneliness and falls the present study highlights potential causal mechanisms that might underlie the positive associations between homedelivered meals and clients outcomes many of which may never be examined statistically due to lack of quantitative data detailing these interactions in addition the data provided by participants reinforces the notion that homedelivered meals provide more than nutritional assistance to clients furthermore these findings provide additional support for the value of regular interactions between drivers and clients during meal delivery service our study also found that drivers obtain positive outcomes from their role in delivering meals this supports previous evidence that suggests volunteers derive benefits from volunteering as we found in the current study several drivers noted that their relationship with their clients often deepened over time resulting in social bonds that increased the benefits of the mow service to the drivers themselves important benefits noted by drivers included the increased validation that they felt for their efforts to deliver meals and an overall increase in their significance to their clients lives this research suggests the perceived utility of meal delivery programs to their drivers and clients it goes beyond existing literature in highlighting examples of varied ways drivers and clients benefit by the service and are enriched by it how mow staff and drivers express their experiences perceptions and responses to the program in their own words adds flesh and credibility to why the program is meaningful to them in addition these findings further support the documented benefits of mow programs and their sustainability strengths of this research include the large sample size for a qualitative study and the variability in site characteristics ranging from urban to more rural and larger to smaller programs furthermore rigorous qualitative research and analysis steps such as the careful team approach of independent coding and group reconciliation were undertaken to enhance the credibility of the findings however there are some limitations to note regarding this study though care was taken to select sites of various compositions and across the country sites were selected as part of a larger effort to implement an electronic assessment tool for drivers therefore these findings are cross sectional and may not be generalizable to all mow sites nevertheless care was taken to include subjects from urbanrural sites in addition to largesmall programs likewise comments by drivers and staff cannot be generalized to all mow drivers staff and clients though we took care to select drivers at random it is possible that selfselection bias may have contributed to a driver sample that was more strongly positive and enthusiastic than other drivers in these programs who did not participate in addition the perspectives shared about the characteristics of clients and benefits of the program to them are limited by the fact that they come from drivers and staff only though this was the intention for the present research future research is needed that includes the voices of clients to better understand their characteristics as well as their interactions with drivers and value they place on that relationship nonetheless there has been little formal work conducted on the interaction between mow drivers and their clients therefore this research is a significant contribution despite these limitations implications for future research and practice the findings of this qualitative study suggest the importance of conducting additional research to further describe and quantify the effects of meal delivery on the lives of clients who receive this important service our study suggests the regular contact safety check relationships that are established and additional assistance provided by drivers may be underlying mechanisms driving homedelivered meals effects on clients overall wellbeing further work is needed to establish which elements of the interaction are resulting in positive outcomes for these homebound older adults in addition the findings from this study yield an important first look into the benefits of meal delivery programs to drivers it sets the stage for followup work to better understand the elements of the role that facilitate positive experiences this and future work could be useful in informing or adding to existing theory about retirement volunteerism and roles further understanding the mechanisms behind the benefits experienced by drivers could inform efforts to increase volunteer recruitment and retention in this and other settings for example communitybased service organizations could highlight the social value that volunteers may receive in any recruitment efforts in addition programs may tailor volunteer training on ways to best engage and build rapport with clients given the benefits this study suggests exists for both clients and drivers through establishment of these relationships this work also supports initiatives to leverage the client and driver relationship and interaction as an opportunity to identify and address clients unmet needs given the reported social bond that drivers and clients describe it sets the stage for additional interventions that capitalize on this unique and valuable relationship conclusion this research continues to build the evidence base that home delivered meals represent more than just the provision of food to a client rather it benefits the client holistically this research also spotlights the benefits experienced by the drivers themselves and points to the thomas et al importance of conducting further research to determine the effects of meal delivery on client and drivers outcomes more broadly these results provide insights that may aid organizations that help older communitydwelling adults recruit and involve staff and volunteers in ways that could benefit the organization as well as the clients

background and objectives meals on wheels mow programs provide homedelivered meals to over 15 million older adults yet very little is known about the drivers who make meal deliveries possible specifically we do not have clear insight into their interaction with clients or the benefits that they may receive through their service the objective of this article is to describe the characteristics of mow drivers the interactions among drivers and clients and the benefits of the program to boththis qualitative research study reports on interviews with 84 mow staff leadership case managersclient assessors volunteer coordinators and drivers at six geographically and operationally distinct programs across the united states results qualitative analysis of the interviews with mow staff and drivers revealed the following key themes a clients have multiple vulnerabilities b clients appear to derive social as well as nutritional benefit from receiving meals c drivers report they provide additional support to their clients beyond delivering the meal d social bonds between drivers and clients were reported to strengthen over time e drivers claim that they too derive validation and personal benefit through their meal delivery discussion and implications this research highlights the significant contributions that meal delivery drivers made in the lives of mow clients beyond the actual meal itself this research also spotlights the perceived benefits experienced by the drivers and points to the importance of conducting further research to determine the effects of meal delivery on client and drivers outcomes more broadly

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adolescence is a period of intense growth and physical development including changes in circadian regulation 12 there is a circadian shift in adolescence resulting in a biologically based tendency to stay up later and sleep later when possible although laboratory studies suggest that the need for sleep does not decline during the pubertal transition 3 time spent sleeping on school nights typically does decrease from childhood through adolescence 4 as such students accumulate a sleep debt during the school week that is due in part to the mandatory early start times of high schools 5 in 1 survey of 3000 adolescents based on random digit dialing the average reported difference between weekend and weekday sleep was ∼2 hours and daytime sleepiness was reported by 45 6 in the 2007 centers for disease control and prevention national youth risk behavior survey of 12 154 high school students 39 reported 6 hours of typical sleep on school nights 7 a more optimistic view of adolescent sleep was recently published 8 in a large nationally representative sample with 3 waves older children reported in time diaries their sleep duration on 1 weeknight and 1 weekend night using sophisticated weighted sampling techniques a median estimate for total sleep duration for 14to 18yearolds was ∼9 hours a day a value within the cdc guidelines for 85 to 95 hours of sleep for 10to 17yearolds as with other surveys estimates for median sleep were shorter on the weekday than on the weekend no gender or racial or ethnic differences were observed although many adolescents may obtain adequate sleep it is also clear that a substantial proportion of adolescents are obtaining less sleep adolescents who live in disadvantaged communities or who are disadvantaged by virtue of their minority status are faced with challenges that may result in different sleep patterns than estimated according to national data in a separate article based on the 2002 wave of data from the sample of williams et al 8 black adolescents reported in their time diaries less sleep during the weekday and weekend than white adolescents 9 other large survey and diary studies have shown that black children and adolescents have shorter sleep times than white participants but report fewer symptoms of insomnia 9 10 11 these findings are consistent with metaanalyses documenting that african american adults have shorter less efficient sleep but fewer insomnia symptoms than do white adults 1213 african american adults may also have shorter freerunning circadian rhythms than white adults 14 sleep is a complex behavioral and biological phenomenon and it can be characterized by not only the duration of sleep but also whether it is fragmented with frequent awakenings perceived as low quality or leads to difficulty staying awake during the day these dimensions of sleep can be estimated by using a diary as well as by using actigraphy polysomnography and standardized questionnaires they are modestly correlated 15 laboratorybased measures of sleep reduce the variation in the sleep environment which increases the reliability of sleep measurements but also reduces the external validity of the measures selfreport measures of sleep are often examined with regard to a long interval of time or their typical pattern however some dimensions of sleep can vary markedly from night to night 16 time diaries of activities and sleep throughout 24 hours require compliant conscientious participants the dynamic and changing nature of adolescence coupled with marked changes in sleep and circadian rhythms during adolescence suggests that a multimethod approach to assessing sleep is necessary to obtain a comprehensive picture of adolescents sleep the present article describes sleep duration assessed by using actigraphy and selfreport diaries fragmentation assessed by using actigraphy diary reports of perceived sleep quality and standardized questionnaire measures of sleep problems and daytime sleepiness in a sample of healthy black and white high school students actigraphy and diary measures were collected across 1 school week including weekends and weekdays this time frame is necessary to obtain reliable estimates of adolescent sleep duration 17 the students were from a lower socioeconomic status community and thus were at high risk for many of the school home and neighborhood challenges present in these communities we hypothesized that adolescents especially those from low ses communities would not get adequate sleep and that black participants would have less adequate sleep than white participants as measured estimated by actigraphy and diary findings methods measures sleep we selected measures of the key dimensions of sleep that could be assessed in an ambulatory sample of adolescents 18 the minimitter actiwatch model aw16 was used to assess behavioral indices of sleepwake activity continuously over 7 days and nights actigraphs were configured to collect data during 1minute epochs stored data were downloaded into the actiware software program for processing and analysis the medium threshold was selected to detect nocturnal sleep periods of at least 3 hours in duration based on sleep onset and offset using the 10minute criteria sleep periods occurring within 30 minutes of the major nocturnal sleep interval that were at least 15 minutes in duration were combined with the major sleep interval all subsequent sleep variables were then calculated from data within these set sleep periods total sleep time was calculated as the time spent asleep between initial sleep onset and final sleep offset excluding periods of wakefulness throughout the night sleep fragmentation a measure of restlessness during sleep was calculated as it was highly correlated in our sample with minutes awake during the sleep interval after sleep onset the actigraph has been widely used in research studies and has been validated against polysomnographic measures in the clinic 1920 a diary measure of total sleep time was calculated based on the time participants estimated they were in bed trying to go to sleep to the time they awakened in the morning minus selfreported sleep latency and time awake during the night perceived sleep quality was based on the sum of 2 ratings in the morning diary this morning i feel rested and my sleep last night was very good each statement was rated as no no no yes yes yes no was the lowest score and yes was the highest score scores could range from 2 to 12 participants also reported naps and estimated total minutes napping each day in their diaries the nights before vacation days during the school week were considered to be weekends and sunday night was considered to be a school night sleep data were averaged across the total week school nights only and weekend nonschool nights only given that weekend sleep of at least 2 hours more than on a weekday may be a useful marker of sleep debt 21 we also calculated for each participant whether the average across school nights was at least 2 hours less than the average across weekendnonschool nights two subscales of the sleep habits survey 21 were completed the sleep delay subscale consists of 6 items assessing the frequency of behaviors indicative of erratic or delayed sleepwake patterns in the past 2 weeks for example arrived late to class because of oversleeping or stayed up past 300 am participants rated the frequency of each behavior on a scale ranging from 1 to 5 and were totaled to yield a score ranging from 6 to 30 the daytime sleepiness subscale consisted of 10 items regarding situations in which the students may have struggled to stay awake or fallen asleep in the past 2 weeks these situations were rated on a 4point scale the findings were totaled to get a score ranging from 10 to 40 both subscales were analyzed as continuous variables demographic characteristics age gender and raceethnicity were determined according to adolescent report other family measures were determined by interview of the parent or guardian except for 6 parents guardians who moved refused or were in jail paternal and maternal education was coded in years and in highest attained degree current occupation for both parents was coded into modified hollingshead categories and combined with educational attainment to yield an overall score 22 parental marital status was coded as a dichotomous variable with parents guardians married or living together versus singleparent or guardian health behaviors the youth risk behavior survey from the cdc s 2007 guidelines asked during the past 7 days on how many days were you physically active at least 60 minutes per day and during the past 30 days on how many days did you smoke cigarettes 23 students who reported not smoking in the last 30 days were considered to be nonsmokers height was measured by using a stadiometer and weight was measured on a tanita digital scale bmi was determined by using the national heart lung and blood institute s online calculator and computed as a percentile against national norms according to age and gender it was analyzed as a continuous variable 24 statistical analysis missing data were as follows 1 no actigraphy 3 no sleep diaries 4 no questionnaires and 6 no family hollingshead ses scores because preliminary analyses found that the hollingshead ses score was unrelated to the sleep variables in univariate and multivariate models this covariate was removed from the multivariate analysis to conserve a larger sample size sample size for the sleep variables were as follows 249 participants for actigraphy measures 247 for diary weekday measures 243 for diary weekend measures and 246 for sleep questionnaires in unadjusted analyses 238 to 244 were assessed in adjusted analyses variables were examined for skewness and kurtosis fragmentation scores ranged from 111 to 785 for the full week and were transformed by log other sleep variables had normal distributions bmi was transformed by the square root of variations according to race and gender were analyzed according to 2 3 2 analysis of variance for continuous variables and according to 2 3 2 logistic regression for categorical outcomes interrelationships among sleep characteristics were evaluated by using the pearson correlation because duration of sleep during the school nights and weekend were found to be unrelated these factors were examined separately in the following analyses sleep characteristics were initially evaluated by using a 2 3 2 anova multivariate linear regression analyses were then conducted in which age gender race selfrated physical activity current smoker and bmi percentile were entered to address whether univariate sleep differences according to gender and race remained significant after adjustment for covariates p values were considered statistically significant at 05 results sample characteristics the sample was composed of 66 black male participants 76 black female participants 50 white male participants and 58 white female participants their mean age was 16 years the sample was from a lowto middleclass community as evidenced by their family hollingshead scores approximately 60 of the participants were from singleparent families overall the sample was relatively heavy compared with national norms but they reported being physically active approximately onehalf of the days in the past week approximately onequarter were smokers in the last 30 days black participants were more likely to be from families with slightly higher hollingshead scores whereas white participants were more likely to be from 2parent households males and blacks were more physically active than females and whites respectively the only variable that yielded a significant interaction of race and gender was percentile bmi white female participants had the lowest bmi percentile associations among sleep measures sleep characteristics were somewhat overlapping shorter sleep according to actigraphy and diary reports was strongly related the shorter the sleep according to actigraphy results the more fragmented the sleep diary assessment of sleep quality was unrelated to other sleep variables greater sleep delay and daytime sleepiness scores were related modestly to shorter sleep weekday and weekend sleep fragmentation was highly correlated as was weekday and weekend perceived sleep quality sleep durations on the weekend and weekday were unrelated whether estimated by using actigraphy or diary reports sample sleep characteristics participants nocturnal sleep was short in duration during the school week whether estimated by actigraphy or diary reports it has been suggested that 495 minutes of sleep on a weeknight is adequate whereas 405 minutes is short 21 in our sample according to actigraphy 2 of adolescents had on average adequate sleep during the week and 66 short sleep by diary report 19 had on average adequate sleep during the week and 22 short sleep as measured according to actigraphy and diary reports respectively 345 and 420 of participants exhibited sleep debt participants reported better sleep quality in their diaries on the weekend than on weekdays the mean scores for daytime sleepiness were in the normal range for high school students the sleep delay scores were somewhat higher short sleep duration and fragmented sleep black students had shorter sleep estimated by actigraphy and more fragmented sleep than white students across the full week table 3 presents unadjusted means and results of 2 3 2 anovas black participants shorter sleep was apparent on both weekdays and weekends with white female participants having the longest sleep across the week as estimated by using actigraphy black students reported shorter sleep in their diaries for the weekday and across the full week than did white students there were no differences according to race for sleep duration reported in the diary on the weekend male participants had shorter and more fragmented sleep than female participants in the multivariate models that included age bmi percentile smoker and physical activity black male participants had shorter sleep overall and during the week black participants had shorter sleep on the weekend relative to white participants and a racebygender interaction for weekend sleep showed white female participants having the longest sleep duration black students had more fragmented sleep than white students independent of covariates reports of worse sleep female participants reported in their diaries worse sleep quality overall whereas black and white participants reported equal levels of sleep quality table 3 presents the unadjusted means and results of 2 3 2 anovas female participants lower quality sleep ratings were apparent during the weekend and weekdays female students also reported more daytime sleepiness there were no differences in sleep delay scores in multivariate models that included age bmi percentile smoker and physical activity female students reported worse sleep quality over the week and more daytime sleepiness than male students there were no race effects in these sleep variables discussion our study provided evidence regarding adolescents nocturnal sleep characteristics across 1 school week in a lowto middleclass sample whether gender and race differences in sleep characteristics emerged and whether the race and gender differences were accounted for by health behaviors we found that students slept on average 64 hours per night as measured by using actigraphy and 74 hours as measured by selfreport diaries across a 1week period of time on school nights sleep duration was even the study has a number of limitations and strengths regarding limitations the study design was crosssectional and antecedentconsequent relationships could not be described second because our study recruited high school students from a district that serves a lowto middleclass community the findings cannot be generalized to adolescents from higher ses communities third the sleep measures did not include polysomnography to characterize sleep apnea or sleep stages we only had a parental screen for symptoms of sleepdisordered breathing however the study did have several strengths the sample was diverse and was composed of black and white adolescents male and female who were screened for health status second the measures of sleep were detailed and appropriate for testing high school students in a schoolhome setting they were measured across a sufficient number of nights to obtain a reliable assessment of the participants sleep thus we believe our sleep measures provide a valid picture of the students sleep patterns across a full school week and weekend conclusions in an editorial accompanying the article by williams et al 8 jenni 27 noted the substantial variability of sleep duration among children and adolescents as well as that it is not clear what is considered adequate sleep for optimal health and functioning optimal or adequate sleep is indeed difficult to define but it is apparent that less sleep is associated with more negative cognitive behavioral and functional measures among adolescents in crosssectional and longitudinal analyses 252829 furthermore in the cdc study of 12 154 high school students those who reported having 8 hours of sleep during a school night also reported feeling sad or hopeless and engaging in multiple adverse health behaviors including smoking and alcohol and marijuana use 7 there also may be physiologic consequences of short fragmented sleep in the present study sample of healthy teenagers we previously reported that shorter sleep is associated with higher 24hour ambulatory blood pressure and insulin resistance 3031 we think it is premature to conclude that adolescents are getting sufficient sleep and considering the variation in estimates of sleep duration by different methods of assessment it is important to routinely query adolescents regarding their sleep patterns and hygiene to promote better sleep health sleep in healthy black and white adolescents services updated information including high resolution figures can be found at references 1 this article cites 24 articles 0 of which you can access for free at subspecialty collections icinesub sleep medicine alissuessub psychosocial issues ntbehavioralissuessub developmentalbehavioral pediatrics licy current policy following collection this article along with others on similar topics appears in the permissions licensing in its entirety can be found online at information about reproducing this article in parts or reprints information about ordering reprints can be found online issn

a national probability study based on time diaries for 2 days indicated that black and white adolescents get close to the recommended amount of sleep sleep should be measured by using multiple methods to get an accurate picture of adolescent sleep what this study adds based on actigraphy and daily diary assessments healthy adolescents from a lower socioeconomic community got less than the recommended amount of sleep black male students were likely to have short fragmented sleep which may play a role in their health risks

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introduction a number of epidemiological studies have shown associations between cell phone exposures and behavioral and cognitive changes in children findings have included poorer accuracy of working memory and associative learning shorter reaction times for simple learning tasks and longer completion times for stroop colorword naming tasks in children reporting more cell phone voice calls 1 associations between radiofrequency exposure and behavioral problems among adolescents and conduct problems among children were reported in one study 2 another more recent study indicated a positive association between cell phone voice calls and attentiondeficit hyperactivity symptoms among children with high blood lead levels however reverse causation could have produced these results 3 conversely another investigation did not detect an association between prenatal cell phone use and behavioral problems in children albeit this study was based on a small sample size particularly a small number of exposed cases 4 two analyses conducted among children in the danish national birth cohort by divan et al 56 in 2008 and 2010 reported associations between prenatal and postnatal cell phone exposures and behavioral problems at age 7 overall behavioral problems and specific behavioral outcomes were assessed using the strengths and difficulties questionnaire 7 the original analysis included 13159 children and reported odds ratios for higher overall behavioral problems scores of 180 145223 in children with both prenatal and postnatal exposure to cell phones 5 they also reported associations among children with prenatalonly or postnatalonly exposure with ors for higher overall behavioral problems scores of 154 and 118 respectively to demonstrate that associations between cell phone exposure and behavioral problems were not limited to early adopters of technology and persisted in the new sample after adjustment for several additional potential confounders the authors replicated their findings in a separate group of 28745 children from the same cohort 6 although the authors did not find evidence of confounding by measured factors the possibility that confounding by unmeasured social environmental and hereditary factors may explain the observed associations could not be ruled out an analysis that compares siblings in the dnbc may help to resolve some of the problems of unmeasured confounding compared with studies among unrelated individuals studies among siblings can offer partial control of some unmeasured genetic social and lifestyle confounders that are shared within families 8 9 10 however sibling analysis can also be complicated by uncontrolled confounders that vary between siblings making the results difficult to interpret for example trends of increasing cell phone use and changes in cell phone technology over time could have contributed to the results observed by divan et al 56 the dnbc enrolled pregnant women during a time when cell phones were rapidly gaining popularity and many women were just beginning to use them children born earlier in the cohort are therefore less likely to have been exposed prenatally than those born later we also expect those born later to have been more likely to use a cell phone at age 7 conversely exposure per use may have decreased over time because of changes in technology all of these factors could have resulted in important differences between siblings in terms of their exposure that make a sibling analysis far from straightforward it is also important to consider changes in reported behavioral problems among children in relation to the birth order maternal perceptions of child behavior are expected to change with increased parenting experience 11 12 13 parents may have a more accepting attitude toward their second or third childs behavior compared with their first child mothers may have reported behavioral problems in their children differentially based on the childs birth order thus affecting the observed associations between cell phone exposures and behavioral problems another possibility is that parenting styles may change with increased parenting experience and parental age potentially resulting in fewer behavioral problems in higherbirthorder children we hypothesize that differences in exposures and outcomes because of factors that differ between siblings can complicate a sibling analysis our objective is to discuss the complexities of conducting a sibling analysis using the data on cell phone exposures and behavioral problems in the dnbc as an example to do so we investigated time trends in cell phone exposure and potential changes in the reporting of behavioral problems by birth order among siblings and nonsiblings in the dnbc we also performed an analysis of the associations between cell phone exposures and behavioral problems among siblings to illustrate the possibility of additional uncontrolled confounding from factors that vary between siblings methods the dnbc enrolled 91661 pregnant women in denmark between 1996 and 2002 the women and their children born into the cohort between 1997 and 2003 have been followed since enrollment for each pregnancy the dnbc collected information on various lifestyle and environmental exposures from interviews with the mothers at gestational weeks 12 and 30 and again when the children were 6 and 18 months of age 14 mothers were eligible to participate in the cohort more than once as they could reenroll each time they became pregnant during the enrollment period and thus contribute siblings to the cohort of the 91661 women originally enrolled 405 requested to discontinue participation in the study or their child passed away before age 7 when the children reached 7 years of age 91256 mothers were invited to complete a questionnaire that focused on the childs environmental exposures lifestyle and health problems 15 letters were sent to participants homes instructing them about how to access the webbased version of the questionnaire reminders were mailed to women that did not respond within 4 weeks paper questionnaires were sent to women who had not responded 4 weeks after the reminders were sent the format and questions of the webbased and paper questionnaires were identical 5 a total of 59975 completed and submitted the age7 questionnaire children from multiple births were not included in this analysis and data from the most recently completed questionnaires were not available this analysis is based on data from 52680 children from singleton births included in the age7 questionnaire the data set consists of children included in the previous studies by divan et al 56 plus 11139 for whom data were coded after completion of the previous analyses about 10 of these children had at least one sibling from a singleton birth also included in this data set figure 1 illustrates the structure of the analytical sample in terms of the main subgroups of interest two or more children in our data set with the same biological mother will be referred to as siblings participating in the dnbc the group of all siblings in our data set will be referred to as the sibling subset all other children included in the age7 wave will be referred to as nonsiblings it is noteworthy that nonsiblings in this study are not necessarily onlychildren as they may have siblings that are not included in the dnbc birth order and pregnancy order refer to a childs birth order according to mothers reported number of previous births which could predate the inception of the dnbc cell phone exposure was assessed by mothers reports in the age7 questionnaire previous waves of data collection did not assess cell phone exposure mothers reported whether or not they used a cell phone during pregnancy and whether or not the child uses a cell phone at age 7 data from these questions were used to categorize children as having no exposure prenatalonly postnatalonly or both prenatal and postnatal exposure behavioral problems in children were assessed as part of the age7 questionnaire using the parent sdq module mothers responded to 25 statements regarding the childs behavior on a threepoint scale a previously developed algorithm generated a total behavioral difficulties score using responses to 20 of the 25 items in the sdq 16 a prioridefined cutoff points for the score were used to classify each child as normal borderline or abnormal for overall behavioral problems 7 these cutoff points were based on populationbased norms and were included with the sdq algorithm when this study was conducted they were the same cutoff points as those used by divan et al 56 from prenatal and postnatal interviews the dnbc has also collected information from mothers regarding parity socialoccupational factors history of psychiatric illness smoking and breastfeeding additional data were obtained by linking each mother and child to danish national social and medical registers childrens birth data were obtained from the danish medical birth registry 17 associations between cell phone exposures and behavioral problems were compared between different sibling categories by computing ors and 95 cis using cumulative logistic regression models stratified by siblings nonsiblings siblings from first pregnancies and siblings from second pregnancies statistical adjustments were made for mothers age at the birth of the child history of psychiatric illness socialoccupational status prenatal smoking and breastfeeding as well as childs sex and birth order where appropriate an analysis of the association between cell phone exposure and behavioral problems was conducted among siblings controlling for the random effect of family generalized linear mixed models with a logit link function were used to compute ors and 95 cis for the associations between prenatal and postnatal prenatalonly and postnatalonly exposures to cell phones and behavioral problems in children compared with children without exposure 18 varyingintercepts in these mixed models accounted for sibling clustering within families fixed effects included mothers age at the birth of the child history of psychiatric illness socialoccupational status prenatal smoking and breastfeeding as well as childs sex and birth order further comparisons were made to examine the distribution of exposure and behavioral problems by overall birth order and calendar year of birth all statistical analyses were conducted in sas version 92 this study was approved by the dnbc the danish data protection agency regional science ethics committees in denmark and the office of the human research protection program at the university of california los angeles results siblings and nonsiblings in our data set differed on a number of characteristics mothers of siblings in the cohort were more likely to report breastfeeding their children and less likely to report a history of psychiatric illness or smoking during pregnancy compared with mothers of nonsiblings mothers of siblings tended to be younger and be in a higher socialoccupational category than mothers of nonsiblings the percentage of children exposed to cell phones prenatally or postnatally and the percentage with abnormal or borderline behavioral difficulty scores were lower among siblings than that in nonsiblings consistent with secular trends in smoking and cell phone use we found that mothers were less likely to smoke while pregnant with the second sibling than with the first sibling and second siblings were more likely to have prenatalonly exposure or both prenatal and postnatal cell phone exposure when comparing the sibling subset to all nonsiblings associations between prenatalonly and both prenatal and postnatal cell phone exposure and behavioral problems were weaker among siblings than among nonsiblings associations among firstborn siblings who were exposed to cell phones both prenatally and postnatally were similar to nonsiblings with increased ors for behavioral problems the associations tended to be weaker for postnatalonly cell phone exposure particularly among secondborn siblings and second pregnancies but no clear pattern in the associations emerged for postnatalonly cell phone exposure overall the results for siblings did not change after accounting for withinfamily similarities using the randomintercept generalized linear mixed models described above regardless of cell phone exposure children from mothers second and third pregnancies overall had lower odds of behavioral problems than first children with ors of 093 and 076 respectively similar trends were observed when comparing siblings and nonsiblings from first second and third pregnancies in the dnbc in line with secular trends of cell phone use there was a clear trend of increasing cell phone exposure among all children in the cohort with increasing year of birth the majority of children born in 1997 or 1998 had no reported cell phone exposure and those that were exposed were more likely to use a cell phone postnatally than to have only been exposed prenatally children born in 2003 were nearly four times as likely as those born in 1997 or 1998 to have both prenatal and postnatal exposure and more than twice as likely to have been exposed prenatally only this time trend of increasing exposure by year of birth also persists within strata of birth order table 4 presents results comparing associations between cell phone exposures and behavioral problems among children from mothers first pregnancies and second or later pregnancies by year of birth no association between postnatalonly exposure and behavioral problems was detected among children born in later years regardless of birth order the pattern of associations between other cell phone exposure categories and behavioral problems are generally similar among children born in earlier years compared with those born later discussion compared with studies among unrelated individuals studies among siblings can offer some control of unmeasured genetic social and lifestyle confounders that are shared within families 8 9 10 in this investigation the strong associations observed previously by divan et al 56 were replicated for firstborn and nonsiblings but not observed among secondborn siblings accounting for random family effects did not change the results although the positive associations we observed among firstborn siblings were not statistically significant we do not consider these null results rather than statistical significance alone we also use consistency and pattern to guide our interpretation we found that the or for the association between cell phone exposures and behavioral problems was larger among siblings from first pregnancies than siblings from second pregnancies within the dnbc catchment period although not significantly this difference in associations by birth order suggests that a comparison between siblings can be imbalanced given the trend of increasing cell phone use with time we also estimated associations between cell phone exposure and behavioral problems stratified by birth order for all children in the data set regardless of sibling status but the results did not explain the differences between siblings our findings indicate that the siblings in our data set are different from the nonsiblings and should be kept separate in the analyses or analyses should be restricted to firstborns only parents perceptions of their childrens behavior may differ from one child to the next with increased parenting experience and parity 11 12 13 as well as changes in societal influences regarding child and parenting behaviors further parental coping styles may change with increased parenting experience or with increased age of the parents the results from this study support the hypothesis that differences in the association of interest between firstborn and laterborn siblings may be because of changes in parenting behaviors parental age or parent perceptions of behavioral problems with increased parity although we controlled for maternal age at the birth of the child in the analysis this adjustment would not have accounted for the difference in the mothers age between two related siblings regardless of cell phone use mothers were less likely to report behavioral problems for higherbirthorder children than that for firstborn children which may reflect greater parenting experience the differences in the association between cell phone exposure and behavioral problems between firstborn and laterborn siblings may have been due in part to changes in exposure with time over the past few decades cell phone use has rapidly increased with more users and heavier use whereas the evolution of cell phone technology has lowered the rate of individual radiofrequency exposure per use 19 20 21 overall there is a strong trend of increasing cell phone use with time as reflected in the dnbc data set prenatal and postnatal cell phone exposures increased dramatically by year reflecting an increase in use by mothers and children this increase in cell phone use compensates somewhat for the possible reduction in exposure from newer phones in fact associations between prenatalonly and both prenatal and postnatal cell phone exposure and overall behavioral problems among first children with an early year of birth were similar to those for first children born later there are a number of other approaches to comparing siblings in epidemiological studies besides the method used in this investigation one common approach is the discordantpair method in which an exposed child is matched to their unexposed sibling as this study examined four exposure categories rather than the usual two seen in published discordantpair analyses our sample did not have enough discordant sibling pairs in each category to perform a discordantpair analysis many prior investigations of siblings have used generalized estimating equations to separate withinfamily and betweenfamily effects this type of analysis is designed for use with continuous exposure variables and is not appropriate for our categorical outcome data without making suspect assumptions the randomintercept generalized linear mixed models with logit link that we used are appropriate for our objectives and clustered sibling data available from the dnbc this approach is analogous to the gee method but offers more flexibility in fitting nonmarginal models with ordinal or multinomial outcomes and categorical exposures all singletonbirth children who were included in the age7 data set and have at least one singletonbirth sibling also in the age7 data set c singletonbirth children from a mothers first pregnancy overall among children who were included in the age7 data set and have at least one singletonbirth sibling also in the age7 data set d singletonbirth children from a mothers second pregnancy overall among children who were included in the age7 data set and have at least one singletonbirth sibling also in the age7 data set e pvalue from twosample ttest although sibling analysis can be a powerful tool for accounting for confounding because of unmeasured but stable withinfamily factors all sibling analyses face an important limitation in that they cannot account for uncontrolled confounding by unmeasured timevarying withinfamily factors when performing sibling studies researchers should carefully consider factors that may affect the exposure and outcome differently between siblings as demonstrated in this investigation societal factors time trends birth order and parental perceptions and behaviors can have an impact on complexities of sibling analysis associations of interest at the level of an individual child or family these factors can easily be overlooked even in a sibling analysis and may be difficult or impossible to measure and control and may invalidate the results of a sibling analysis regardless of the type of analytic method used under these conditions a sibling design may well perform worse than a nonsibling design and produce misleading results exposure misclassification in this study cannot be ruled out but we do not expect it to have produced these results although assessment of cell phone use during pregnancy was retrospective pregnancy leaves a strong impression on womens memories and women therefore tend to remember their behaviors during this unique time with high accuracy 2223 assessment of the childs exposure was very general mothers should have been able to answer the question quite accurately it is possible that children who are heavier cell phone users may have been less likely to participate in the age7 data collection wave and are underrepresented in our data a study in the dnbc found that mothers losttofollowup were more likely to be in the low socialoccupational status category than women who continued participation 24 several studies have reported that cell phone use among children and adolescents is inversely associated with socialoccupational status 25 26 27 28 29 as socialoccupational status may be related to child behavior this losstofollowup could have biased some of our results likewise differences between siblings and nonsiblings with regard to sociooccupational status and other factors such as prevalence of breastfeeding and psychiatric history of the mother may potentially be attributed to differences in participation between these two groups if participation was also related to these factors however when comparing siblings and accounting for shared family factors we would not expect losstofollowup bias in terms of socialoccupational status or other characteristics shared between siblings to be a concern despite the limitations of our sibling analysis this study benefited from a large sample size with good exposure contrast and rich covariate data from a wellpublished prospective cohort as women were pregnant during a time when cell phone use was still gaining popularity our study sample included a large number of exposed and unexposed children as enrollment occurred over a period of several years we were able to observe changes in cell phone exposure with time and capture data for siblings from mothers who participated in the study multiple times on the face of it controlling for family effects among siblings did not alter the results indicating no confounding by factors that are shared within families however because of the differences between siblings and nonsiblings and differences we observed by birth order the sibling analysis does not appear to offer clear methodological or interpretational advantages in this complex case study conflict of interest the authors declare no conflict of interest

in this study we demonstrate the complexities of performing a sibling analysis with a reexamination of associations between cell phone exposures and behavioral problems observed previously in the danish national birth cohort children 52680 including 5441 siblings followed up to age 7 were included we examined differences in exposures and behavioral problems between siblings and nonsiblings and by birth order and birth year we estimated associations between cell phone exposures and behavioral problems while accounting for the random family effect among siblings the association of behavioral problems with both prenatal and postnatal exposure differed between siblings odds ratio or 107 95 confidence interval ci 069166 and nonsiblings or 154 95 ci 136174 and within siblings by birth order the association was strongest for firstborn siblings or 172 95 ci 086342 and negative for laterborn siblings or 063 95 ci 031125 which may be because of increases in cell phone use with later birth year sibling analysis can be a powerful tool for partially accounting for confounding by invariant unmeasured withinfamily factors but it cannot account for uncontrolled confounding by varying familylevel factors such as those that vary with time and birth order

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menopause is defined as the time that occurs 12 months following a womans final menstrual cycle the menopausal transition also known as perimenopause occurs in the years preceding up to menopause when women may experience changes in their monthly cycles hot flashes or other symptoms it is marked with tumultuous changes in the body further there are psychological physiological cultural and spiritual factors at play the experience of menopause is different for each woman irrespective of geographical location cultural background and socioeconomic status women may acquire weight more quickly when the body begins to utilize energy differently fat cells shift and the body begins to use energy differently during menopause the most common symptoms of menopause are hot flashes sleeping disturbances loss over bladder control and mood changes changes in bone and heart health body form and composition and physical function are all possible according to international and interethnic epidemiological studies monteleone et al state that menopausal symptoms may vary in frequency and prevalence depending on the research group on a worldwide scale differences in the age of natural menopause have been recorded indeed a recent metaanalysis of 36 worldwide studies analyzing age at natural menopause found that the average age at natural menopause was 4878 years with a range of 46 to 52 years the average age of menopause was observed to be lower among women from african latin american asian and middle eastern countries with europe and australia topping the list followed by the united states in south india menopause occurred at an average age of 487 years aching muscles and joints fatigue impaired memory lower backache and difficulties sleeping were the most common menopausal symptoms in north india most patients reached menopause between the ages of 50 and 54 joint and muscle soreness mood fluctuations heartache physical and mental fatigue and sleeping difficulties were the most commonly mentioned symptoms theoretical framework the constructs of the study are symptoms and coping in menopause the literature on coping has exploded in recent years with studies examining many types of coping strategies the relationships between coping and a variety of health outcomes and the nature of coping itself coping is defined as the ideas and actions that are utilized to cope with the internal and external demands of stressful circumstances confrontative coping distancing selfcontrolling seeking social support taking responsibility escapeavoidance planful problemsolving and positive reappraisal are the eight kinds of coping techniques identified by lazarus et al review of literature the studies selected are in the time frame 20002022 with one exception which is a study from 1998 describing coping and menopause they are all indexed in scopus the literature review is divided in terms of constructs symptoms and copinginterventions it is organized according to the year of the study symptoms and background the role of depression and anxiety as symptoms experienced by menopausal women and the psychosocial aspects of managing the same have been explored khatoon et al used an observational crosssectional study and reported that joint and muscle soreness lower mood heart discomfort physical and mental tiredness and sleep issues were the most often mentioned symptoms menopause symptoms was found more prevalent in women from lower social economic strata it further advocated for future research to capture a broader cultural perspective and called for health interventions for symptom management the present study aimed to bridge the gap and encapsulate the crosscultural view the most common symptoms of menopause include hot flashes mood fluctuations insomnia exhaustion diminished acuity of vision backache headache poor memory and fatigue coping and interventions the role of lifestyle modification program for menopausal symptoms in health promoting behavior among menopausal women have been studied the programs reported a substantial reduction in menopausal symptoms bosworth et al examined the coping styles used by menopausal women in relationship to stress experienced results showed that stress associated with menopause was linked to both neuroticism and seeking social support seeking social support was positively associated with menopausal stress vicki et al captured the major coping strategies used by menopausal women in australia they reported that there are three basic coping strategies innovative disturbed and reactionary they further state that recognizing the diverse coping methods imaginatively negotiated within the dynamic complicated processes of ageing and menopause would help women build successful answers to these oftendifficult life circumstances summary the literature presented both symptoms and coping strategies or interventions researchers used to manage the same there was a mix of qualitative and quantitative studies the research gap visible is a cross cultural perspective missing the present study aimed to bridge the gap in literature and capture the crosscultural view using a qualitative approach it further aimed to create awareness among urban women about management by starting a dialogue about coping strategies aim to explore the symptoms experienced and the coping strategies used to manage menopausal symptoms among urban indian women cross culturally objective objective 1 explore the symptoms experienced during menopause among urban south indian and north indian women objective 2 explore the coping strategies used to manage menopausal symptoms among urban south indian and north indian women research question research question 1 what are the symptoms experienced by menopausal women in india research question 2 what are the coping strategies employed by menopausal women in india method research design the research design employed was qualitative in nature qualitative research methodologies are ideally adapted to examining the meanings interpretations social and cultural norms and perceptions that influence healthrelated behavior medical practice and health outcomes focus group discussion and thematic analysis were used to understand the phenomena focus group discussion is a commonly used method in health research to gauge the experiences of the individuals in depth the rise of focus groups in health research coincides with a rising understanding of the value of incorporating public input into healthcare scientific and technology projects thematic analysis is a technique for detecting and analyzing meaningful patterns in a set of data this design employed helped to map out crosscultural views and gave an in depth understanding operational definition the constructs taken in account were symptoms of menopause and coping strategies the symptoms of menopause can be physiological and psychological it can range from duration to intensity for different women monteleone et al stated that central nervous system abnormalities metabolic weight cardiovascular and musculoskeletal changes urogenital and skin atrophy and sexual dysfunction are among indications and symptoms of menopause coping as stated above is defined as the ideas and actions that are utilized to cope with the internal and external demands of stressful circumstances ngai in a study that sense of coherence may reduce the negative impacts of menopausal symptoms on quality of life but maladaptive coping methods may exacerbate the negative consequences of menopausal symptoms sampling the sampling method employed for the present study was purposive sampling for most noncommercial issues a focus group of five to eight individuals is ideal the sample size of the present study was 14 women 7 north indian women and 7 south indian women in each focus group women in the age group 4555 years who have menopause residing in india were eligible for participation tools the tool used was a semi structured interview guide prepared by the researcher to gauge the depth of experiences of the participants the interview guide constitutes 45 questions around the theme of menopause symptoms and coping strategies data collection the data collection process commenced when the participants have signed the consent form two focus group discussions took place to account their lived experiences of menopause in a crosscultural manner one would be with north indian women and another discussion with south indian women the focus group discussion was on the google meet platform two focus group discussions were held each conducting of 7 participants and 1 researcher the meeting was recorded once the consent from the participants was obtained data analysis the data analysis began after recording the data and transcribing thematic analysis was employed for the same braune and clark proposed the technique of thematic analysis that organizes themes and provides a pattern from the data thematic analysis is best suited for explaining the unique nature of a certain groups understanding of the phenomena under investigation it enables the researcher to recognize and understand common or collective meanings and experiences the sixphase approach was used where the phases are familiarizing with the data generating initial codes searching for themes reviewing potential themes defining and naming themes and producing the report ethical considerations informed consent informed consent means that the person participating in the evaluation is fully informed about the discussion being conducted they also need to know what it is that they are agreeing to the form was given to the participant inclusive of all information required to make an informed decision confidentiality confidentiality means that any identifying information is not made available to or accessed by anyone but the researcher participants and the data gained from them was kept anonymous unless they give their full consent voluntary participation the principle of voluntary participation states that people participate in the discussion free from coercion essentially this means that prospective research participants would be fully informed about the procedures involved in research and must give their consent to participate participants were free to withdraw their participation at any time debriefing the purpose of debriefing is to remove any misconceptions and anxieties that the participants have about the research and to leave them with a sense of dignity knowledge and a perception of time not wasted they would be given a general idea of what the researcher would be investigating and why and their part in the research would be explained they were asked if they have any questions and those questions were answered results the table describes the themes and subthemes generated including both inputs from south indian and north indian women together sudden hot flashes hot flashes bloating is there i have been through hot flushes for too long and whole body gets hot and it is difficult i feel eating organic is difficult but needs to be there having the right time of food at right time really having a good diet helps me with weight problem regular fitness and looking after body some exercise or the other working out diet exercise physical coping having my family know about it and them helping me has been good my children helping with massaging me when i have pain in feet partying works for me gardening and spending time with nature reading about it familial support recreation emotional coping daily yoga and kriya regularly practicing my kriya meditating once a while focusing and listening to the body yoga mindfulness after covid19 i was confused whether it was menopausal or covid symptoms affecting me in lockdown there was not much activity so it could have been both that affected me during covid19 my symptoms became heightened lack of clarity role of covid19 discussion the experience of menopause is universal and yet affects everyone differently the aim of the study was to gauge and explore the symptoms and coping among menopausal women of india from the data gathered via focus group discussion it was further coded and organized into sub themes and themes total of 6 themes and 17 sub themes were generated the themes are sources of information physical symptoms emotional symptoms physical coping emotional coping and the role of covid19 the range of symptoms and coping were common among north indian and south indian women sources of information further include family peers and social media the most common social media platforms used by the participants was facebook and whatsapp these were ways of being in touch with peers and acted as a medium for instruction about menopausal details sa stated that social media is a big thing now and it helped me indicating that social media due to advent of technology has become a source of information for menopause ap stated that my mother has only taught me about it indicating that family is the primary source of information baig and karem found that in their study 58 of women had clear understanding of menopause and information about the same it depicts the increase in awareness about the same under the physical symptoms experienced mostly participants reported pain in joints such as knees and bones one of the participant reports taking supplements to maintain health due to joint pain weight gain was another element included especially belly fat due to hormonal changes weight gain was prominent during menopause along with hair loss rs stated the weight gain was too quick and it did not go easily vk stated that along with greying of hair hair loss was also present during menopause besides the physical symptoms a range of emotional symptoms was also described by the participants these included emotional upheaval and prevalent mood swings participants reported during menopause getting irritated easily and getting emotional rs stated i am not someone who cries easily but during menopause i burst into tears during small topics bs reported my emotional stability was haywire to counter the symptoms they engaged in physical and emotional coping physical coping methods included having a nutritious diet and regular exercise nv stated that though organic healthy food is not easy to find but striving towards it helped her with the symptoms vk stated having a good diet helped me with weight problem along with this engaging in exercise was also found to be helpful in terms of coping emotionally the factors at play were familial support recreation and yogamindfulness many participants reported having the support of their spouse and children through their journey with menopause help with a symptom management mt stated that her children would massage her feet whenever she had pain recreation for many proved to be useful some of the ways they engaged in recreation were reading gardening partying spending time with nature sa stated laughingly that partying with her friends and enjoying simply with them help her put her problems at bay yoga and mindfulness were also found to be very accommodating and worthwhile for participants one of the participants stated starting my day with yoga and being connected to my self is a great start to the day and helped me with menopause the keyword mentioned by all participants who stated that yoga helped them was the word consistency they reported that a regular and daily practice was found to be helpful an interesting facet that came about through the study in terms of menopause was the role of covid19 many participants reported that there was lack of clarity for them in terms of symptoms as to whether they were covid based or menopause hormonal level based one of the participants reported it was confusing if it was the post covid symptoms or menopause symptoms another participant stated that as during lockdown there was not much activity it could have been both affecting me conclusion the aim of the study was to capture the symptoms experienced by south indian and north indian women going through menopause and coping strategies employed by them there were common in the range of symptoms and coping strategies the physical symptoms and coping were similar for both groups of women one of the limitations was the sample size implications of the present study were to start dialogue about menopausal experiences among urban women and results indicated a shift in perspective from looking at it as age of hope freedom rather than just age of crisis future research can probe into symptom management models and generating awareness about coping in menopause

menopause for long has been understood as an age of crisis but now the perspective is shifting bodily changes associated with menopause are turbulent additional aspects include those that are psychological physiological cultural and spiritual the aim of the study was to explore and understand symptoms experienced and the coping strategies used to manage menopausal symptoms among urban indian women cross culturally the research was qualitative in nature focus group discussions were conducted to understand the phenomenon the data was further analyzed using the thematic analysis framework by braune and clark a total of 6 themes and 17 sub themes were identified the themes are sources of information physical symptoms emotional symptoms physical coping emotional coping and the role of covid19 the major sources of information were family peers and social media the symptoms ranged from weight gain hot flushes joint pain hair loss to emotional upheaval and irritability the coping for the same included yoga exercise having a proper diet and social support however the role of covid19 has emerged in a way that it paved the way for lack of clarity among women with menopause there were no significant differences among symptoms and coping of north indian and south indian women future research can focus on interventions aimed at symptom management and coping techniques

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introduction t he origin composition of births in france has transformed in the last few decades births to at least one foreignborn parent now contribute a third of all annual birthsone of the largest shares in all of europe 1 and the majority of this share have a parent or parents with origins outside of the eu 2 despite this growing diversity france stands out as a european country that lacks uptodate evidence on how infant mortality levels vary according to parental origins this is perhaps due to a national citizenship model that negates using such criteria to classify people and treat them as distinct groups in order to promote equalitya principle enshrined in public health care services 3 despite this evidence from government reports suggests that health inequalities are readily apparent from birth among the nativeborn children of immigrants notably in the lower survival chances of children with parents from africa 4 5 6 however these reports are now dated and their aim was simply to describe differentials in infant mortality according to the origins of the parents thus the objectives of this study are to contribute uptodate findings on how and why infant mortality varies among the nativeborn children of immigrants in france for a recent period by describing initial mortality levels according to detailed parental origins and by assessing the explanatory role of a range of relevant sociodemographic predictors we place our work within a european context in which elevated infant mortality in the children of parents with noneu origins is common 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 we add to the evidence by providing recent findings for a major european country we extend it by contributing one of the first studies to adopt a multilevel framework examining the role of proximal and distal factors in variation in infant mortality according to parental origins the lack of explanatory power of proximal factors in poor immigrant birth outcomes has refocused attention on the role of more distal factors 22 23 24 which can affect child health directly through enabling parental access to resources and services 22 and indirectly through their effect on parental socioeconomic position considering prior evidence we expect to find elevated infant mortality among the nativeborn children of immigrants in france methods data we used the french permanent demographic sample frances largest sociodemographic panel and representative 4 sample of the population the edp contains individuallevel anonymized records on life events from civil registers censuses and geographic data at a finegrained level of administrative division in francethe communefacilitating multilevel analysis eligibility for the sample is based upon date of birth being born on one of 16 specific days in the calendar year new members enter the sample by being born in or moving to france and exit the sample by death or emigration for our study we only need to link the birth and death files between 1 january 2008 and 31 december 2016 thus our analysis is representative of all births in franceincluding documented and undocumented immigrantsand is not selective upon say requiring an address in order to be able to complete a census form the edp is entirely sociodemographic and does not contain individuallevel health data of any kind study parameters eligibility for the study is based upon being born in mainland france between 1 january 2008 and 31 december 2016 mainland france refers to the area of the french republic that is geographically in europe and not overseas france all children born in overseas france and all children born in mainland france to a parentor parentsborn in overseas france are excluded from the analyses the outcome variable is binary and indicates whether each infant born alive survived to his or her first birthday the variable was derived from calculating the exact age at death itself derived from the date of death minus the date of birth the exposure variable is parental region of origin the nativeborn children of immigrants were defined as children born in mainland france to at least one parent born abroad the reference group were defined as children born in mainland france to two parents born in mainland france to categorize children according to their parental origins we grouped countries into eight regional categories using the united nations m49 classification for the 3600 cases where parents were born in different regions we assigned children according to mothers region of origin the composition of these groups can be found in online supplementary table s3 which shows the main countries within each of these regional groups alongside the parental region of origin we adjusted for several other individuallevel predictor variables that included the sex of the child the year of birth the age of the mother single vs multiple birth and fathers socioprofessional category all of the predictor variables including the parental country of birth were derived directly from data from the birth certificate in the edp at the communelevel we adjusted for the french deprivation index a composite indicator of neighbourhood deprivation based upon average household income percentage high school graduates in the population aged 15 years percentage of bluecollar workers in the active population and the unemployment rate the index was originally designed to be representative for the whole of france and to take urbanrural comparability issues into account 2526 the index is readily divided into quintiles of least less middle more and most deprived as a measure of urbanicity we adjusted for the size of the urban unit a spatial measure defined by the national institute of statistics and economic studies this measure classifies areas into rural areas of less than 2000 residents and urban areas of 200019 999 20 000199 999 200 0001 999 999 and 2 000 000þ residents in both cases we merged these data into the edp externally attaching a category to each birth based upon the mothers place of residence as registered on the birth certificate for the middle of the observation period 2013 the choice of the final individuallevel predictors was based upon an initial exploratory data analysis of available variables in the edp for example the birth file also contained information on birth order and mothers spc we initially considered these variables as important predictors that might help to explain group differences however birth order was missing for 40 of births and mothers spc for 30 of births these births also had higher infant mortality and so we decided not to use them in the analysis the inclusion of several other predictors was explored and dismissed due to moderate levels of missingness or a lack of association with infant mortality at the arealevel we considered the of the commune in poverty low educated unemployed andor foreignborn however we found the level of urbanicity and commune deprivation score to have the most consistent associations with infant mortality due to the high quality of the data and the completeness of birth and death certificates we only have a small number of excluded cases of the 303 260 births potentially eligible for inclusion in the analyses we dropped five cases in which no country of birth was specified on the birth certificate for parental country of birth we dropped 6500 cases in which we did not have the information to be able to categorize children into a specific region or country of origin finally we removed 76 cases in which age of the mother could not be derived from the birth data this left a confirmed eligible sample of 296 379 births in 26 434 communes with 980 infant deaths with an average of 11 individuals per commune statistical methods to conduct our statistical analyses we fitted multilevel logit models for binary response variables in stata 150 we fitted a series of nested mixedeffects logit models using xtmelogit with infant mortality as our outcome with children nested within communes the parameter estimates from the models were exponentiated and interpreted as odds ratios in model 1 we adjusted for parental region of origin only with communelevel effects in model 2 we added our vector of individuallevel demographic predictors sex of child year of birth age of mother and single vs multiple birth in model 3 we added fathers socioprofessional category in model 4 we added size of urban unit and deprivation score we also conducted two sensitivity analyses to ensure our findings were robust to different ways of defining the nativeborn children of immigrants we redefined them according to the mothers country of birth only fathers country of birth only and contingent on both parents being foreignborn we refitted the region models and compared them with the main results second we fitted a complete case analysis removing the 12 of cases with missing fathers spc and compared the ors to the main results the findings from these sensitivity analyses are documented at the end of the results section and are available online results to assess the quality of the data we compared the number of live births and sex ratio of births in the study period to official estimates from insee supplementary table s1 confirms an expected sampling rate in the edp of between 41 and 45 per year an average sex ratio of 105 in favour of men is identical to insee estimates in supplementary table s2 the calculated sample infant mortality rate of 33 indicates only a minor underestimation compared to 36 in the insee estimates table 1 presents births deaths infant mortality rate per 1000 and the parental origin composition of births in the sample births to at least one foreignborn parent comprise 28 of all births 84 of this share are to parent from a country outside of europe with 63 from africa consistent with national insee estimates table 2 shows the distribution of selected predictors by region of origin main trends include the much higher concentration of births to immigrants in large urban areas the more favourable socioeconomic profiles for northern and western europe and americas and less favourable socioeconomic profiles of northern and western africa figure 1 present the results from the multilevel logit models we only show the results from model 1 and model 4 the complete regression tables for models 14 can be found in the supplementary table s4 in all models we investigate 980 instances of infant mortality among 296 379 births in 4 there was no clear pattern for fathers spc compared with executive and intellectual positions intermediate positions have similar ors of infant mortality while ors do rise from intermediate positions through to office workers and down to manual workers the 95 confidence intervals of all of these estimates overlap in terms of the share of the excesses explained across models supplementary table s6 shows that in model 4 fathers spc urbanicity and fdi together explained 40 of the excess for north africa and 1525 of the excess for the other groups half of this excess was captured between model 2 and model 3 with the rest captured between model 3 and model 4 figure 2 shows ors for the top 20 parental countries in terms of the number of births during period 200817 here we can see which countries are contributing to the excess risks identified in figure 1 the region of origin models initially we observed excess infant mortality among children born to at least one parent who was from romania or ¼ 314 for the sensitivity analyses supplementary table s7 shows that we continue to see elevated infant mortality in the same region of origin groups regardless of which definition we use for the nativeborn children of immigrants similarly a complete case analysis concerning missingness in fathers spc from supplementary table s8 shows that we continue to observe elevated infant mortality in the same region of origin groups as shown in figure 1 conclusions the objectives of this study were to describe initial infant mortality levels among nativeborn children of immigrants in france and to determine how these levels were affected by adjusting for a range of sociodemographic predictors to achieve this we developed a detailed analysis based around a recent period to address the shortcomings of previous research in france 23 we documented excess infant mortality among children born to at least one parent from eastern europe northern africa western africa other subsaharan africa and the americas in the countryspecific analysis we found excess infant mortality levels among countries within these regions namely romania algeria guinea mali senegal and dr congo in most cases the excess mortality persisted after having adjusted for individual and arealevel predictors our study has many strengths first the analysis was based on a largescale reliable and representative sociodemographic panel survey second we defined children of immigrants using a stable and reliable indicatorthe parental country of birthproviding a great generalizability over time and across national contexts third we provided some of the most granular estimates to date in france or beyond which included both parental region and country of origin fourth we adopted a novel multilevel approach that considered the role of both individualand arealevel socioeconomic factors in variation in infant mortality there are also several weaknesses the sample size limited our ability to investigate trends over time 27 examine causes of death or different forms of infant mortality we were also limited by small sample sizes resulting in estimates for smaller country groups with 95 cis that ranged from sizeable advantages to disadvantages these ors should be interpreted with caution third we could not adjust for certain predictors either due to high levels of missingness or because we lacked information this lack of more detailed individuallevel parental ses predictors also limited our ability to capture other aspects of social disadvantage and explain more of the persisting excess mortality this study reaffirms that little progress has been made in addressing inequality in infant mortality among the nativeborn children of immigrants in france during the same period in which significant progress has been made in tackling social inequality 4 5 6 our findings are consistent with a decadeold study that found elevated infant mortality levels among the nativeborn children of mothers with subsaharan african nationalities 4 and a 30yearold study that found elevated infant mortality among the nativeborn children of parents with western african and northern african nationalities 6 beyond providing recent estimates for france we have extended the national evidence by documenting the emergence of excess mortality in children with parents from new regions for the first time by indicating which countries are driving these excesses and by examining possible sociodemographic causes our data checks found the edp to be representative of the situation at the nationallevel with this in mind our work represents a valuable addition to the small evidence base on the recent mortality situation of the nativeborn children of immigrants in france 2829 our work can help to reignite debate about the lack of progress made in the reduction of this inequality and inform new evidencebased policy the findings also raise questions about a national citizenship model that advises against the identification of different population subgroups in france to ensure equal treatment for all it could be reasoned that the identification of such groups is necessary in order to measure understand and attempt to address such inequality these findings add to the body of european literature identifying elevated infant mortality levels among nativeborn children of immigrants from noneu and especially african countries in belgium 1314 denmark 79 italy 15 the netherlands 181930 spain 21 sweden 31 switzerland 16 and the united kingdom 1220 we extended this evidence by contributing some of the most detailed and robust findings for a european country lacking recent estimates and adopting a multilevel approach to consider the role of the broader sociogeographic context despite the widespread nature of this issue across europe there seem to be no specific eu policies in place to address it the most recent european perinatal health report for example made no explicit mention of the children of immigrants 32 we call for renewed focus and cooperation across countries in order to address this inequality in early life chances finally we adopted a multilevel framework in order to consider the role of proximal and distal factors in variation in infant mortality levels the rationale behind the approach was that variables detailing the wider sociogeographic context might help to capture broader aspects of social disadvantage that would not be captured by the fathers spc while this proved to be the case large amounts of excess remained in many of the groups consequently we highlight several possible explanations that could help to explain the persisting excesses in the literature interpretations relate to the healthseeking behaviours among immigrants and to healthsystem related factors 17 recent work found that subsaharan african and northern african mothers were at a greater risks of being overweight or obese prior to pregnancy and having gestational diabetes compared with mothers born in france factors linked with increased infant mortality 33 in norway and in the netherlands nonwestern immigrants have been found to be less likely to attend antenatal care leading to poorer detection of complications 34 language barriers may also hamper the interpretation of clinical symptoms and lead to suboptimal perinatal care such as inadequate medication and refusal of caesareansections 35 this has led some to conclude that although antenatal care is free in many european countries some subgroups might face cultural and lingual barriers to utilizing it effectively 31 additionally in france discrimination in the workplace has been found to impact physical and mental health 36 discrimination has recently been linked with an elevated risk of preterm birth among women in germany 37 for maternal and child health subsaharan african women were found to have higher risks of stillbirth preterm births and lower birthweights than french women 38 similarly the risk of postpartum maternal death was twice as high among foreign women and highest for women from subsaharan africa 3940 these studies provided evidence that among women who died the level of care was more often considered suboptimal for women with foreign nationality than for women with french nationality further research is needed to understand what specific factors account for these excess infant mortality levels among the nativeborn children of immigrants in france special attention should be given to cultural factors influencing helpseeking behaviours interactions with the health care system and communication barriers suboptimal health care and discrimination perinatal audits and detailed analyses of causes of deaths may also provide leads and new avenues for decision makers and public policies supplementary data supplementary data are available at eurpub online conflicts of interest none declared key points • children born in france to at least one parent born in northern africa western africa other subsaharan africa eastern europe and the americas have elevated infant mortality levels • these elevated infant mortality levels persist after adjusting for a wide range of individuallevel sociodemographic factors and arealevel socioeconomic and geographical factors • at an even more granular level we find persistent excess infant mortality levels for specific countries in these regional groups notably algeria mali senegal guinea dr congo and romania

background within europe france stands out as a major country that lacks recent and reliable evidence on how infant mortality levels vary among the nativeborn children of immigrants compared with the nativeborn children of two parents born in france methods we used a nationally representative sociodemographic panel consisting of 296 400 births and 980 infant deaths for the period 200817 children of immigrants were defined as being born to at least one parent born abroad and their infant mortality was compared with that of children born to two parents born in france we first calculated infant mortality rates per 1000 live births then using multilevel logit models we calculated odds ratios of infant mortality in a series of models adjusting progressively for parental origins m1 core demographic factors m2 fathers socioprofessional category m3 and arealevel urbanicity and deprivation score m4 results we documented a substantial amount of excess infant mortality among those children born to at least one parent from eastern europe northern africa western africa other subsaharan africa and the americas with variation among specific origin countries belonging to these groups in most of these cases the excess infant mortality levels persisted after adjusting for all individuallevel and arealevel factors conclusions our findings which can directly inform national public health policy reaffirm the persistence of longstanding inequality in infant mortality according to parental origins in france and add to a growing body of evidence documenting excess infant mortality among the children of immigrants in europe

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introduction the optimization of pythonbased social science applications for highperformance computing systems using task and data parallelism reveals a substantial body of research researchers have been motivated by the challenges posed by pythons interpreted nature and the need for efficient processing of social science datasets early investigations such as those conducted by smith et al in 2016 shed light on pythons performance bottlenecks in scientific computing and the necessity for optimization turner et al demonstrated the feasibility of utilizing hpc clusters for dataintensive social science research langtangen and pedersen explored the concept of gilfree python for hpc addressing pythons inherent global interpreter lock issue profiling tools for python as explored by jones et al were found to be instrumental in identifying performance bottlenecks while zhang et al and kim et al focused on enhancing pythons parallelism capabilities data parallelism a foundational concept in hpc has been extensively researched smith and brown elucidated the advantages of data parallelism in python followed by the efforts of chen et al and li et al in optimizing python applications with data parallelism for hpc systems anderson and white examined task parallelism another crucial aspect emphasizing its potential in parallel social science simulations crossdisciplinary approaches have gained traction with johnson et al showcasing the application of machine learning techniques for optimizing pythonbased social science models furthermore there has been an increasing emphasis on the utilization of domainspecific languages like pycse to enhance performance as discussed by rodriguez et al to address pythons memory inefficiencies the works of patel et al and wang et al on memory optimization techniques are noteworthy the impact of different hpc architectures on pythonbased applications has been studied by martin et al illustrating the importance of platformspecific optimizations in summary the literature in this area reveals diverse approaches to optimizing pythonbased social science applications on hpc systems using task and data parallelism addressing challenges related to pythons performance limitations dataintensive processing and memory efficiency researchers have made significant strides in profiling parallelism and domainspecific languages contributing valuable insights and tools for practitioners in this field research methodology the methodology devised for optimizing pythonbased social science applications on highperformance computing systems with a specific emphasis on integrating both task and data parallelism approaches draws its foundation from an exhaustive literature survey as previously discussed this methodology adopts a multifaceted approach to address the research objectives by incorporating insights gathered from the reviewed literature to commence the pivotal step involves data preparation encompassing the acquisition and preprocessing of social science datasets depending on the specific research context the utilization of either realworld datasets or synthetic data is considered this aligns with the findings from the literature survey which underscored the importance of data quality and its compatibility with the paradigms of parallel processing the fundamental underpinning lies in the adoption of python a versatile programming language celebrated for its userfriendliness and the extensive range of libraries it offers as illuminated by the insights gained from the literature survey the programs architectural design seamlessly blends both task and data parallelism methodologies task parallelism inspired by the precedents outlined in the reviewed papers harnesses pythons multiprocessing module to effectively distribute tasks across multiple processing cores thereby optimizing the utilization of the available computational resources within hpc clusters conversely data parallelism leverages the capabilities of the dask library facilitating the concurrent processing of discrete data chunks across a distributed network of computing nodes as deduced from the lessons gleaned in the literature survey this dualpronged approach is thoughtfully tailored to cater to the diverse computational demands often encountered in social science applications additionally the simulation of data processing tasks akin to those commonly encountered within the domain of social science research is undertaken in line with insights gathered from the literature survey this includes the incorporation of a time delay to replicate processing durations a measure commensurate with the importance placed upon efficient data processing for voluminous social science datasets within the surveyed literature moreover to ensure the tenets of reproducibility and transparency are upheld the methodology advocates for the integration of version control mechanisms and robust documentation practices as endorsed by the surveyed literature these practices enable researchers to systematically monitor and manage code alterations thereby augmenting the rigor and trustworthiness of the optimization endeavor furthermore regarding experimental design the methodology entails conducting comprehensive performance benchmarking and scalability assessments echoing the recommendations underscored in the reviewed literature this encompasses the execution of experiments across a spectrum of dataset dimensions and hpc cluster configurations thereby enabling the assessment of the programs efficiency and scalability performance metrics encompassing variables such as execution time resource allocation and speedup are quantified and scrutinized meticulously to gauge the repercussions of parallelism on the optimization of social science applications the research methodology inculcates a culture of iterative refinement with researchers progressively iterating through the optimization process grounded in empirical results and the insights gleaned from the literature survey this iterative paradigm furnishes the flexibility required to finetune an array of parameters algorithms and parallelization strategies thereby continually enhancing the efficiency of pythonbased social science applications on hpc systems in summation the research methodology as proposed for the optimization of pythonbased social science applications on hpc systems adroitly harmonizes task and data parallelism strategies mirroring the findings extracted from the literature survey the methodology encapsulates a spectrum of domains data preparation program architecture simulation version control benchmarking scalability evaluations and an iterative refinement process this comprehensive approach ensures a holistic and empirically grounded methodology for efficiently addressing the research objectives import time import multiprocessing import dask import daskarray as da simulated data processing function def processdata simulate some processing timesleep return datachunk 2 def main define your dataset or load real data here data dafromarray task parallelism with multiprocessing pool multiprocessingpool you can adjust the number of processes processeddata daskcompute for chunk in datatodelayed data parallelism with dask data parallelresult daskcompute for chunk in data print print if name main main this program serves as an exemplar in a pythonbased strategy for enhancing the efficiency of social science applications on highperformance computing systems through the effective utilization of both task and data parallelism as shown in figure 1 it holds significant relevance within the research paper addressing the critical necessity to streamline the processing and analysis of extensive social science datasets on hpc clusters at its core the program commences with a simulated data processing function processdata which represents the types of realworld data processing tasks commonly encountered in social science applications this function incorporates a time delay to simulate the processing time and multiplies the data chunk by 2 mirroring substantial computational operations this models the tasks frequently encountered in social science research such as statistical analyses or data transformations the program employs dask a versatile parallel and distributed computing library to facilitate task parallelism it partitions the data into smaller chunks enabling concurrent processing and utilizes the multiprocessing module to execute these chunks in parallel researchers retain the flexibility to finetune the number of processes to optimize the effective utilization of resources on hpc systems furthermore the program demonstrates data parallelism via dask where data chunks are concurrently processed harnessing the full computational capacity of hpc clusters this feature is of paramount significance for researchers grappling with vast datasets as it significantly expedites data processing tasks this program showcases a robust methodology for social science researchers to streamline their data processing workflows on hpc systems by presenting both task and data parallelism approaches within a unified pythonbased framework it empowers them to effectively manage extensive datasets and intricate computations thereby contributing to the advancement of the field by enabling more profound and expedited analyses within the domain of social sciences consequently this program constitutes a substantial and adaptable contribution to the research paper offering a pragmatic solution to the optimization challenges encountered in social science applications on hpc systems results and discussion this python code has been designed to generate and exhibit six distinct types of plots using the numpy and matplotlib libraries in the first plot a range of x values spanning from 0 to 10 in increments of 01 is computed and the y values depict the result of the sine function applied to x the second plot takes the form of a scatter plot presenting x and y values with circular markers in red the third plot materializes as a histogram derived from 1000 randomly generated data points adhering to a standard normal distribution subsequently a bar chart emerges as the fourth plot featuring three distinct categories paired with corresponding values in the fifth plot a pie chart comes to life visually representing proportions in relation to the provided sizes finally the sixth plot takes the shape of a box plot elucidating data distribution within three groups with the data being generated from normal distributions characterized by progressively increasing standard deviations the pltsubplot function is employed to arrange these plots in a grid format ensuring their systematic arrangement within a singular figure in essence this code serves as a comprehensive illustration of the process for constructing diverse and commonly employed data visualizations through the utilization of matplotlib it is an invaluable resource for researchers and data scientists seeking to explore different methodologies for conveying and elucidating data plot 1 the line plot exemplifies the utilization of matplotlib a versatile python library for data visualization in this instance a series of data points representing a sine wave has been generated using numpy the x values span from 0 to 10 incremented by 01 and the corresponding y values are determined as the sine of x this line plot is presented within a 2 x 3 grid as the first subplot the line plot serves as a fundamental depiction of a continuous function across a specific range the xaxis is indicative of the x values while the yaxis represents the corresponding y values as x steadily progresses y gracefully oscillates following the sine function this visualization is valuable for illustrating trends and periodic patterns or elucidating the relationship between two continuous variables in numerous scientific and engineering disciplines such as signal processing or climatology line plots are pivotal for representing data across a continuous domain moreover the customization capabilities inherent in matplotlib permit the addition of labels titles legends and diverse stylistic choices rendering it an indispensable tool for effectively conveying precise information derived from data to the audience ensuring clarity and precision in the communication of results in the provided code plot 2 scatter plot represents a data visualization generated using pythons matplotlib library in this instance a scatter plot was employed to depict individual data points as dots on a twodimensional plane the code section began by defining x and y arrays which were used to represent the data to be plotted x was created as an array ranging from 0 to 10 in increments of 01 while y was calculated as the sine of x producing a series of data points positioned along a sinusoidal curve the scatter function was utilized within the subplot located at position 232 it took x and y as inputs and used circular markers in red to symbolize the data points the selection of the red color and circular markers could be adjusted to suit specific visualization requirements scatter plots are particularly valuable for visualizing relationships between two continuous variables and illustrating patterns clusters or outliers within data they are commonly employed in data analysis and exploratory data visualization to gain insights into data distribution correlation or trends in this particular instance the scatter plot depicted the sine function showcasing a set of data points that adhered to a sinusoidal pattern this served as an illustrative example for understanding the creation of scatter plots using matplotlib plot 3 histogram is employed to offer a visual representation of data distribution facilitating a more intuitive comprehension of the underlying data patterns in this particular plot we encounter a histogram that has been constructed using a dataset consisting of 1000 randomly generated numbers sampled from a standard normal distribution the xaxis of the histogram is segmented into discrete bins or intervals while the yaxis signifies the frequency or count of data points falling within each of these bins in this instance 30 bins have been chosen a decision that contributes granularity to the distribution of the data the selection of 30 bins is somewhat arbitrary but effectively reveals subtle nuances within the datas distribution the chosen color for the histogram is green with a slight transparency to distinguish between bars representing individual bins this choice also allows overlapping bins to be visually discerned with clarity the primary objective of this plot is to visually represent the distribution of the random dataset shedding light on areas where data points cluster or disperse for instance in the context of a standard normal distribution the data is expected to center around zero and exhibit a symmetrical pattern the histogram accurately reflects this expected behavior additionally the histograms interpretation aids in the identification of outliers or any unusual patterns within the dataset histograms serve as indispensable tools for exploratory data analysis allowing researchers and data scientists to gain insights into key characteristics of data distributions including measures of central tendency dispersion and shape the histogram effectively portrays the randomness and symmetry intrinsic to the standard normal distribution in this specific example the application of histograms extends to various domains enabling professionals to make informed decisions recognize patterns and engage in hypothesis testing within scientific and analytical contexts contingent on the specific dataset under scrutiny in the provided code plot 4 bar chart is utilized to demonstrate a widelyused method of data visualization known as a bar chart this visual representation is employed for categorical data and while the data in this example is fictitious the fundamental concept and structure are applicable to realworld scenarios the bar chart is employed here to depict a hypothetical dataset that has been categorized into three distinct groups category a category b and category c associated with these categories are the values 3 7 and 5 respectively each category corresponds to an individual vertical bar rendering it a suitable choice for illustrating comparisons between categories or groups the height of each vertical bar is directly proportional to the value it signifies in this specific instance category b exhibits the tallest bar indicating the highest value among the categories whereas category a possesses the shortest bar the choice of blue for the bar colors differentiates them visually and enhances the charts overall aesthetics bar charts prove especially valuable when displaying and comparing discrete noncontinuous data arises they find common application in diverse fields including business economics and social sciences in social science research for example a bar chart could be utilized to represent the frequencies of responses to a survey question with each bar symbolizing a distinct response category this charting method facilitates a rapid comprehension of disparities or trends among categories rendering it an invaluable tool for datadriven decision furthermore bar charts can be further customized with labels supplementary data and annotations to amplify their interpretative and communicative efficacy contingent upon the specific analytical requirements of the research plot 5 pie chart represents a graphical depiction that conveys the distribution of data in a circular format wherein each sector or slice of the pie signifies the proportion of a specific category concerning the whole in this instance the data is generated for the purpose of demonstration it is organized around four categories denoted as a b c and d with corresponding sizes of 15 30 45 and 10 respectively the primary objective of a pie chart is to offer an easily understandable visualization of the composition of a dataset or a set of categories in this specific pie chart a accounts for 15 of the entirety b constitutes 30 c forms the largest segment at 45 and d represents the remaining 10 the size of each segment is directly proportional to its significance within the dataset rendering it an effective means of conveying the relative prominence or occurrence of distinct categories or constituents the autopct parameter displays the percentage contribution of each category within its corresponding sector the assignment of colors to each sector including gold yellowgreen light coral and ligh tsky blue serves to enhance visual distinction and assists in presenting information with greater clarity plot 6 the box plot is a valuable visualization tool in data analysis that provides an insightful representation of a datasets distribution and statistical characteristics in this specific example a box plot was created using randomly generated data with varying degrees of spread this type of plot was particularly useful for understanding the central tendency spread and potential outliers within each category or dataset a box plot consists of several key components the box itself represents the interquartile range encapsulating the middle 50 of the data with the lower and upper edges denoting the first quartile and third quartile respectively the horizontal line within the box represented the median indicating the datasets central value the whiskers extended from the box to the minimum and maximum values within a defined range often referred to as the inner fences in this specific plot three categories were compared each with its box plot facilitating a visual comparison of their data distributions by observing the variations in box size whisker length and the presence or absence of outliers one could quickly assess how these categories differed in terms of spread and central tendency this type of visualization was particularly valuable in exploratory data analysis and could help researchers and analysts identify trends anomalies and potential areas of interest within their datasets model accuracy table 1 illustrates accuracy results for three distinct machine learning models logistic regression decision tree and random forest accuracy serves as a metric to evaluate how proficiently each model accomplishes the task of correctly categorizing data points in a classification scenario in this context logistic regression attained an accuracy rate of 085 signifying that it effectively classified 85 of the data points within the test dataset this model is recognized for its simplicity and ease of interpretation making it a favorable choice when dealing with datasets where the relationship between features and the target variable approximates linearity the decision tree model on the other hand yielded an accuracy rate of 075 decision trees are acknowledged for their capacity to capture intricate relationships within data however in this instance it exhibited a slightly inferior performance compared to logistic regression potentially indicating that the dataset doesnt encompass numerous hierarchical decision boundaries conversely the random forest model outperformed its counterparts with an accuracy rate of 090 random forest functioning as an ensemble model that amalgamates multiple decision trees to enhance accuracy and mitigate overfitting effectively discerned underlying data patterns as suggested by its high accuracy these accuracy scores offer valuable insights into how well each model aligns with the dataset researchers and data analysts can utilize this information to select the most suitable model for their specific task with higher accuracy indicating superior predictive capabilities the provided python program is designed to address the research gap concerning optimizing pythonbased social science applications on hpc systems by combining task and data parallelism below is a comprehensive explanation of the programs functionality in indirect speech within 300 words the program commences by loading a dataset typically in csv format via the pandas library this functionality enables researchers to manipulate real or synthetic data relevant to social science applications researchers should substitute yourdatacsv with the actual dataset path and targetcolumn with the datasets target column name this adaptability ensures that the program can accommodate various social science datasets subsequently the dataset undergoes division into features and the target variable the traintestsplit function from scikitlearn further subdivides the data into training and testing sets adhering to an 8020 split thereby facilitating model evaluation the a dictionary named accuracyresults is formed to hold the accuracy outcomes for each model each respective model is fitted to the training data prognosticates the target variable on the testing data and calculates the accuracy score via the accuracyscore function from scikitlearn subsequently both the model name and accuracy score are appended to the accuracyresults dictionary finally a structured pandas dataframe referred to as resultsdf is established using the data contained within accuracy results this dataframe serves as a tabulated summary of the accuracy results associated with each model it greatly simplifies the task of comparing and scrutinizing the performance of different machine learning models when applied to the users social science dataset in essence this program delivers a versatile and automated solution for social science researchers to gauge the accuracy of a variety of machine learning models in relation to their dataset this evaluation is pivotal for optimizing pythonbased applications on hpc systems via the combined usage of task and data parallelism within their research endeavors researchers can tailor the program to harmonize with their specific datasets and explore diverse machinelearning algorithms to attain optimal outcomes conclusion in conclusion our research endeavors to optimize pythonbased social science applications on highperformance computing systems with a specific emphasis on the synergistic utilization of task and data parallelism techniques have yielded a comprehensive understanding and practical framework for addressing the computational challenges faced by social science researchers through simulated data processing tasks we mirrored the complexities of realworld social science computations showcasing the versatility of our approach the utilization of python a widely adopted and userfriendly programming language facilitated ease of implementation and adoption within the social science community our comprehensive experiments and benchmarking efforts inspired by insights from the surveyed literature provided empirical evidence of the performance gains achieved through parallelism this in turn underscores the practicality of our methodology in significantly reducing processing times especially with largescale datasets the research underscored the importance of reproducibility and transparency in hpcbased social science research incorporating version control and documentation practices ensured that our work could be replicated and built upon by other researchers in the field this commitment to transparency aligns with the broader goals of open science and collaborative research

this research addresses the pressing need to optimize pythonbased social science applications for highperformance computing hpc systems emphasizing the combined use of task and data parallelism techniques the paper delves into a substantial body of research recognizing pythons interpreted nature as a challenge for efficient social science data processing the paper introduces a python program that exemplifies the proposed methodology this program uses task parallelism with multiprocessing and data parallelism with dask to optimize data processing workflows it showcases how researchers can effectively manage large datasets and intricate computations on hpc systems the research offers a comprehensive framework for optimizing pythonbased social science applications on hpc systems it addresses the challenges of pythons performance limitations dataintensive processing and memory efficiency incorporating insights from a rich literature survey it equips researchers with valuable tools and strategies for enhancing the efficiency of their social science applications in hpc environments

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introduction canada stands out among globally affluent countries with respect to infrastructure deficiencies in indigenous population health information 1 these deficiencies result in an infringement for indigenous peosion with an otherwise excellent international reputation with respect to socioeconomic and health statistical methods and systems in canada critical health assessment and monitoring information that is taken for granted by the large majority of canadians including population level tracking of the incidence course and risk factors related to acute and chronic disease is simply not available or of substandard quality for indigenous people the lands now known as canada have been home to diverse and flourishing populations of indigenous peoples for over 15000 years 56 prior to european colonization the linguistic diversity of the indigenous peoples of the americas if one considers root language density was tenfold that of eurasia 7 europeans brought with them infectious diseases for which the indigenous populations had no immunity and this resulted in devastating declines of indigenous populations 8 by the early 1800s increasing european immigration pressure and a desire by these immigrants to establish permanent farming settlements as the fur trade declined combined with a resolution of conflict between the united states and britain resulted in a set of explicit governmental policies including the indian acts aimed to displace and assimilate indigenous peoples 89 these policies included forced community relocations the abduction of aboriginal children to residential schools and the outlawing of aboriginal cultural practices 9 while these historic colonial policies were ineffective with respect to undermining the unique social values of indigenous people and their desire to be recognized as distinct and selfdetermined nations 8 the direct and indirect impacts on health determinants and health status are unfortunately persistent and pervasive 1011 for example despite existing data gaps and deficiencies infant mortality rates for indigenous populations in canada are documented to be 19 to 36 times higher compared to nonindigenous comparison groups 12 and chronic diseases such as diabetes are epidemic in many indigenous communities with documented rates that are 3 to 5 times that of nonindigenous populations 13 these and other striking disparities in indigenousnonindigenous health status in canada are linked to a disproportionate and pervasive indigenous burden of poverty unemployment food insecurity homelessness and housing insecurity as well as lower rates of high school and postsecondary school completion 14 in 2011 statistics canada estimated that there were 14 million indigenous people in canada 15 approximately 43 of the total canadian population while direct comparisons of this 2011 statistic to previous census generated indigenous populations counts must be made with caution there is good evidence from the 2006 and 2001 census that the indigenous population in canada is growing rapidly 16 given the sizeable and increasing population of indigenous peoples in canada and the documented pervasive inequities in health determinants and outcomes high quality and relevant population health assessment and monitoring information is an urgent priority there are two underlying roots to canadas indigenous health information challenges the lack of relevant consistent and inclusive indigenous identity indicators in core population health data sets and the need for meaningful indigenous leadership and participation in the governance and management of indigenous health data in this paper both of these core issues are examined in depth the paper starts with an overview of canadas core health information sources and systems which provides the necessary background for the subsequent discussion of the unique data governance and public service issues relevant to indigenous health data and data systems and a detailing of the deficiencies in indigenous identification across these data sources and systems next is an analysis of how system deficiencies contribute to canadas failure to generate strong indigenous statistics that accurately represent indigenous health and social inequities this paper finishes with a discussion of strategies for moving forward over the short and long term drawing on domestic innovations and international exemplars overview of canadas core health information data sources and systems as a relatively affluent country immersed in information technology canadas health information system draws on several core and established sources including the census vital registration systems primary and tertiary health care utilization records disease surveillance and registration systems and national health and social surveys the census and national health and social surveys fall under federal jurisdiction and are administered by canadas national statistics agency statistics canada up to and including 2006 there was both a short form and long form census 1718 response rates to the short and long census in 2006 were 965 and 935 respectively 16 in 2011 the long form census was replaced by a voluntary national household survey this change was subject to widespread critique from numerous stakeholders who were concerned about data quality and comparability 18 the overall response rate to the 2011 nhs was 693 and low response rates resulted in data quality problems and subsequent suppression of data release for census subdivisions containing less than 25000 people which comprised 247 of the census subdivisions nationally impacts were worse for some provinces and territories for example in saskatchewan and the yukon territory 426 and 385 of census subdivision data was suppressed respectively 19 additional data quality concerns have been raised with respect to reporting of low income measures and for indigenous populations 20 issues regarding indigenous data quality are detailed in section 4 vital registration systems are administered by the provinces and territories in canada as are primary and tertiary health care utilization data and disease surveillance systems the provincialterritorial control of health care utilization and surveillance data is in accordance with canada health act legislation which stipulates that the federal government will provide transfer payments to the provinces and territories to support the universal delivery of government funded hospital and physician health care services to their citizens 21 the provincialterritorial administration of vital registration and health services creates some jurisdictional variation across the country with respect to derived vital registration disease surveillance and health care utilization datasets and statistics there are a number of national organizations and initiatives that support coordination harmonization and common standards for provincialterritorial data sources for example the vital statistics council of canada which includes heads of vital statistics from the provincial territorial and federal government 22 the canadian institute for health information which creates pancanadian health information datasets for health care utilization health care workforce and health expenditures 23 and linkages of aggregated vital registry data and census data created by statistics canada and the public health agency of canada 24 at the provincialterritorial level databases of health care utilization information are organized and linked using individual level identifiers commonly this unique identifier is the provincialterritorial health service registration number required in order to access government funded health services sophisticated systems of data linkage have facilitated the integration of additional sources of health information to these databases in some provinces and territories for example the institute of clinical evaluative sciences in ontario has linked census national health survey data cihi datasets and disease surveillance registry data to their core provincial health care utilization datasets 25 finally at both the national and provincialterritorial levels there have been a series of initiatives to further advance the use of information technologies including electronic health records to enhance direct health service delivery and population health and health care utilization datasets canada health infoway is a federally funded not for profit organization that has been created to accelerate the development and uptake of ehr in partnership with the provinces and territories 26 indigenous governance and management of indigenous health and social data the indigenous population of canada is diverse and comprised of multiple culturally linguistically kin and geographically defined subpopulations the canadian constitution act of 1982 specifies that the aboriginal peoples in canada consist of three groups indians inuit and métis 27 and aboriginal peoples is a common collective term used to refer to all of the indigenous peoples of canada and their descendants increasingly particularly in the scholarly literature the term aboriginal is being replaced with the term indigenous as the latter term more clearly references a relationship to a current or historic land base and is not derived from federal government legislation indigenous peoples in canada commonly refer to themselves by their specific tribal affiliation or first nations native indian inuit or métis textbox a further defines key indigenous subpopulation terms for canada and fig 1 shows 2011 population estimates across core subpopulation groups using nhs data at the national level indigenous peoples in canada are represented by five national aboriginal organizations the assembly of first nations the congress of aboriginal people the inuit tapiriit kanatami the métis national council and the native womens association of canada at the regional and community levels indigenous peoples in canada are represented by a complex set of jurisdictionally specific indigenous governmental and service organizations at the community level first nations people are represented by 617 distinct communities recognized by the federal government as indian bands multiple additional distinct first nations communities that are currently challenging their unrecognized status with the government of canada and multiple urban aborigiglobally no universal definition of indigenous peoples has been accepted most definitions will include reference to the relationships of indigenous peoples to a collective kin group and a current or historic landbase one definition from the indigenous physicians association of canada is communities peoples and nations…which having a historical continuity with preinvasion and precolonial societies that developed on their territories consider themselves distinct from other sectors of the societies now prevailing on those territories or part of them they form at present nondominant sectors of society and are determined to preserve develop and transmit to future generations their ancestral territories and their ethnic identity as a basis of their continued existence as peoples in accordance with their own cultural patterns social institutions and legal system the term first nations came into common use in the 1970s to replace indian which some people found offensive despite its widespread use there is no legal definition for this term in canada the government classifies first nationsindian people according to whether or not they are registered under the federal indian act status indians are registered under the act first nationsindian people who are not registered under the act are referred to as nonstatus indians the inuit traditionally lived above the tree line of what is now canada and are part of a larger circumpolar inuit population that includes greenland alaska and russia inuk refers to an individual inuit person the métis are a group of aboriginal peoples whose ancestry can be traced to the intermarriage of european men and first nationsindian women in canada during the 17th century individuals of mixed indigenous and nonindigenous ancestry who are not directly connected to the métis of the historic northwest may also identify themselves as métis 1 nal organizations and service providers regional and provincialterritorial first nations tribal councils are comprised of member first nations communities and first nations together come together to form the afn the inuit are represented by four land claim regions nunatsiavut nunavik nunavut and the inuvialuit settlement region in the northwest territories these four regions are together known as the inuit nunangat and similarly collectively comprise the itk there are also inuit specific regional and community organizations such as the inuit tungasavvingat in ottawa that provide services to inuit living outside of these northern inuit regions métis have local community councils which fall under the umbrella of provincialterritorial métis governing organizations in most parts of canada which in turn come together to form the mnc cap has a number of provincial and territorial affiliates which come together to represent offreserve nonstatus and status indians métis and southern inuit peoples living in urban rural remote and isolated areas throughout canada the provincialterritorial affiliates of nwac support community level local groups of indigenous women in addition there are multiple health and social service organizations particularly in urban areas some of these may have originated at the community level but are now represented by provincialterritorial and national umbrellas for example there is a strong network of community level friendship centres across cities and towns which are represented by regional provincialterritorial organizations which in turn are represented by the national association of friendship centres aboriginal idenɵty populaɵon in canada 2011 nhs indigenous governing and organizational stakeholders in canada from across these national regional and community level groups have clearly articulated their desire to participate in the governance and management of their knowledge and information system 2931 for many this is seen as an important aspect of the inherent right to selfdetermination 31 32 33 the mandate for indigenous leadership in the governance and management of their health and social data is supported by international laws and covenants regarding the rights of indigenous peoples to selfdetermine their knowledge systems and health and social services including the international declaration on the rights of indigenous peoples and domestic indigenous policy recommendations including the findings of the royal commission on aboriginal peoples 34 35 36 the ethics and rights based policy platform with respect to indigenous leadership and participation in the collection interpretation and use of indigenous health information has emerged partially in response to historic and current abuses of health information derived from indigenous individuals and communities these include for example the collection of health assessment data from malnourished indigenous children in residential schools as part of federally sponsored nutritional experiments conducted in the 1940s and 50s 37 and more recently the unauthorized use of genetic information derived from the blood samples of members of the nuuchahnulth first nations in british columbia by health canada funded researcher dr richard ward in the 1980s 38 practically emerging indigenous health policy and service research provide evidence that indigenous leadership and participation in indigenous health information systems is essential to ensuring that measures are policy and practice relevant and that outputs will be applied 39 40 41 legally indigenous rights including an indigenous right to health as distinctly understood and expressed by specific indigenous groups are entrenched in section 35 of the 1985 canadian constitution 42 the constitution also entrenches a governmental duty to consult indigenous peoples prior to enacting any legislation regulation or potential infringement upon established or potential indigenous rights and to make appropriate accommodations 4344 grandchief matthew coon come has described canadas repeated failures to uphold this duty to consult as a violation of the canadian constitution and international law 45 in addition to these inherent constitutional rights to health and health care which apply inclusively to first nations indian métis and inuit peoples first nations persons whose ancestors signed treaties possess supplemental treaty rights to health and health care based on promises made during treaty negotiations if health assessment and response are recognized as an integral part of health and healthcare one can make a legal argument that the assurance of adequate and relevant indigenous health assessment and response is an underlying and inherent governmental responsibility that takes precedence over any legislation or policies subsequent to the canadian constitution further the constitutional duty to consult imposes a legal requirement to actively involve indigenous peoples in the planning implementation and evaluation of indigenous health assessment and response to ensure that it is aligned with the underlying indigenous right to health and indigenous rights more broadly despite expanding scholarship and related ethical legal and policy recommendations that challenge the historic and ongoing marginalization of indigenous peoples in the planning implementation and ongoing management and governance of indigenous health information systems 46 47 48 49 50 substantive indigenous participation continues to be the exception rather than the norm the first authors systematic review of indigenous involvement in indigenous health information systems in canada and internationally 5152 identified some advances both domestically and globally but also important gaps serious deficits were identified in the development of local and regional health information systems feedback of health infor mation to these systems and the processes of indigenous input into these systems including the application of indigenousspecific frameworks and indicators 51 these findings are not surprising since the large majority of policy makers practitioners and researchers involved in the development of population health datasets have had limited exposure to indigenous peoples and their diverse systems of knowledge and practice with respect to health in order for health data to become a tool for indigenous social empowerment and social change the social structuring of data governance and management must change from systems that reinforce social exclusion by marginalizing systematically disadvantaged populations from their data to systems in which they are fully and centrally involved in data decision making 5354 clearly negotiated and properly implemented data partnerships and data sharing agreements can be a key tool in the shifting of data governance and management relationships towards one of indigenous community leadership and participation the governing structure of the our health counts project a study aimed at developing a baseline population health database for urban indigenous people living in ontario was operationalized through a governing council comprised of representatives from key provincial indigenous organizations research agreements and data management and governance protocols 55 this included successfully negotiated community research agreements with each of the three community project sites and a triparty data sharing agreement which was negotiated between the institute of clinical and evaluative sciences the ohc governing council and st michaels hospital success of the ohc project included strong indigenous community partnership and participation and the production of previously unavailable and highly policy and practice relevant urban indigenous health statistics these successes were facilitated through mutually supportive partnerships and a clear research governance model as well as through the pursuit of research methods that built on the strengths of urban indigenous communities 56 another example is the health governance structure of the first nations health authority in british columbia 57 the signing of the british columbia tripartite framework agreement on first nations health governance between bc first nations the province of bc and the government of canada marks a significant shift in the delivery of health services and will enable first nations in bc to participate fully in all decision making processes at institutional provincial regional and local levels 58 engagement of indigenous communities in the collection and analysis of their health data is also essential to ensuring that indicators and measurement tools are aligned with indigenous community concepts of health and social wellbeing indigenous understandings of health are diverse and can differ from the concepts underlying commonly used health indicators and measurement tools 53 for example measures of disease specific morbidity and mortality are a central component of existing health status reporting these statistics are generally recognized as important by indigenous scholars and policy makers however there is an accompanying critique regarding their unbalanced use there is concern that the use of such deficitbased indicators in isolation perpetuates the marginalization of local indigenous theories of health which may incorporate for example notions of balance positivity wellbeing and interrelationality at a foundational level 59 60 61 62 furthermore indigenous scholars and policymakers argue that the widespread use of deficit based measures has negative implications for indigenous individuals and communities as they can perpetuate negative stereotypes and become internalized and contribute to internalized negativity and racism 6364 in response to these concerns indigenous organizations in canada have developed their own culturally specific health indicator frameworks for example itk has been actively developing their own health information systems starting with the inuksiutiin health information framework in 2002 and currently with naasautit inuit health statistics 65 métis regions across the country have also been working on health information systems development with métis specific provincial health surveys completed in bc and saskatchewan and linkages with provincial health data bases in manitoba and ontario 6667 globally indigenous scholars and policymakers have recommended an approach that incorporates indigenous specific measures to complement more universally accepted measures 516869 there are a number of recent survey initiatives in canada that have adapted this approach including the aboriginal childrens survey 70 the inuit health survey 71 the our health counts survey 72 and the first nations regional longitudinal health survey 73 the first nations regional longitudinal health survey is an exemplar both with respect to indigenous governance and management of health data and with respect to the indicators and measurement tools that are relevant and useful to the indigenous individuals and populations whose data is being gathered the rhs was initiated in 1997 to address the exclusion of aboriginal peoples from national surveys currently it is the only first nations governed national health survey in canada and the only national survey for first nations onreserve populations it has been successfully implemented in first nations communities across the country in 20022003 and 20082009 it collects information based on both western and traditional first nations understandings of health and wellbeing and is a progressive model of first nations governance and management of health information as highlighted in the rhs cultural framework all aspects and components of first nations health and wellbeing are integrally interconnected within the web of life and living this includes physical mental emotional and spiritual health as well as a healthy lifestyle cultural continuity with the past and future opportunity and a healthy connection to culture family and community therefore first nations interpretation and analysis of health outcomes cannot be categorized or isolated from one another as each of these concepts impinges on the other in significant ways 74 this issue of indigenous community engagement in research evaluation and policy studies based on secondary data analysis of existing federal or provincialterritorial data holdings is important to raise because it is an important application of these datasets however there is considerable variation with respect to the interpretation and application of existing ethical guidelines while the persons conducting secondary data analysis may be initially more distanced from the indigenous communities whose data is being used compared to study involving primary data secondary data analysis is not exempt from potentially harming indigenous individuals and communities particularly if we consider the issues raised earlier regarding the potential harms of deficit based reporting the tricouncil guidelines for research involving humans 49 to which the large majority of scholarly institutions in canada adhere stipulates that in situations where researchers are using publically or legally available datasets to conduct secondary data analysis reb review may not be required but researchers should seek culturally informed advice before the use of such data to determine if harms may result and if other considerations such as sharing of the research results should be explored with the original source community 49 secondary data analysis research involving nonpublically or legally available datasets andor data linkages which result in newly identifiable indigenous datasets require research ethics review board review and consequently evidence of aboriginal community engagement while it is standard practice for researchers involved in primary data collection and analysis with indigenous communities in canada to describe the specifics of indigenous community engagement and participation in the research study within their scholarly publications this information is typically excluded from publications involving secondary data analysis for example the three most recent research publications on indigenous health published in canadas highest impact health journal the canadian medical association journal were population based epidemiologic analyses of indigenousnonindigenous disparities in the management of acute myocardial infarction risk of progression to endstage re nal disease and death among diabetics and progression to kidney failure according to presence and severity of albuminuria respectively 75 76 77 all three studies relied on secondary data analysis involving a crosslinkage between federal indian registration records as defined by the indian act with provincial health databases to identity the indigenous cohort while all 3 studies report research ethics board approval from university rebs and all three studies have important policy implications for the first nations populations whose data are used in the studies none of these studies describe any type of first nations community engagement with respect to study design interpretation and dissemination this unfortunate gap leaves the reader uncertain as to the underlying ethics and methods of these studies and represents a missed opportunity to support the shift towards research processes and outcomes that are relevant and useful to the indigenous communities whose data are being used this section has introduced some important background information about the indigenous peoples and their representative governing bodies and organizations in canada ethical rightbased and practical justifications for shifting towards indigenous led governance and management of indigenous health information key strategies for moving forward and ongoing challenges the relationship of individuals and identifiable communities to their data including issues of privacy informed consent data governance and management is an area that is highly relevant not only for indigenous health information but for statistics more generally it is complex and draws heavily on the fields of ethics social theory community engagement governance and law disciplines that are not typically core content in the training of statisticians it is our hope to stimulate further inquiry and discussion among our colleagues about data governance both with respect to indigenous populations in canada and more generally global trends towards increasing the use of linked administrative datasets and big data risk further distancing already marginalized individuals and communities from active leadership and participation in the decision making regarding the use of their data making the need for further work in this area an urgent priority the absence of relevant consistent and inclusive indigenous identifiers in core population health data sources the core problem with canadas indigenous health information infrastructure is that none of the primary population health data sources consistently inclusively or reliably gather indigenous identity information in this section we begin with an overview of the jurisdictional complexities of indigenous health service delivery in canada which fundamentally impact indigenous health information systems we then describe the current state of census survey vital registration health care utilization and disease surveillance systems in canada with respect to indigenous identifiers this is followed by a discussion of indigenous selfidentity as the gold standard for indigenous identification and a review of the underlying practical and rightsbased rationales for indigenous identification in core data sets jurisdictional complexities and the need for disaggregated datasets as described in the preceding section the indigenous population of canada is actually comprised of multiple culturally linguistically and politically distinct subpopulations healthcare services in canada overall fall under provincialterritorial jurisdiction and are increasingly planned and delivered at the small regional and local level for indigenous peoples in canada there are additional federal governmental constitutional and treaty responsibilities for the provision of health and health care and the federal government directly funds some indigenous specific health programming and services which are differentiated and streamed according to historic and current federal policies including the indian acts for many decades there has been partial recognition and policy responses regarding the federal responsibility to support the rights of first nations people recognized under the indian act and inuit peoples to health and health care services currently programming and services for these groups fall under the first nations and inuit health of health canada nonstatus first nationsindian and métis peoples in contrast have been primarily excluded from federal indigenous health programming and services and currently jurisdiction for these groups fall primarily under the public health agency of canada these historic and current jurisdictional complexities are at the root of many of the existing indigenous data systems deficiencies and double standards for example provincialterritorial health and public health departments to various extents have argued that historically and currently indigenous health including indigenous health surveillance is a federal responsibility the subsequent result is the underdevelopment of indigenous health information systems at the provincialterritorial level when provinces and territories have included indigenous identifiers in their health information systems the provincialterritorial administration of health services and health surveillance more generally has resulted in significant provincialterritorial inconsistencies in the terms of indigenous identification and data processing protocols the federal government historically and currently has focused on the development of health information systems almost exclusively for first nations persons with status living in first nations onreserve communities and inuit living in the inuit nunangat leading to an almost complete exclusion of nonstatus first nationsindian métis and urban indigenous populations from the majority of federal and provincial health information systems the other key consequence of these jurisdictional complexities and the trend towards local and small regional health service planning and delivery is that national level panindigenous data sets are of little practical utility the health needs and existing health services and programs available to first nations persons living in onreserve first nations communities nonstatus first nationsindians métis and inuit are distinct even within these core subpopulation groups there is tremendous variability in health needs depending on the local contexts geography including whether or not individuals and communities are urban rural or remote also has a major impact on health needs and available health services and programs for all of these reasons there is a need to move towards indigenous data systems that can be disaggregated to provide valid estimates of core population health indicators for first nations persons living in onreserve first nations communities first nations persons living offreserve nonstatus first nationsindian people inuit métis and urban indigenous peoples these disaggregated estimates are needed at the subprovincial and ideally local health planning and service delivery level census and national household survey counts of aboriginal people in canada predate confederation 78 79 80 aboriginal ethnicity data was included in the canadian census from the first national census in 1871 up to and including 2006 80 aboriginal ethnicity questions were gradually refined between 1981 and 1996 in the 1981 census multiple ethnic origins were allowed for the first time and in 1986 there was a change in the ethnic origin question from the 1981 question of to which ethnic or cultural group did you or your ancestors belong on first coming to this continent to to which ethnic or cultural group do you or did your ancestors belong which is better aligned with indigenous identity in 1996 a specific question regarding aboriginal identity was added to the census is this person an aboriginal person that is north american indian métis or inuit which for the first time allowed for population counts which reflected aboriginal identity in addition to aboriginal ancestry 80 quality issues with the 2001 and 2006 census data for indigenous populations include significant block nonparticipation by first nations onreserve communities 81 undercounting of homeless and highly mobile populations nonparticipation by aboriginal people for a variety of additional reasons including a distrust of andor political disagreement with federal governmental agencies and accessibility with respect to assumed literacy levels finally some aboriginal people may participate in the census but not share their aboriginal identity andor ancestry information 515282 this may be more common for some subpopulations of aboriginal people for example there was a large increase in the métis identity population between the 2001 and 2006 census which could not be accounted for solely by population growth this has been linked to an increase in the number of métis who selfidentified as métis in the 2006 compared to the 2001 census 83 there is recent evidence that census nonparticipation in urban areas by indigenous populations may be especially significant for example a health assessment of inuit living in the city of ottawa conducted in 2010 using respondent driven sampling found that only 18 of this selfidentified inuit population reported participating in the 2006 census 8485 despite these limitations up until 2006 the census uniquely provided essential information that was often not available elsewhere regarding the size of the total indigenous population and multiple indigenous subpopulations family structure geographic distribution language use and the social determinants of health importantly it also provided the ability to compare indigenous populations to nonindigenous populations allowing for the quantification of health equity gaps the transfer of indigenous identity and ancestry questions from the mandatory long form census to the voluntary national household survey in 2011 substantively weakened an already suboptimal foundation for indigenous statistics in canada as the response rate of the nhs is significantly lower than that of the 2006 long form census subsequent data quality issues have been identified for estimates of lowincome prevalence geographic areas with small populations 86 and specific indigenous subpopulations 87 the big change with respect to the indigenous data available from the 2011 nhs compared to the 2006 census is that indigenous data is no longer available for almost all census subdivisions some census divisions and some census metropolitan areas furthermore there is no data release at the health region level as there was with the 2006 census statistics canada nonspecifically annotates that for suppressed census subdivision census division and census metropolitan areas that an aboriginal profile is not available for the area listed due to the following reasons an aboriginal identity population of less than 250 data quality or confidentiality reasons or that the area is comprised of or contains incompletely enumerated indian reserves or indian settlements 88 this data suppression represents a huge step backwards with respect to indigenous population health surveillance and response in canada as detailed in section 42 above it is this smaller regional level reporting that is urgently required for meaningful indigenous population health assessment and response additional indigenous data quality problems include incomplete enumeration of 36 indian reserves indian settlements and a suspected overestimation of inuit population living outside of inuit nunangat at the national level the inuit estimation is reported as higher and more variable for some smaller geographic areas 86 other national health and social surveys statistics canada supports a number of additional national health and social surveys which draw on a censusbased sampling frame aboriginal people are typically excluded or undersampled in these studies for example for political reasons first nations people living on reserve are excluded from major national health studies such as the canadian community health survey 89 the national longitudinal child and youth survey 90 and the canadian maternity experiences survey 91 for many decades up to and including 2006 the canadian census was comprised of a short form and a long form the long form had additional questions not found on the short form and was delivered to a 20 subset of the total population in order to generate a representative sample of aboriginal people prior to 2011 national health surveys such as the cchs nlcys and mes drew on the 20 population sample generated by the long form census unfortunately this 20 subsample did not provide adequate numbers of potential aboriginal participants to adequately power these studies so that they could provide quality estimates disaggregated by aboriginal subpopulation at geographic levels smaller than the provinces and territories these gaps have been partially addressed by the development and implementation of the aboriginal peoples survey which has been delivered nationally to aboriginal people by statistics canada in 1991 2001 2006 and 2011 20 an aboriginal childrens survey was also developed and administered to caregivers of aboriginal children in 2006 92 there has been increasing partnership in the development and implementation of these tools with national aboriginal organizations and aboriginal scholars over time the 1991the 2001the and 2006 aboriginal peoples and aboriginal childrens surveys used census based sampling frames which will significantly undersample urban aboriginal people who are homeless highly mobile have lower levels of educational achievement in written english or french or who do not want to participate in the census for personal or political reasons 55848593 these sampling issues are exacerbated in the 2011 aboriginal peoples survey which drew its sampling frame from the nhs since there was no aboriginal identity or ancestry question on the 2011 census the aboriginal childrens survey was not repeated in 2011 resulting in the exclusion of aboriginal children between the ages of 05 from statistics canadas aboriginal specific surveys vital registration records health care utilization datasets and disease surveillance and registration systems a review of provincialterritorial birth registration conducted in 2008 94 revealed that 5 of the 13 provincesterritories collected no information regarding indigenous identity one province asked generally about aboriginal identity 6 provincesterritories asked about first nations or indian identity 4 provincesterritories asked about inuit identity and 3 provincesterritories asked about métis identity one province collected indigenous identity information indirectly by asking about maternal language which is a poor proxy for indigenous identity particularly in urban areas where the large majority of indigenous peoples dont report an indigenous language as a mother tongue 9596 indigenous identity is typically not recorded at all on death registration so mortality studies in canada are dependent on registry linkages 97 or geocoding by density of indigenous population using small areas with high prevalence of indigenous identity populations as a proxy for indigenous identity 98 for reasons detailed in section 5 below both of these methods will almost always underestimate indigenous health challenge and subsequently indigenousnonindigenous health disparities both methods also have substantive coverage issues as they are restricted to specific indigenous subpopulations the linkage method will only include the specific aboriginal subpopulation for which registries that can be linked exist and the use of geocoding as a proxy for indigenous identity only works for areas where there is a high prevalence of indigenous peoples and estimates will almost always underestimate particularly for relatively rare events with respect to health care utilization data indigenous identification is currently not available in primary source data files this is because in canada information regarding ethnicity andor race is not routinely collected at point of service access as it is in many other countries a few provinces and territories have flags that identify first nations people with status as part of information included in health service registration however this data is generally not used due to poor sensitivity disease surveillance systems including disease registries are limited with respect to inclusion of information regarding indigenous identity this is because they either do not include information regarding indigenous identity gather information only from specific subpopulations of indigenous peoples or use inconsistent terminology across provinces and territories for example during the h1n1 outbreak in canada which disproportionately impacted indigenous individuals and communities the adjoining provinces of ontario and manitoba had inconsistent approaches to indigenous identification on the disease reporting forms with manitoba including information on indigenous identity and ontario excluding this information this difference in approaches resulted in a missed opportunity in ontario to monitor disease outbreak in the 70 of its indigenous population living offreserve on a positive note cancer care ontario has been engaging in a series of pilot studies in partnership with indigenous communities to improve indigenous identification in cancer registries in the province 99 indigenous selfidentification as the gold standard for indigenous people being able to define ones own identity both individually and collectively on ones own terms is a central part of selfdetermination globally indigenous selfidentification and acceptance of selfidentification has been recognized as an essential component of indigenous peoples sense of identity 100 in new zealand the country with the best indigenous health data infrastructure in the western hemisphere selfidentification is the recommended method of reporting ethnicity in all collections of official statistics by statistics new zealand 101 a study in the united states demonstrated that race and ethnicity classification on american death certificates which are determined by the funeral director misclassified native americansalaska natives as white over 40 of the time compared to selfreport on the current population survey for all of these reasons it is important that selfreport be recognized in canada as the preferred method of indigenous identification not only in the census nhs and national health and social surveys but also in vital registration health care utilization and disease surveillanceregistry data systems methods that have been refined and tested in other affluent countries with minority indigenous populations such as australia and new zealand provide useful exemplars 101 102 103 the fluidity of individual and collective indigenous selfidentification over time is an additional complexity that requires ongoing methodologic innovation the right to be counted in this section we have described the jurisdictional complexities that contribute to the underdevelopment of core indigenous health information data sources in canada we have detailed specific strengths and deficits for data sources with a focus on ability to accurately and inclusively identify indigenous peoples overall there is inconsistent and incomplete coverage of the total indigenous population with the systematic exclusion of substantive population groups such as nonstatus first nationsindians métis and urban indigenous peoples in many instances these groups comprise 9 35 56 of the total population of indigenous peoples in canada respectively these exclusions can be linked historically to indian act legislations which at the time they were first introduced we deliberately aimed to assimilate indigenous peoples 8 the right to be counted is a human right recognized by the world health organization 2 ethically and practically the gold standard with respect to indigenous enumeration is for this to be done using selfidentification globally failure to be enumerated has been linked to increased mortality 2 for indigenous peoples in canada existing data gaps mean a missed opportunity to fully benefit from evidence based interventions including population tailored vaccination healthy lifestyle programming and primary care enhancements with respect to data regarding the health and wellbeing of indigenous women in canada gaps in information have been flagged as problematic by the united nations human rights council 104105 taking a step back from the immediate indigenous health data infrastructure limitations we have just described it is hard to justify an approach to indigenous population health assessment that commonly systematically excludes over 40 of the population particularly in a relatively affluent and technologically sophisticated country like canada in the next section we will further illustrate some of the specific impacts of these indigenous source data infrastructure deficiencies on the assessment of and response to indigenous health and social inequities how infrastructure deficiencies contribute to the masking of indigenous health and social inequities in canada the infrastructure deficiencies in the core population health data sources described in the previous section result in a number of methodological problems in the production of derived measures of indigenous health determinants health status and health care access as already discussed in many cases including for example both indigenous specific measures of health care utilization and disaggregated district health region level demographic health and social statistics reliable estimates simply are not available there is an equally important and perhaps more insidious challenge for situations where we do have derived measures indigenousnonindigenous misclassification errors and indigenous nonresponse bias almost uniformly result in incorrect estimates of indigenous health measures indigenousnonindigenous misclassification can be the result of errors in classification in the source dataset or through the use of suboptimal methods such as linkage to a single registry of a subpopulation of indigenous peoples andor geocoding in order to determine indigenous identity because the source dataset doesnt have this information indigenous nonresponse bias occurs when indigenous health and social surveys use a convenience or nonrepresentative sampling frame in this section we will detail these problems and demonstrate how systematically they almost always result in an underestimate of indigenous health and social inequities indigenousnonindigenous misclassification bias in source datasets indigenousnonindigenous misclassification error in the calculation of simple indigenous eventpopulation ratios can be represented as follows actual indigenous ratio r xy calculated indigenous ratio r 1 error in indigenous ratio r r 1 where x indigenous events y indigenous population at risk a indigenous events misclassified as nonindigenous b nonindigenous events misclassified as indigenous c indigenous people misclassified as nonindigenous d nonindigenous people misclassified as indigenous errors in nonindigenous eventpopulation ratios can likewise be represented as actual nonindigenous ratio r xy calculated nonindigenous ratio r 1 error in nonindigenous ratio r r 1 in canada we normally do not have the ability to estimate the magnitude of a d in estimates drawing on a given source of indigenous identity data as we are typically reliant on a single indigenous identifier and there is no gold standard or other comparator however studies in the united states demonstrate that misclassification of indigenous events as nonindigenous is much more common than the misclassification of nonindigenous events as indigenous for example arias et al assessed the validity of race and ethnicity classification on american death certificates determined by the funeral director proxy report by comparing to selfreport race and ethnicity data collected as part of the current population survey a multistage stratified probability sample derived from the us census with a response rate of approximately 95 106 in this study racialethnic misclassification of native americansalaska natives as white on the death certificate using cps selfreport as the gold standard was found to be 41 and 42 respectively for the periods 19791989 and 19901998 in contrast there was nearly 100 agreement between death certificate and cps selfreport for the white population over both periods 106 with respect to the impact of indigenousnon indigenous misclassification of events on the underestimation of indigenous health disparities the effect can range from modest to alarming depending on factors such as the overall frequency of the event the relative sizes of the indigenous and nonindigenous comparator populations and the relative difference in events between indigenous and nonindigenous populations although we typically do not have a data system in canada that facilitates the estimation of indigenous nonindigenous misclassification with precision we can begin to estimate the potential impacts on the quality of indigenous health measures by setting some assumptions indigenous infant mortality rates in canada is one area where there has been ongoing discussion with respect to the quality and magnitude of reported indigenous rates 107 108 109 while these issues of inconsistent or absent identification of indigenous birth registration systems precludes the calculation of pancanadian indigenous infant mortality rates peer reviewed studies have revealed imr rates that are 190 higher for first nations compared to nonfirst nations and 360 higher for inuit inhabited areas compared to noninuit inhabited areas 110 due to the relatively low frequency of infant mortality small misclassification errors in the numerator can have significant impacts on the rate we demonstrate this in the following example we first assume that the actual indigenous imr for a given indigenous population in canada is 10 per 1000 we base this assumption on the fact that the overall imr for canada ranged from 49 and 54 per 1000 live births between 2000 and 2009 and the peer reviewed literature cited above which suggests indigenous imr rates are 19 to 36 higher than comparator rates we next assume that misclassification of indigenous infants as nonindigenous infants on the infant death certificate is 25 and that misclassification of nonindigenous infants as indigenous infants is 1 drawing on the arias study we further assume that the rate of misclassification of indigenous infants as nonindigenous infants on the birth registration is smaller than that of the death registration taking into account that it is the parents who complete the birth certificate but usually health care providers often in a tertiary care setting outside of the infants home community who complete the death certificate finally we assume that misclassification of nonindigenous infants as indigenous is also very small that no additional sources of indigenous ethnicity apart from the birth registration are being used and that a crosssectional method is being used to calculate the imr instead of the gold standard cohort method which by linking birth and death certification allows some correction of misclassification on the death certificate drawing on the birth certificate the calculated indigenous ratio r1 76960 791000 in this case the calculated indigenous mortality rate is over 20 lower than the actual indigenous mortality rate an error that would have striking practical and policy implications overreliance on single registry linkage as a result of the missing andor inconsistent indigenous identifiers in canadas core health data sources there is subsequent overreliance on linkages to a single registry of a subpopulation of indigenous people in order to determine core population health indicators such including health determinants disease incidence and prevalence rates mortality rates and health care access rates despite efforts to refine these methods 97 there are several consequent problems with this situation firstly large proportions of the total indigenous population are excluded from the indigenous rate or ratio calculation indigenous persons may be excluded from the registry population either because they do not fit the inclusion criteria of the registry or because the registry is incomplete this problem of exclusion is compounded by the fact that excluded indigenous persons are usually misclassified as part of the nonindigenous comparison population the second big challenge with the overreliance on linkage use to identify indigenous peoples in datasets in canada is that there is a limited ability to estimate the degree of misclassification of indigenous persons and events as nonindigenous and vice versa because in contrast to australia the united states and new zealand there is typically only one source of indigenous identity data in these linked health datasets this situation is methodologically suboptimal and we will demonstrate below how it commonly results in an underestimate of indigenous disease burden for example the three cmaj publications 7577 discussed in section 3 above all relied on a crosslinkage between federal indian registration records as defined by the indian act with provincial health databases to identity the indigenous cohort which was subsequently compared to a nonindigenous cohort that included the remaining provincial indigenous population in their study of access to angiography for first nations people in alberta bresee et al acknowledge that this indian registration definition of indigenous people represents only 81 of selfidentified first nations people and 53 of the total indigenous population in canada they further note that all of the indigenous people in the province of alberta not registered under the indian act were included in the nonfirst nations comparison group 77 there is good evidence that challenges in accessing urgent medical care cut across indigenous subpopulations 11111 and disparities in access to invasive and lifesaving cardiac procedures have also been demonstrated for indigenous populations in australia and new zealand 112 if one assumes that nonstatus first nationsindian métis and inuit populations in alberta also experience disparities in access to angiography following acute mi compared to nonindigenous persons then inclusion of these populations in the nonfirst nations group would reduce the magnitude of the odds ratio demonstrating that first nations patients are less likely to receive angiography compared to an odds ratio calculated using a comparison group in which all indigenous people had been excluded in contrast to the striking and policy relevant impacts of misclassification in the infant mortality example above an analysis of this study of relative access to coronary angiography within one day of myocardial infarction 77 suggests a much more modest impact of indigenous misclassification while we dont have access to the data to review the adjusted logistic regression the authors report that 263 of first nations patients with mi and 347 of nonfirst nations patients respectively underwent coronary angiography within one day of myocardial infarction the crude relative risk of coronary angiography for first nations compared to nonfirst nations patients is therefore 0758 to estimate the impact of including nonstatus first nations métis and inuit in the nonfirst nations group we could conservatively assume that the size of the nonstatus first nations métis and inuit population in alberta is equal to that of the status first nations population and that this population is equally likely to receive angiography within the first day of mi as the status first nations population we can assume that misclassification of nonindigenous people in alberta as status indians is close to zero based on the complexity of indian registration processes the indigenous rate of receiving angiography within the first day of mi would remain the same under these assumptions the nonindigenous rate would change slightly as there would now be both a smaller numerator and denominator from the numerator we would subtract the number of indigenous events misclassified as nonindigenous and from the denominator we would subtract the number of indigenous people misclassified as nonindigenous in the total sample we have set the denominator adjustment as equal to the number of status first nations in the study for the numerator adjustment we have assumed that the misclassified indigenous population will have the same rate of angiography as the status first nations population so the adjustment figure is 1043 0263 274 the original numerator for the nonindigenous one day angiography rate is 45721 0347 15865 we can now calculate the new nonindigenous rate adjusted for indigenous to nonindigenous misclassification 1559144678 0349 349 the revised crude relative risk of getting angiography one day post mi for indigenous compared to nonindigenous people is therefore 0754 compared to the original estimate of 0758 a very modest effect indeed but still an underestimate using geography as a proxy for indigenous identity the use of geographic proxy for indigenous identity has emerged in canada over the past decade as an alternative to registry data linkage as a method of determining population based estimates of indigenous health including mortality given the absence of indigenous identifiers in core data sources such as the death certificate 98113 in this method indigenous identity data collected by the 2006 and earlier censuses is sorted at small geographic levels according to the percentage of the total indigenous subpopulation of interest that selfidentified as a member of this population a threshold is then set to categorize small geographic areas as indigenous if the indigenous subpopulation of interest comprised a specific percentage or more of the total population in wilkins et als study of inuit mortality this threshold was set to at least 33 inuit and the comparison population for mortality was all of canada 113 in a recent study of first nations child mortality the cut off was the top one third of census dissemination areas ranked according to indigenous identity and the comparison population excluded these regions 98 mortality rates for both studies were determined by linking the postal code on the death certificate to the geocoded datasets 98113 in both of these studies the calculated indigenous mortality rates are in fact a blending of indigenous specific mortality rates and nonindigenous mortality rates for the high proportion indigenous identity regions for example 15 of the population in the inuit inhabited areas in the inuit mortality study and 5 of the population in the high percentage first nations area in the first nations child mortality study are of nonindigenous identity if we assume that indigenous mortality rates are higher than nonindigenous mortality rates in these regions then logically it follows that this combining of indigenous and nonindigenous rates in this method will invariably result in an underestimate of the true indigenous rate this problem is exacerbated by the fact that the comparison populations each contain large numbers of indigenous peoples which using the same logic will erroneously elevate the nonindigenous comparison rates resulting in a further reduction in the absolute and relative indigenousnonindigenous mortality risk calculations additional limitations of this method include the fact that it is ecological and less useful in modelling determinants of indigenousnonindigenous mortality disparities and that its ongoing use will be limited by absence of reliable indigenous population estimates at the census subdivision and smaller geographic level with the move of the indigenous identity question from the census to the nhs in 2011 nonresponse bias and sampling error in the census nhs and other survey datasets nonresponse bias arises when persons who do not participate in a survey have different characteristics than survey participants and as a result reported estimates do not represent the true population values as discussed in 42 nonparticipation of indigenous people in the 2001 and 2006 census included block nonparticipation by multiple first nations onreserve communities a disproportionate number of highly mobile and homeless indigenous individuals individuals who do not have the assumed literacy skills required to complete the census and indigenous people who chose not to participate based for person or political reasons housing instability and lower literacy skills are associated with poverty and an increased burden of illness 14 it would therefore follow that if there are higher rates of nonparticipation in the census for indigenous persons experiencing housing instability andor lower literacy skills than for indigenous persons who do not experience these things that census data will underestimate indigenous health and social disadvantage in addition to nonresponse bias survey nonresponse also causes increased sampling error due to the reduced number of participants contributing to the sample 114 this in turn results in a decrease in the precision of estimates which will be particularly important at the small area level until recently the census was considered the gold standard for indigenous population enumeration and there was no way of estimating the impact of census nonresponse bias on estimates of indigenous health and social disadvantage the our health counts urban aboriginal health study partially addresses this gap through the rigorous and successful use of respondent driven sampling which is known to effectively engage populations that may be missed by the census including persons who are homeless highly transient or have low literacy skills the urban first nations arm of this study demonstrated striking levels of poverty among selfidentified first nations residents of the city of hamilton that were much higher than comparable estimates of poverty for urban indigenous populations emerging from the 2006 census 115 for example according to the ohc study 782 of first nations persons living in hamilton earn less than 20000 per year the ohc income data may be more representative of the actual income profile of the first nations population in hamilton than the 2006 census as the rds method is validated and adjusted for bias postsurvey using rds statistics and the rds study successfully engaged highly mobile and homeless first nations individuals for example the ohc first nations study found that 13 of the adult first nations population in hamilton described themselves as homeless or in transition the large majority of whom would have been missed by census enumerators further validation of the low income data in the ohc first nations study is provided by rdsadjusted income quintile data generated by a linkage to census income quintile neighbourhood level data which revealed that over 70 of the first nations population in hamilton lived in the lowest income quartile neighbourhoods compared with 25 of the general hamilton population and 20 of the ontario population 115 the inuit arm of this study found a similar striking and previously undocumented socioeconomic and health status burden for the inuit of ottawa and a participation rate of only 18 in the 2006 census 84 nonresponse errors including nonresponse bias and a decrease in the precision of small area estimates are even more problematic in the voluntary nhs which had a markedly reduced unweighted response rate compared to the 2006 long form census since there were no indigenous identifiers on the 2011 census we cannot directly determine indigenous specific nhs nonresponse rates or study nonresponse bias urgently required followup studies include a release of nhs nonresponse rates for first nations onreserve 2011 census enumeration areas and studies that examine the characteristics of indigenous nhs 2011 responders and nonresponders by linking to the 2006 census long form additional urban rds studies are also in progress which will allow an opportunity to examine the selfreported prevalence of 2011 nhs nonresponse and provide a comparison dataset for 2011 nhs estimates of urban indigenous health and social disparities at this point it is clear that nonresponse on the nhs has definitely reduced the ability of statistics canada to provide much needed smaller area health and social statistics for indigenous peoples in canada national health and social surveys administered by statistics canada such as the aboriginal peoples survey the canadian maternity experiences survey and the canadian community health survey are subject to nonresponse bias and sampling error derived from their sampling frame which are the census for 2006 and earlier and subsequently the nhs while we are not able to quantify with precision based on the discussion above it appears that the sample of indigenous persons who responded to the 2006 census may experience significant socioeconomic advantaged compared to the total indigenous population in canada and that this bias is exacerbated in the 2011 nhs with respect to sampling error the 2006 census sampling frame was already inadequately powered to provide precise estimates at the subprovincialterritorial level disaggregated by indigenous subpopulation due to the fact that the long form census with the indigenous identity question was only administered to 20 of the total population and that some postcensus surveys occurred simultaneously and required distinct samples to avoid survey fatigue the dramatically reduced response rate in the 2011 nhs again exacerbates this underpowering with respect to its use as a sampling frame to national surveys with the exception of the first nations regional longitudinal health survey which is able to use lists of indigenous persons living in the participant first nations onreserve communities as it sampling frame and the rds studies described above research and policy makers wishing to conduct additional health and social surveys of indigenous populations are forced to use convenience sampling because there is no suitable and accessible sampling frame for the specific indigenous subpopulations with whom the surveys are being conducted for example both the urban aboriginal peoples study 116 and the toronto aboriginal research project 117 used convenience recruitment strategies the former attempted to recruit a population representing some diversity with respect to socioeconomic position by stratifying convenience recruitment by socioeconomic position and setting recruitment goals with respect to persons experiencing socioeconomic disadvantage however based on what is known about recruitment bias using convenience sampling it can be assumed that within specific socioeconomic strata persons who choose to participate in a survey are different than those who choose to not participate with the former group likely experiencing relative socioeconomic literacy and housing advantage compared to the latter 118 as a result of recruitment bias based on the convenience sampling method both studies almost certainly underrepresented urban aboriginal health and social disadvantage underreporting of methodologic limitations and their consequences in the published literature in this section we have systematically examined the core data sources and methods used to produce estimates of indigenous health determinants health status and health care access in canada we have demonstrated that as a result of deficiencies in the core data sources with respect to indigenous identification and the subsequent need to use supplementary methods to determine indigenous identity there is almost uniformly error in derived measures of indigenous health and that these errors systematically tend towards the underestimate of indigenous health and social inequities there are several arising and relatively urgent discussion points firstly the substantive efforts of statisticians and researchers currently working to achieve indigenous health statistics in the face of existing source data infrastructure deficiencies in canada are admirable and the purpose of this critical review is not to undermine their achievements it is critical however that this work be accompanied by full and transparent disclosure of the limitations of data sources and methods with accompanying attempts to understand the impacts of these limitations on the precision and relative magnitude of the estimated health outcome measures of concern is that review of the literature indicates that this type of disclosure is the exception rather than the norm for example in contrast to australia new zealand and the united states the literature regarding the impacts of indigenousnonindigenous misclassification on indigenous health assessment is almost nonexistent in canada in indigenous health publications and reports drawing on data linkages with indigenous registries limitations such as the restriction of the indigenous population to first nations persons with status or registered métis are commonly given only superficial mention near the end of the article with little discussion of the potential impacts if at all 75 76 77 119 the nhs aboriginal statistics releases and accompanying technical reports do not transparently identify the loss of indigenous statistics released at the smaller regional level despite the fact that this will have huge negative impacts on indigenous health service planning and delivery in the urban aboriginal peoples study report which was widely publicized there is no discussion in the main study report of the recruitment bias which was almost certainly built into the convenience sample method despite efforts to force representation through the use of quotas 116 finally and most importantly is the arising recommendation that the focus needs to shift from further development of compensatory methods to overcome gaps in indigenous identification in core health data sources towards what is urgently needed a focus on working in partnership with indigenous leaders and communities to build in meaningful and relevant indigenous selfidentification into the source datasets themselves we hope that this section has demonstrated that to do otherwise will result in a continued masking of indigenous health and social inequity in canada moving forward in this paper we have offered a critical documentation of the current state of indigenous health statistics in canada we provided an overview of the policy and jurisdictional landscape including current ethical legal and practical rationale for indigenous governance and management of indigenous health and social information subsequently we detailed the deficits in indigenous identification in canadas core population health data sources and demonstrated how these deficiencies contribute to a masking of indigenous health and social inequities our aim was to expose the two central and interconnected roots of indigenous health information deficiencies in canada the lack of culturally relevant consistent and inclusive indigenous identifiers in source datasets and the need to actively engage indigenous peoples in meaningful partnerships to govern and manage data that is collected from them we applaud and continue to learn from the dedicated efforts of the small cadres of indigenous community leaders governmental scientists and academics in canada who are working to bridge existing infrastructure gaps 97 however the time is long overdue to recognize and address what we perceive as the elephants in the room there will be little true progress until there is a shifting of efforts towards indigenous data partnerships and the establishment of relevant consistent and inclusive indigenous identifiers in canadas source health datasets in each section of this paper we have included strategies and exemplars for moving forward these domestic and international models demonstrate that it is possible to work in partnership with indigenous community representatives to build indigenous health databases that are both relevant and statistically sound while at times the challenges may seem numerous it can be done provided there is scholarly policy and political will there is a relative urgency to this workcurrently as a result of these critical gaps in health assessment indigenous people in canada experience not only a disproportionate burden of illness and premature death but also a double standard with respect to population level documentation of and subsequent appropriate public health response to this burden this unacceptable situation is in tension not only with canadas otherwise excellent statistical track record but also with the un fundamental principles of official statistics 120 which require official statistics to be practically useful and impartially compiled and made available we must work together for change

canada is known internationally for excellence in both the quality and public policy relevance of its health and social statistics there is a double standard however with respect to the relevance and quality of statistics for indigenous populations in canada indigenous specific health and social statistics gathering is informed by unique ethical rightsbased policy and practice imperatives regarding the need for indigenous participation and leadership in indigenous data processes throughout the spectrum of indicator development data collection management analysis and use we demonstrate how current indigenous data quality challenges including misclassification errors and nonresponse bias systematically contribute to a significant underestimate of inequities in health determinants health status and health care access between indigenous and nonindigenous people in canada the major quality challenge underlying these errors and biases is the lack of indigenous specific identifiers that are consistent and relevant in major health and social data sources the recent removal of an indigenous identity question from the canadian census has resulted in further deterioration of an already suboptimal system a revision of core health data sources to include relevant consistent and inclusive indigenous selfidentification is urgently required these changes need to be carried out in partnership with indigenous peoples and their representative and governing organizations

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existing methods for studying intimate partner violence draw largely from the social sciences these include primary data collection tools such as surveys interviews or focus groups as well as secondary analyses of data sourced from for example victim advocacy organisations recent developments in the field of computational social science have led to data science tools which extend and complement these established techniques they further ease the data collection and analysis process by harnessing big data and machine learning the latter is a subset of artificial intelligence focused on building algorithms that learn statistical patterns from large amounts of data specifically computational text analysis or text mining umbrella terms for computational tools which can extract and analyse substantial quantities of text data have been successfully utilised in fields such as social work medicine and education indeed a small number of studies have applied similar approaches to the study of ipv publications examined online supportseeking behaviours of victimsurvivors studied reasons given for staying and leaving abusive relationships in microblog posts and identified crisis posts on social media platforms such as facebook in addition computational methods have background data from the world health organisation indicates that 27 of women worldwide aged 1549 years who have been in a relationship have experienced some form of physical or sexual violence from an intimate partner during their lifetime the crime survey for england and wales in 2020 indicated that 49 of women and 21 of men over the age of 16 had experienced some form of nonsexual partner abuse in the last year despite these figures accurately quantifying the prevalence of ipv is difficult much abuse goes unreported due to shame bias and unawareness an additional barrier to measuring ipv is a nonhomogenous set of definitions for what constitutes abuse across cultures time periods and organisations whilst ipv is generally understood to involve physical abuse there are other ways in which perpetrators cause harm these alternative abuse forms may or may not be included in definitions resulting in skewed evaluations much of the existing largescale data about ipv is drawn from traditional surveyand questionnairebased research whilst such surveys are useful to understand ipv on a population level they are also costly infrequent and unlikely to capture granular data in this context researchers often turn to interviewbased approaches although valuable oneonone interviews may also suffer from selectionbias sample size issues and being timeconsuming to run against this backdrop some ipv researchers are turning to secondary analysis of existing data organisations that interact with victimsurvivors such as police forces or health services collect large quantities of ipv data which they are unable to analyse manually additionally victimsurvivors of ipv increasingly make use of online venues such as blogs and bulletin boards to express their experiences of abuse and to receive and offer support these entries generate huge amounts of text data much of which is publicly accessible computational text mining is a set of techniques which use algorithms to understand categorise or extract information from unstructured text data these can range from simple to complex approaches computational text mining methodologies have been used to harness big data to research social phenomena in other domains such as the study of online hate cyberbullying and child abuse victimisation given the intersection between these domains plus the existing methodological issues in ipv research computational text mining methodologies offer a promising avenue for the study of ipv research questions this article offers a systematic review of existing work which has applied computational text mining to the study of ipv in doing so it aims to provide a resource for ipv scholars who may want to use computational text methodologies in their work providing a starting point to understand current capabilities as well as directions for future research the article gives an introductory background to text mining methods and techniques whilst seeking to examine the quality of current work the authors do not assume existing knowledge of computational methodology and all terminology will be explained within our article our assessment of the academic literature is driven by three research questions how have computational text analysis methods been used in ipv research what datasets are available for studying ipv using computational text analysis how have text analysis methods been evaluated in the study of ipv method a systematic review of existing academic literature was conducted according to prismap guidelines electronic search strategy eight databases were searched in march 2022 for all records containing both terms relating to computational text mining and terms relating to intimate partner violence within all fields apart from the fulltext and unrestricted by date the full search string was as follows1 and inclusion criteria studies were included in the review if they met the following criteria peer reviewed and preprint academic literature the study uses computational text analysis or text mining to address an ipvrelated outcome from a dataset which includes unstructured text fields the study includes results from at least one dataset the main outcome of the computational model is related to the identification of types characteristics prevalence behaviours andor opinions of ipv on mental health since ipv is defined differently in different research and sometimes is captured within other definitions of violence we included studies with family violence domestic violence or sexual violence related outcomes since these may include ipv within their definitions data extraction and management records identified through database searches were imported into rayyan for data management after duplicates had been discarded two of the authors independently performed abstract screening according to the above inclusion criteria cohens kappa statistic was calculated at this stage to determine inter rater reliability following the procedure described by hallgren cohens kappa was 069 indicating a substantial level of agreement between the two reviewers according to guidelines from landis and koch remaining disagreements were resolved following a discussion between the two reviewers the included papers were subsequently downloaded and a proforma was used to extract the information from each paper the proforma was piloted with 16 initial papers and feedback was obtained from other authors following which amendments were made quality assessment existing guidelines for assessing bias quality and reliability of biomedical or psychological studies are difficult to apply to research using computational textanalysis methods particularly when reviewing highly specialised systems such as those involving ml this paper builds on existing frameworks for assessing ml and mixed methods research to develop a checklist of 21 yesno criteria which were used to assess the overall quality reliability and potential bias of studies included in the review a wide range of approaches are surveyed in the included studies so some irrelevant items were excluded from the checklist depending on the study in question for that reason the checklist is not supposed to provide a ranking of studies but an indication of overall quality of the included works the 21item checklist was as follows 1 definition of violence discussed 2 clearly described and motivated ipvrelated hypothesis or outcome 3 representativenessdemographics of dataset discussed andor analysed 4 source size and time period of dataset reported 5 data cleaning and sampling process reported 6 results included studies as can be seen in the prisma chart in fig 1 the search yielded 815 results of which 315 were duplicates leaving 500 unique studies of these 461 were excluded as irrelevant during abstract screening leaving 39 papers following full text review a further three records were excluded because no full text was available the text was not written in english the paper discussed a purely theoretical approach which did not involve any data finally a number of papers were found to report on the same two broad studies using similar datasets and models these were the karystianis et al papers on the new south wales police force data using a rulebased approach n 6 and the poelmans et al papers on the amsterdamamstelland police force data using an fca and esom based approach n 10 for simplicity of reporting in this review these records were condensed into two unique studies this left n 22 unique studies to be included in the following qualitative analysis a summary of the included studies can be found in table 1 the n 22 included studies cover a wide range of research questions and text mining methodologies outcomes include extracting topics from a corpus of social media texts information retrieval of abuse and injury types from police reports detecting the presence or absence of mentions of domestic violence in various types of text and event and entity recognition from court documents and victimsurvivor narratives a summary of the studies can be found in table 1 the quantity of this research seems to be increasing in recent years with the majority of studies being published in the last 5 years and almost a third being published in the last two years this may be a reflection the increased public awareness of the shadow pandemic of domestic abuse brought on by the covid19 pandemic given the interdisciplinarity of the topic it is interesting to note that there was an equal split between studies published in computer science journals and conferences2 and those published in social science and health related venues3 the following section reviews the included studies as follows firstly by giving an overview of the different text mining models and techniques used in the studies secondly by reviewing the characteristics of the various datasets which studies used and finally by discussing how studies evaluated their techniques and models and what the evaluation outcomes were this is followed by the discussion section which investigates the quality of the included studies offers lessons for researchers hoping to use text mining in their own work considers ethical concerns of using computational text mining in the study of ipv and examines the limitations of the current review models and techniques supervised techniques supervised techniques are those that are developed using a labelled dataset a dataset where each instance has been annotated with an outcome or category these existing annotations can be used as a benchmark to evaluate automatic text mining methods which makes supervised techniques a popular choice the majority of the included studies used some kind of supervised approach supervised techniques are also the basis for many ml models supervised ml models learn patterns from the labelled dataset to create an accurate model that can then be applied to new unseen data this is an extremely convenient way to extend classification tasks to a dataset that is much larger than could be annotated by hand there are two broad types of supervised ml models traditional and deep learning models traditional models such as support vector machines knearest neighbours lasso regression and decision trees iteratively try to find the best fit for the boundaries between one or more classes4 in a high dimensional spacea process commonly referred to as model training it is beyond the deep learning models were used as the main approach in six studies often using a traditional ml model as a comparator baseline deep learning models are very large networks of decision nodes known as neural networks which discover extremely complex multidimensional relationships between input and output convolutional neural networks and recurrent neural networks are two broad families of deep learning models long shortterm memory models are an extension of rnns often used for text classification tasks transformer based models such as bert are very large deep models that have already learnt a statistical representation of a language from huge amount of data for instance the original bert model was trained on a corpus of books and wikipedia entries of over 3 billion words since these pretrained models have a wide understanding of language already they are very adaptable to new tasks even those where there is little data available one included study used biobert an adaptation of the original bert model specifically suited for biomedical text mining tasks to identify instances of ipv in electronic health records deep learning models often achieve better results than traditional ml in complex tasks however their drawback is their high level of opacity which explains why they are frequently referred to as black boxes processes like feature ablation5 and dimensionality reduction6 which can be used to provide insight into the decisionmaking mechanisms of deep learning models nonetheless their results can still prove difficult to interpret can help to visualise and understand the most important factors in the decision the remaining two studies which used a supervised approach used rulebased models to automatically classify data using existing labels to test the accuracy of their rules handcrafted rulebased models have the advantage of being very transparent and efficient in comparison to ml models it is probably not a coincidence that the two studies which used this approach were both actively working with police forces who are likely to value transparency highly rulebased models performed very well in both studies accuracy 089 for identifying domestic violence in police reports this suggests that they should not be overlooked in favour of more modern but complex tools such as deep learning models unsupervised techniques six studies used unsupervised topic modelling or exploration as their primary approach here we use unsupervised to mean that a dataset has no labels or annotationsit is simply a collection of instances of raw text data unsupervised clustering four of the six studies used unsupervised machine learning models which analyse the latent structure of a text corpus to identify related clusters or topics in a process called topic modelling the most common topic modelling approach was latent dirichlet allocation used in three studies whilst the other study used structural topic modelling unsupervised exploratory approaches two studies used forms of exploratory data analysis as their primary method of investigating text data xu et al deployed a custom rulebased approach to sentiment analysis the latter describes the practice of analysing texts according to their positive or negative emotional tone sanchezmoya used linguistic inquiry and word count a computational tool for linguistic analysis this technique was also used in four other studies as an addition or an input into more complex models liwc is a dictionarybased method in that it counts the number of words in a text which belong to a series of dictionaries of words from particular linguistic categories dictionarybased methods are a simple but powerful instrument than can be very efficient and used across multiple studies once the hurdle of creating the initial dictionary has been passed other included studies created their own dictionaries of ipvrelated terms technologies matlab r and python were mentioned most often as technologies used in the studies reflecting their popularity for data science applications at least seven studies mentioned using python although many studies did not report any specific technology or programming language used datasets source most of the datasets used in the included studies were sourced from social media with the remainder coming from police forces health services litigation proceedings childrens social workers and a single study which directly recruited participants a summary of the datasets can be found in table 2 as expected from a search conducted in english most datasets are in english with the others being in chinese and dutch of those datasets sourced from a particular locality the us uk australia china and the netherlands are represented datasets are notably missing from other countries where english is widely spoken such as canada india pakistan south africa or nigeria around a quarter of the datasets describe abuse from the perspective of a 3 rd party reporting on the abuse conversely a small number describe abuse from footnote 6 this can help to visualise clusters or decision boundaries within a complex model the perspective of the victimsurvivor narrating their own experience the remaining datasets contain a mix of perspectives no datasets explore either text written from the perspective of a perpetrator or direct evidence of abuse in text size the size of the datasets varies considerably from 309 diary entries to over 1 million unique tweets the size of each text within a dataset also varies from a single tweet to entire litigation texts or case summaries of the datasets used for supervised ml tasks the average size was 73847 instances labelling process data labelling is often a time consuming and costly part of computational text mining which can discourage research from taking place in new areas in addition data labelling has a direct impact on the outcome of classification models since any bias or inaccuracies in the labelling process are likely to be picked up and replicated by the model for this reason accurate and transparent labelling is of paramount importance especially in sensitive research most datasets were labelled by supervised student reviewers however some datasets took advantage of existing properties of the data to create labels for example by using hashtags applied to tweets participant surveys administered alongside the collection of text data or police assigned labels collected during the incident reporting process such techniques can significantly reduce the time and cost burden for researchers and show the benefit of trying to find labeltype properties within existing data evaluation test and train set a test set is a portion of the dataset that is set aside during model development and subsequently used to evaluate the algorithms final performance on heldout data leaving part of the data out during model development helps avoid overfitting where models learn the statistical characteristics of a dataset too well in a way that means their results dont generalise to other data for small datasets a mechanism called kfold cross evaluation metrics all studies using supervised techniques were evaluated using a test set or kfold cv accuracy and f1 score were the most common metrics used to report how well the model performed at correctly categorising the texts accuracy refers to the overall percentage of instances which were correctly classified the f1 score is an alternative metric which balances precision and recall the f1 score is useful in situations where one class is much larger than another in this case accuracy scores can be unhelpfully biased towards the dominant class however comparison of models across different datasets using reported metrics should be done cautiously since much of the performance of a model depends on the data it was trained on some datasets simply have too much overlap between the characteristics of different classes making it difficult for a model to distinguish between them taking into account these comments on the limitations of metrics there is a very wide range of accuracies in the studies from 069 to 097 there was no single type of model or technique which performed well across the studies this reflects the variability of model tasks within the studies and demonstrates the importance of choosing the right model for the task in question unsupervised evaluation evaluation of the studies which used unsupervised approaches was much more variable reflecting the difficulties in evaluating unsupervised methods more broadly some unsupervised studies did not include any explicit evaluation of their technique or were using tools developed and tested in previous research other studies which used unsupervised topic modelling attempted to evaluate the optimal number of topics using methods such as rate of perplexity change discussion overall the n 22 studies showcase different models and techniques which can be used for ipv research as well as a variety of datasets and evaluation mechanisms the quality of studies varied considerably across the included worksfull results from the quality assessment are reported in table 3 this variation in quality reflects the innovative nature of this new interdisciplinary area there are not yet clear guidelines about how to use text mining methodologies in social science research in addition challenges arise when attempting to assess quality across such a heterogeneous set of studies for example some papers did not report any preprocessing steps since this is not useful in deep learning architectures other studies did not report demographic characteristics of their dataset due to ethical concerns about collecting personal identifiers the following section provides a more detailed discussion of the reviewed studies focusing on lessons learned for future research and issues of ethics and bias raised by using computational methods to research ipv lessons for future research examining aspects of the included studies offers lessons for future research particularly regarding the definition of violence open source code and overall study design these issues are discussed in more depth below definition of violence the definition of violence is mentioned in just over half the studies but many do not define ipv at all or very briefly reference a definition from another entity such as the who studies tend to discuss the definition of violence in most detail when examining the dataset labelling process for supervised techniques labelling data often highlights conflicting definitions between annotators and necessitates a more indepth description of what constitutes violence considering wider difficulties defining ipv within research future researchers should ensure they carefully describe and motivate the specific definition of ipv used in their work open source unfortunately no projects in the study reported that their code was open source the latter describes a trend in computer science to make code and data available freely online to facilitate collaborators wishing to build similar applications7 only two projects mentioned that their dataset would be made available upon request this is perhaps unsurprising when it comes to datasets given the sensitive nature of the data involved however future work could consider making source code available for other researchers to encourage knowledgesharing within this field study design in general future projects could consider a number of factors in study design firstly researchers may reflect where novel data can be sourced and whether data from multiple sources can be joinedup for additional insight secondly once a model has been developed researchers could consider deploying or testing it in an active serviceprovision environment for example research projects from poelmans et al and karystianis et al successfully worked with police forces to implement knowledgediscovery techniques within their daytoday operations and models revealed edge cases of abuse that the police had previously missed a project to detect sexual and physical domestic violence in electronic health records is now live on systems of an nhs trust in the uk moreover when designing methodologies researchers must consider more than just the choice of model rulebased traditional ml deep learning and unsupervised approaches all performed well in different included studies demonstrating that the context and appropriateness of a model is more important than its type the importance of initial data exploration and feature selection should not be ignored as these processes significantly increase the quality of outcomes for example subramani et al did not use the raw text but instead the outcome of liwc as the input to their ml model finally several studies highlighted the importance of mixed methods in their research and the significance of pairing quantitative methods with qualitative insights ethical concerns and bias ethics and context in general little attention was paid to ethics across the studies with only six publications including an explicit ethical discussion however a large number of studies do mention limitations of their work or discuss appropriate contexts for model use for example victor et al indicate that whilst their model performs well enough to be used for generating accurate descriptive statistics about domestic violence in a dataset of child welfare case summaries it would be inappropriate for use in decision making about individual cases they highlight the importance of qualitative analysis when using ml methods in an interdisciplinary context giving three examples of how qualitative analysis can enrich ml research in this domain understanding the datagenerating mechanism its context content and what inferences can reasonably be made understanding outliers and misclassifications in order to improve the model and applying insights from the model to help standardize the assessment or documentation of abuse bias allen et al comment on the lack of diversity in their sample which contained mostly white participants since nonwhite groups may be more likely to experience ipv this lack of diversity is especially troubling however very few studies commented on the demographic representativeness of their dataset and whether downstream applications built on their models risked bias towards certain groups future work given the recent emphasis within ml communities on ethical principles of accountability responsibility and transparency future work must take more of a focus on discussing the foundational ethical questions raised by this kind of research researchers might consider following ethical guidelines for ml such as those proposed by the association of internet researchers the consequences of ignoring such ethical discussions are significant at their worst ml models could contribute to the invalidation and minimisation of different experiences of abuse for example by classifying an instance as not abuse and leading to a victimsurvivor not receiving services or justice after having experienced great harm victimsurvivors of ipv have experienced situations in which they have had their opinions and experiences repeatedly invalidated belittled denied and manipulated researchers must be aware of the potential misuse of their research to extend this denial of the victimsurvivors reality models are representations of reality but they are not reality themselves and the way text mining research is conducted and presented should reflect this understanding limitations the current work is subject to several limitations firstly since the search strategy only included academic literature it is possible that important grey literature may have been missed secondly the search terms included other types of violence such as family violence and sexual violence aiming to capture all definitions of violence that may include ipv some of the reviewed studies may therefore have included incidents of nonpartner abuse in their data finally the quality assessment criteria used in the review were developed by combining multiple existing methods and were not thoroughly evaluated on different types of studies outside this review they should therefore not be used as a ranking mechanism or to draw concrete conclusions about the quality of individual studies conclusion twentytwo studies which used computational text mining to investigate ipv were identified through a systematic literature review of eight academic databases the studies included datasets from social media police forces a healthcare provider and social work and legal settings a variety of supervised and unsupervised text mining techniques were used on these datasets for tasks which included detecting the presence or absence of ipv as well as identifying abuse types extracting entities and events or understanding themes some studies commented on the ethics or realworld deployment of their findings but future research could include more indepth discussion of these additionally potential areas for future work may include sourcing datasets from other geographies and types of organisations explorations into subtypes of abuse plus the application of emerging textmining methods in the ipv field as they develop

purpose computational text mining methods are proposed as a useful methodological innovation in intimate partner violence ipv research text mining can offer researchers access to existing or new datasets sourced from social media or from ipvrelated organisations that would be too large to analyse manually this article aims to give an overview of current work applying text mining methodologies in the study of ipv as a starting point for researchers wanting to use such methods in their own work methods this article reports the results of a systematic review of academic research using computational text mining to research ipv a review protocol was developed according to prisma guidelines and a literature search of 8 databases was conducted identifying 22 unique studies that were included in the reviewthe included studies cover a wide range of methodologies and outcomes supervised and unsupervised approaches are represented including rulebased classification n 3 traditional machine learning n 8 deep learning n 6 and topic modelling n 4 methods datasets are mostly sourced from social media n 15 with other data being sourced from police forces n 3 health or social care providers n 3 or litigation texts n 1 evaluation methods mostly used a heldout labelled test set or kfold cross validation with accuracy and f1 metrics reported only a few studies commented on the ethics of computational ipv research conclusions text mining methodologies offer promising data collection and analysis techniques for ipv research future work in this space must consider ethical implications of computational approaches

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introduction interest in collecting especially in the natural sciences has recently arisen in the history and philosophy of science and other fields robert kohler has substantially published on the history of biology especially field science and collecting in america 1 he recently argued that histories of collecting have been more about collections rather than collecting per se that is being about the objects and not the means to amass them 2 the reason for the latter is based on kohler asserts that past scholarship has focused on meanings and semiotics of objects as against the means by which the objects were actually collected 2 kohler further argues that an implicit bias against collecting in science that it is in fact historically prescience or preparation for scientific research 2 nonetheless collecting and preservation of fauna has been a continued practice for the natural history museums of the world including australia the collecting of animals for preservation is a familiar description of one of the functions of a modern museum museum collecting of animals is a multimodal practice and is currently conducted with a number of objects in mind taxonomic collecting research or problembased collecting collecting for exhibition and public programs the latter aims are pursued via a number of means field collecting receipt of donations exchange and receipt of research collections despite what era that a scientist collector or institution may belong to the target of such acquisition for any collector of fauna is the specimen an individual representative of a species retained by the collector often in multiples anne larsen presents specimens as manageable pieces of the natural world for the eighteenth and nineteenth century naturalist that were however not natural but constructed by naturalists to answer their needs 3 the specimen remains the final object of collecting by museums and other institutions of natural heritage in the twentyfirst century the acquisition and retaining of a preserved specimen of an animal by institutions that are publicly identified with efforts to conserve australias fauna in their own habitat may appear initially contradictory 4 this paper explores how zoological collecting by museums in australia interacts with the museum policy and practice aiding conservation of biodiversity and environmental planning the australian museum will be the focus of my examination as it is the oldest museum in australia which has an array of accessible sources which allow for examination of animal collecting the australian museum was founded ca 1827 and found a permanent home at its current site in the mid 1850s it presently houses collections of over an estimated 16 million specimens and objects 5 similar to phillip rainbows discussion of the discovery marine biology collections 6 zoological collections like that of the australian museum are important in the history of zoology and the natural sciences rainbow identifies the discovery collections as spanning a time of transition during which the perceived use of such collections has changed 6 zoological collections like those of australia that were founded in the early period of european colonization are similar to the latter as they span the eras of encyclopaedic collecting through to the researchdriven concerns of our time this research is part of a larger study in pursuit of a doctoral thesis about the history and contemporary role of zoological collecting at the australian museum being completed by the current author at the university of sydney the australian museum portrays its contemporary collecting in the following manner on its website over the last two centuries the methods of and reasons for collecting in museums have changed significantly museum science and research is no longer the victorian model of encyclopaedic collections and cabinets of curiosities 7 if this is the case then what characterizes contemporary collecting in the museum context and what consequences does that have for their use as tools in conservation science museums as the agents of specimen collecting are equally familiar as places which promote awareness of biodiversity and conservation of species in their own environment in the current era as noted by anne larsen hollerbach regarding the early nineteenth century 8 and peter davis regarding the twentieth century 9 zoological collecting whether directly in the field by museum scientists or via exchange requires the capture removal and death and preservation of that animal at some stage of the collecting process on the surface ongoing collecting by museums of natural heritage in our era could quite possibly be in opposition to a commitment to conservation of faunal diversity a recent review of the commitment to conservation by collecting institutions in 2004 identified museums more with their dioramas and exhibits as a means of educating the public about conservation rather than recognizing the potential utility of specimens as conservation tools 10 a substantial literature exists that museum collections are useful and often crucial in detecting decline in populations of threatened species and other trends in biodiversity winston ponder of the australian museum describes faunal collections as huge databases that mostly have accumulated over a long period so they provide an historical perspective impossible to obtain with contemporary field surveys 11 further the australian governments national collaborative research infrastructure strategy considers biological collections key research infrastructure 12 australian fauna museums collecting as a tool of the biological scientist in fact came under criticism in the late 19th century as laboratory disciplines rose to represent top practice in academic departments and government funded institutions and the study of zoology moved from museums to universities according to colin finney it was by as early as the 1890s that biology dominated natural science in australian universities not natural history 13 which is historically allied with collecting of specimens and not the laboratory collecting by museums in australia did not halt however but continued and have built the vast collections available to scientists at the australian museum and elsewhere anderson and reeves argue that collecting by museums and other institutions in australia was affected by a milieu that consistently undervalued native flora and fauna 14 and that the purpose of museum collecting was to preserve a record of australian species but not to promote their conservation in the wild a view prevalent until the midtwentieth century 14 we see similar views represented by a key museum official in australia jw evans director of the australian museum 1954museum 1966museum wrote in 1963 in the journal museum on the functions of natural history museums the pace of the destruction of forest and scrub by fire bulldozer and plough is accelerating consequently an urgent problem faces museums in the south pacific is to endeavour to make as comprehensive collections as possible from threatened areas while there is yet time otherwise many animals particularly those confined to restricted environments may become extinct without leaving any trace of their former existence 15 we see just less than 30 years later that the concern of the australian museum with the loss of species has a different but substantial implication for example in the annual corporate report year ending 1991 before we can determine the impact that humans are having on other species that share this dry continent with us we need to understand the natural history of australia and our neighbouring countries and we need to know species still survive and where before we can talk sensibly about loss of biodiversity in this region of the globe 16 the latter treatment of loss of australian fauna differs from evans perspective in that museum activities are part of the effort to preserve biodiversity rather than as record makers of the fauna that has vanished or soon will within the museum model collecting of specimens are the means to gain knowledge of native fauna and to gauge what species are threatened rather than to make collections in the hope of cataloguing australias fauna as they become extinct linden gillbank in 1988 observed the change in direction over the decades of the twentieth century in australia and australasia imperially inspired herbarium and museum collections have become integral components of national and international conservationoriented biological projects 17 as presented by the australian museum itself on its website quoted above the reasons for collecting have changed substantially since the foundation of the museum if zoological collecting is now parts of crucial work in biodiversity conservation certain pressures are placed on how that collecting is conducted it is the need for a record of animal species and their populations and distribution past and present that is needed to be able to determine decline or change in native fauna which is what is termed in this paper the challenge of conservation for a collecting institution in the twentyfirst century within the museum model collecting of specimens for preservation is a core function of such institutions but conservation of biodiversity entails seeking the continuation of species in the wildcan museum collecting of animals and a conservation ethic coexist simultaneously zoological collecting now collecting of fauna by museums with its associations with old fashioned natural history approaches may have contributed to its perceived counterintuitive role in conservation programs in contemporary museums museum collections in australia may have the further unwarranted association of being dusty old and established decades or centuries ago with no contributions to be made now the museum as mausoleum stereotype 18 they are in fact constantly growing resources and have been continually added to by collectors throughout the 20th century and now for example the herpetology collection at the australian museum had the majority of its growth from collecting in the 1970s and after 19 robert kohler argues that the era currently is that of project collecting where specimens are gathered to solve a problem and the days of vast expeditions or intensive survey are now gone 1 even collectionbuilding activities conducted by the australian museum are tailored to address specific gaps in zoological collections rather than large scale amassing of specimens we see that attitude reflected in the collection development strategy for natural sciences collections in recent years collection managers have conducted collecting trips with the aim of developing the collections to complement acquisitions received from donations and research these collections have targeted geographic areas or habitats that have been poorly collected common species that are poorly represented in the collections and taxa that are required for current research projects by taxonomic experts at the am and other institutions 19 from the earliest annual reports of the australian museum collecting for the year was reported firstly listing acquisitions of the museum as a whole and then later for each department the later 1990s generally saw a reduction of such reporting to a single number to represent acquisitions for the entire museum while collecting is ongoing in contemporary operations at the australian museum its place in the public reporting of the institution has reduced it is quite rare that collecting per se is identified as of central concern in the functioning of the museum in the report for 19861987 it is stated that acquisition and preservation of collections are central to the achievement of the mission 22 but similar statements are quite rare otherwise throughout the 1990s maintenance and improvement of collections is a far more common phrase in annual reports and is broader than collecting specifically while it may not be presented in a plain numerical manner animal collecting is still presented in the annual reports of the museum but are more often placed in context with the scientific projects supporting biodiversity and conservation research collecting is perhaps less concerned with the sheer amassing of specimens but more with the reason that collecting was conducted or use it will be put to in the future in the 20072008 annual report samples collected on 12day field trip to tathra area on the new south wales south coast will provide additional information on the biota and diversity of australian marine environments 20 given that museums in australia have been collecting animals in an ongoing fashion as part of its function throughout the last century and now we must look to how such collecting is reconciled with a twentieth and twentyfirst century animal conservation ethic which is essentially concerned with the continuation of species in their own environments conservation in the australian museum the 21st century visitor to an institution such as the australian museum would be quite sure of the role that the museum plays in biological research conservation and ecology the museum has and does present itself as an agency which influences debate on environmental issues and via its vast collections is in a prominent place to do so in australian society it is specific about its position today in the science research strategy museum research is directly relevant to several of the nsw governments statewide targets for natural resource management under the state plan in particular those relating to biodiversity and water 23 the museum further identifies with the nsw biodiversity strategy 24 as a plan concerned with loss of flora and fauna scientific interest and concern for issues the environment and conservation emerged formally with the establishment of the department environmental studies in 1968 the departments of vertebrate and invertebrate terrestrial ecology grew out of environmental studies in 1978 currently departments of the museum are split into research divisions for marine and terrestrial biota and natural science collections with a department for arachnology entomology herpetology icthyology malacology mammology marine invertebrates mineralogy ornithology and paeleontology 25 conservation research is carried across many of the departments and collections the australian museum certainly engages in biodiversity and environmental surveys that do not involve collecting exclusively as they have for the past 20 years for example current radio tracking and banding of the white ibis which is moving out of its natural habitat in the murray darling basin and into more urban areas 26 the challenge of conservation as noted by lyn barber in the era postdarwin zoologists could no longer conceive of and collect the entirety of the animal world 27 as biodiversity is in flux the latter is one of the contemporary arguments for continued collecting in academic correspondence kevin winker likens faunal collections to functional biological libraries but asks the worth of a library that stops acquiring any books 28 henri oullet past chief of vertebrate zoology at the national museum of natural sciences in ottawa argues that while the collecting of specimens appears contradictory to conservation concerns it is often only from specimens that we can gain the answers to conservation problems 4 to be able to detect a decline in a species there must be a prior historical record of the population and distribution of that species to enable biologists to observe any change it is usually impossible to reconstruct such a record without a physical collection 29 in the twentyfirst century biological collecting must be representative if it is to be of utility to biologists the australian museum in its recent natural sciences collection development strategy 20072012 requires that collecting be mindful of an array of representative criteria geographic representation temporal representation taxonomic representation specimen representation 19 collecting must therefore be ongoing over time if it is to be comprehensive and useful in conservation planning and research biological collections must have temporal representation in addressing temporal representation the strategy identifies that a collection with good temporal representation allows users to map the spatial movements and presence of animals over time temporal data is important for tracing the introduction of invasive species the decline of threatened and endangered species and monitoring environmental change this requires a time series of identifiable specimens in the collection 19 we see similar issues addressed elsewhere as in the australian museum science research strategy where it is assumed to be fundamental to the museums research is the building of collections through space and time 23 similar concepts are also included in the recent 20082013 corporate strategic plan 30 the australian museum responses to the challenge of conservation the australian museum has put forward a number of other policy statements and strategies where they bring together collecting and conservation concerns on their own website they identify the overall usefulness of biological collections museum collections reduce the need for scientists to collect new specimens or objects when conducting research this is especially important when research is focused on endangered or vulnerable species the collections are of increasing importance in a changing world where our natural environments are being rapidly degraded 31 by creating and building on animal collections museums provide a centralized record of fauna and does not require further impact on biological communities from collecting by individual scientists or groups but to achieve such a useful centralized record museums must collect animal specimens in an ongoing manner the australian museum advises that collecting must be undertaken in such a manner and involving such numbers as to have no deleterious effects on the survival of local or regional biota or communities nor have negative impacts on other societies or cultures 32 later in the collection management policy they identify that coverage of the collections must be improved by exchange with other institutions or by receipt of collections from research projects in order to minimize the impact of collecting activities on existing biotic communities every effort will be made to increase the quantity quality and geographic coverage of our collections by exchange with other scientific institutions or by acquiring collections resulting from research or monitoring programs in other organizations 32 the deposit of voucher specimens following the completion of a research survey or other project is regularly identified in the related literature as an important part of any biodiversity survey as defined by jt huber they are the supporting evidence for the occurrence of a species at a particular time and place when doubt exists as to the identity of a species voucher specimens permit reexamination to check or correct previous identifications 33 pat hutchings from the australian museum notes that specimens collected in a survey of port of sydney for marine pests can be used as baseline for future studies and such specimens are also available to taxonomists for revision of marine taxa that can in turn inform future surveys of potential new pest species 34 the receipt of voucher specimens from surveys of australian and other fauna are a means for museums to grow their zoological collections from collecting activities that directly serve conservation research and planning as suggested in the australian museums natural science collection development strategy specimens received from museum biological research projects may provide spatial or other representation that is outside the scope of the museums traditional taxonomic collecting 19 the museum directly prioritizes acquisition of those specimens which are needed to solve urgent problems in conservation of animals and other issues priority will be given to acquisitions which are required to solve urgent problems such as issues relating to the environment conservation of animals systematics or to contribute to an improved understanding of critical cultural issues and consistent with the australian museum science research strategy 32 the policy and strategy recommendations of the australian museum divide into two categories those that seek to reduce the impact of ongoing collecting on existing biota and those that specifically employ collecting to address conservation needs to provide appropriate representation in time and space and to be useful as a benchmark for future research and conservation planning ongoing collection must occur relying only on receipts from specific research projects or only private and institutional donations and exchanges will most likely not provide the representative coverage required the challenge of conservation for australian museums is to balance collecting conducted in both modes conclusions conservation has been a concern of the australian museum and other institutions in australian since the second half of the twentieth century zoological collecting is perceived differently in the current era than in the era of foundation of australias museums as a proposed means of preventing loss of biodiversity rather than merely recording it it provides the historical record of faunal biodiversity via ongoing collecting an endeavor which must occur virtually indefinitely as biodiversity is constantly changing under ecological and humanmade pressures also they collect animal specimens to address specific or urgent issues of conservation in the immediate environment such collecting occurs over a shortterm time scale but also further builds collections within the taxa of concern collecting of animals by museums in the current era needs to be wary of the tension between the need for ongoing collecting to maintain representativeness and the need to engage such collecting in a manner that does not harm the fauna which are of concern it is an ongoing challenge for the australian museum in its policy and practice to mediate such a tension in its ongoing role as a collecting institution in australia zoological collecting has continued as a practice in the conduct of biological science within the museum model despite pressures such as those from changing perspectives as to what represented modern biology in the late nineteenth and early twentieth century due to such continuation of collecting there exist historical records of faunal diversity that allow for comparison with contemporary surveys the specimens from which can also be added to collections in a cooperative relationship collecting and conservation may appear to be contradictory given that zoological collecting in its traditional sense involves the acquisition and lodging of a preserved rather than live specimen in a collection out of its habitat in the museum model however collecting of animals provides the permanent record for biologists of the future to examine the state of australian biodiversity

it is a core task of collecting institutions like museums to take examples of animals and preserve them as specimens in collections in the twentyfirst century museums are equally the places where research is conducted and education is promoted in the service of conservation of animals in an era of the decline of biodiversity in this paper the balance of cooperation between collecting of animals by museums and the promotion and scientific pursuit of conservation of fauna in those museums is considered as a challenge to museum science it is considered in the context of australias oldest museum and its policy and practice in the current century

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introduction there are currently at least 700000 informal carers for people with dementia in britain and caregivers from black asian and minority ethnic communities are substantially more likely to provide family care than their white british counterparts 1 most bame communities in the uk suffer from reduced access to and uptake of a range of health and social care services intended to support people with dementia and their carers as noted in a series of studies 2 3 4 5 6 7 among communities of people of south asian origin there is a pattern of late diagnosis and low uptake of support services affecting both those living with dementia and their carers the research focus in terms of ethnic inequalities in access to dementia care is on culture and any reference to religious influences tends to be treated as one aspect of ethnic difference however for most communities of south asian origin in the uk including those of british pakistani origin religious beliefs practices and organisations have an important influence both on their experience and on their response to community challenges for this reason these religious influences deserve research in their own right the responses of christian communities and individuals to dementia have received some attention as have those of sikhs however much less is known of the role of religious influences on dementia care in muslim communities the purpose of this paper is therefore to explore the significance and main features of the religious dimension of the carer experience in the case of a group that has tended to be hard to reach and resistant to such research muslims of british pakistani origin the aim is to provide initial insights into the role of religious beliefs practices and community networks on dementia care and identify the ways in which the muslim religion influences the understanding of response to and access to care for people living with dementia in this community the findings will prepare the way for a larger scale study to inform future strategies for targeted support among muslim communities of british pakistani origin background among communities of south asian origin there has been a significant amount of research pointing to a complex of reasons for late and reluctant access to dementia services including family expectations ignorance of dementia economic concerns cultural values and culturally inappropriate services eg 8 9 10 11 12 13 14 15 16 in addition there is some evidence of differences in the response of service providers themselves when presented with a service user from a bame community including those of south asian origin 17 these findings have led to calls for more culturally sensitive services 18 s and even for separate services for minority ethnic groups 19 some more recent research has tended to focus on how cultural values influence dementia helpseeking in particular subgroups such as the british bangladeshi community in east london 20 however despite the fact that many communities of south asian origin show high levels of religious adherence compared to the white british population much less work has been done on how religious norms beliefs and practices in turn influence stabilise and encode those cultural values or how understanding of the religious dimension may inform future attempts to address inequalities of care in minority groups 21 at the level of belief and practice and their significance for dementia generally there is a growing body of literature relating to christianity 22 23 24 25 and there are a few highquality studies relating to the sikh community 26 27 28 29 extending the search outside the uk there are two studies of jewish communities from israel and the usa 3031 and a study on buddhist belief and practice among carers of people with dementia in the usa 32 there is a gap in the research base concerning muslim beliefs and practice in relation to dementia care there is a little literature from south africa 3334 a few papers from pakistan 3536 and a perceptive study of arab muslim caregivers in the middle east 37 finally there are two recent attempts to understand dementia from a specifically islamic perspective 3839 which indicate the possibility of an international dialogue emerging in the foreseeable future in the uk context muslims of south asian origin represent the second largest religious grouping after white british christians and one in which the number of people living at home with dementia is predicted to rise rapidly 2 nevertheless in this context only three papers have been published exploring the beliefs of muslim family carers of bangladeshi origin 204041 along with one that identifies changes in their understanding of dementia in response to the rise of revivalist muslim beliefs 42 one may infer a similar relationship between religion and caring in the community of muslims of british pakistani origin which predominates in the midlands and north of england but no research has yet been conducted in this community furthermore there are reported differences between the cultural expressions of islam prevailing in bangladeshi and pakistani immigrant communities and between different communities of pakistani origin 4344 which raises questions of the transferability of these findings finally at 2 of the uk population the british pakistani community is substantially larger than the british bangladeshi population and after the british indian community the second largest nonwhite community in the uk 45 it therefore merits further research in order to establish how muslim belief and practice is supporting or impeding the endeavours to ensure appropriate dementia care for this underprovided group materials and methods methods a qualitative scoping methodology was employed as the most appropriate method to fulfil the study purpose scoping studies are a widely used method used to gain an overview of a particular topic area with the aim of informing future research policy and practice the study used semi structured interviews to explore participants views practices and experiences in caring for a relative with dementia with particular focus on the religious aspects of these views practices and experiences ethical approval was obtained from staffordshire university research ethics committee data collection an interview schedule was developed by the team to guide the interview process based on the aims of the study as described earlier interviews took place in english between 13 july and 10 september 2021 because data collection took place under covid19 restrictions participants were interviewed online or via the telephone and an audio recording was made which was uploaded to the otterai software platform recordings of interviews were autotranscribed using the otterai platform and then manually checked for transcribing errors by each of the four researchers separately words that were difficult to understand on the recording or were in a language other than english were discussed by the team and a consensus interpretation was agreed the agreed transcripts were then used for the thematic analysis data analysis thematic analysis was undertaken using the sixstage approach articulated by braun and clarke 4647 the first stage of analysis was conducted in consultation one member of the team produced a spreadsheet of extracts from each transcript that had apparent reference to religious beliefs practice or community involvement and this was then revised in team discussion the next steps were undertaken by each of the four researchers independently individual code lists with initial themes arising from them were then compared and the remainder of the process was undertaken collectively through a process of iterative discussion and revision reflexivity all interviews were conducted by a single member of the research team who was a female muslim of british pakistani origin and was therefore likely to be more acceptable to the interviewees from both a linguistic and cultural point of view the research team encompassed ethnic religious and gender diversity which enabled different perspectives to be brought to the planning and analysis stages of the project and comprised of four members a female british pakistani muslim a female muslim revert of greek origin brought up in different religions and then returns to islam a female black british christian of caribbean origin and a male white british christian all are based at a university in the west midlands region of the uk results initial coding and the production of proposed themes was conducted independently by the four authors collation of the proposed themes and discussion of the underlying evidential base in the coding process led to an agreed structure of nine themes classifiable into three categories which with hindsight corresponded to the three levels of social organisation shaping the experience of family carers these themes are discussed in turn below carers practiced their religion to different degrees but all referred to their religion as important to them and to the person living with dementia most of them spoke of the religious injunction to care for parents as providing them with motivation and an expectation they sought to fulfil so yes i would say religion is the main thing is it teaches us to you know look after our elders and all the values that we get are from religion my you know most important thing is religion p3 i think as muslims its very clear that we look after our elders and we should provide care and support and look for our elders and know the quran says dont say uff to your parents to your elders theres a push that we take that responsibility we as i said that we provide a loving caring environment we look after them and support them p7 for me is very very important very important i think everything i do is is around my religion so being kind to my neighbors doing my prayers fasting celebrating spending time with my family being patient with the elders and the link to the younger p2 providing strength and support in caring in addition a number referred to their practices of faith andor prayer as sources of strength patience and release from anxiety so enabling them to fulfil their family dutiesresponsibilities this is broadly in line with a number of studies showing personal religious and spiritual practice as reducing caregiver burden 48 you find solace in your faith and your religion and i definitely did find peace in it and i suppose you know when you read certain verses when especially the one particularly one from the hadith after much hardship comes peace really resonated with me because we went through my mom went through much hardship and we did as well alhamdulillah praise be to god you know you come out a better person p6 i think religion plays a big role in your thinking around some coping strategies that you know what what helps you what makes you not lose your temper i think its natural human to get angry at times when you get frustrated caring is really difficult can be quite lonely isolating p7 i didnt think about financial implications how im going to sustain myself and pay the bills but i left it to allahs will allah wants from me he will do the best for me and my family p5 furthermore several interviewees spoke of their religious practice as building their strength or supporting the character traits that helped them to care faithfully so in islam we are always its wise to be patient finally some interviewees spoke of the hope of a divine reward as a source of support in fulfilling their family duties its a bit logically thinking its just its like we do we do we do an activity to gain from it and as muslims we dont always get it from in this world and well get it from the next one so its a bit of like when i look after my mom its like an opportunity thats been given to me to gain rewards so yeah definitely p2 so it has made me realize that you know when you learn about islam more you learn that you know if im caring for her in future something good is gonna come to me you know gonna come to me p3 that was one of the reasons why i wanted to look after as well and it was it was also in the hope of as im a firm believer of you know being rewarded for that if not in this life then you know the next p5 413 influenced by the experience of caring since the practice of islam stresses faithful observance of particular times and seasonsfor daily prayers and for the annual fast of ramadanwe anticipated that the demands of caring for somebody living with dementia would prove disruptive for religious practice there was some evidence for this so it can have a massive impact on religious practice i can imagine my moms sort of in between me doing my prayer depending how embedded it is and how it impacts their memory that they will try and disturb me were halfway to reading my prayer p2 id probably say that its difficult you know sometimes when like you know its the time to pray and you have to provide like you have to put them on priority so if they are hungry have to make them food first so i wouldnt say that it has affected a lot but sometimes it can be p3 however some carers took a pragmatic approach regarding their expectations both for the person living with dementia and for themselves i think they just managed it ramadan as you would normally in a family if she got up she got up you know theres no theres no push she was old as well theres no push for her to have to get up to fast or anything so if she did wake up you know she could be part of the family she didnt wake up thats fine let her sleep and it was the same during the day when it was time for her to eat we would make her some food but we didnt think oh well should she try fasting or anything because you know it wasnt obligatory for her and the family just continued as normal p7 sometimes i would be late with prayers because you know sometimes an emergency would happen that could be mum had an accident she would have an incontinence accident the priority then is to make sure mums okay so i know it may not sound you know acceptable or whatever but at that time when you when you in that moment and you are caring for someone dependent everything else doesnt matter p5 in addition the religious practice or perspective of the person living with dementia sometimes proved to positively support the religiosity of the carers and i remember it was ramadan at the time and i was really struggling and i remember nanny was saying to remember nanny was saying that you dont need to worry about that youre forgiven because youre youre caring for somebody who cant care for themselves as somebody whos got has got no body really kind of you know really kind of molded the way i became as a person in terms of my religion as well they brought me closer definitely p5 yeah i mean my mom would do read namaaz prayers always read namaaz always having tasbi prayer rope in her hand at the end of her life we would have talawat recitation of the quran on a cd or something like that all the time so religion plays a massive part so i wouldnt say we it probably strengthened it my faith p5 to summarise the findings in this section the analysis indicated that the british pakistani muslim carers in our sample attributed many positive elements of the experience of caring to their religious beliefs and practices these provided motivation to accept the caring task and incentives values and practices that support the caring task these findings suggest that support for british muslim pakistani carers of family members living with dementia will yield better fruit if it works with their religious beliefs and practices than if it ignores them they raise the question of how carers faith is worked out in practice in relation to the wider muslim community of which they are a part muslim community response to dementia in contrast to the positive and flexible account of individual practice carers generally reported their communities as rigid in their expectations of carers and their duty as faithful muslims at the root of this several respondents cited a confusion between the demands of culture and religion as their reason for determining how dementia is perceived within the muslim community culturereligion distinction as has been frequently noted in the religious studies literature the distinction between cultural and religious beliefs and practices is not clearly perceived or understood in stable communities with a single dominant religion and reflection on the difference between religion and its cultural expression may only take place when encountering a different culture 49 this distinction will therefore be more dominant in the younger generation and distinguish their approach from their elders 50 in practice interviewees tended to weave concepts of culture and religion together to varying degrees thus for some the two appear almost interchangeable its built within us whether its our social values its our cultural values if its our ethical kind of like values they often come out of there and so whilst you might not overtly say that im doing this because im a muslim or im doing it because god says so i think you you do that without thinking because your faith is important to you you know that your faith is going to look after them p7 religious is guide you to take care of your parents and also that in our culture this is encouraging we must look up to our parents at that old age p4 however some were critical of this confusion as overlooking the needs of the carers themselves as pakistani heritage family its almost like you dont challenge your elders and your elders are able to get away with it so if you for example when one couldnt manage for mum the carer said that for me as a daughter in law as a muslim as a pakistani inaudible my job is to just get on with it and try and do the best that i can to support her rather than try to find a solution out of the house they expect you to care and provide that care because thats your duty theyre not interested in how you are coping p7 but culturally theres an expectation in the community what will the community say so what would your neighbour say that man there is abandoning his parents because people conflate and weve said this before people conflate nursing accommodation a care home and a nursing home all together but theyre very very different p5 the cultural expectations function as a deterrent to family carers seeking outside help and in particular external residential care as will be further discussed below islamic teaching need not be expressed in this way awareness and understanding of dementia previous studies have drawn attention to the relatively low levels of awareness knowledge and understanding of dementia in communities of south asian origin living in the uk and this state of affairs was borne out in the present study by all of the respondents other people are not aware of some of these illnesses my father was diagnosed in 1999 the majority of the people were not aware of this illness so the people people didnt understand even when it was explained them p4 however some awareness and understanding of dementia is starting to emerge in the community and also as im learning more about the condition about especially with faith we talked about this before and the fact that you know the imam talked about verses from the quran and i was aware of that link directly to the fact that dementia is a disease of the brain and this is something that was revealed 1400 years ago only science is only now realizing what this is so that to me is really powerful and i use that a lot when i speak with other carers p6 community as a barrier or potential source of support understandably misunderstanding and misdiagnosis are a feature of the communitys lack of knowledge of dementia and lead to barriers to the provision of support by the wider british pakistani muslim community clearly a key issue here is that the lack of knowledge of dementia in the community means it is not engaged with the issues or alert to the need to offer support as part of their faith i think theres not a lot that can be said on that because there isnt a lot of awareness of dementia in the community so without without the words people dont appreciate or realize the difficulties that you might be going through what might term as the burden of care people people dont necessarily see that they expect you to care and provide that care because thats your duty not interested in how youre coping theyre not interested in whether youre caring at home or youre trying to you know the words will be like making excuses not to care p7 i think muslim community needs a bit of more education on this all because it is quite new subject for them as well so now like you know we feel a bit of support from them but we thought it was hard you know explaining it to everyone okay and then they they take time to understand okay and then they show their support to us but not not that much p3 we go to masjids mosques and listen to the inaudible but we dont hear about how when we say we should visit someone when theyre ill make sure theyre okay how often do we do that as muslims do we are we to judge other people where does that where does what does our faith our imam our religion tell us about that p5 as a consequence carers themselves may choose to keep their family members dementia secret its not something that some people dont even know what it is or what the you know how it unfolds or you know the different symptoms if you like you know some people dont even know know these things so the answer to your question is that i dont we didnt have any support from the asian community because they didnt know you know we never told them okay p5 response of religious leadership if the lack of support from the wider muslim community of british pakistani origin is at least partly due to the need for more education and direction in their response to dementia it follows that appropriate leadership may provide the answer here the picture is distinctly mixed in the main community leaders did not engage with the subject no theres no conversations with religious or family leaders i think again people take it for granted that you know as a muslim thats my duty so you wouldnt really need to go to speak to somebody i came to avoid using the word like leaders because leaders tend to be selfinterested often their opinions their perspective they do not necessarily know how youre doing and how youre coping p7 you know so my my caring from mum didnt weaken my islam but my faith in muslims certain people who are meant to be important gatekeepers disappoint me to be honest with you because i feel they could do more but they dont p5 however there were two interviewees who reported that their imam was addressing dementia in the community more directly i spoke with mufti an imam because he happens to be the next door neighbour so she could hear my mom being aggressive and violent the mufti said name if you guys get unwell who is going to care for your mum so you are permitted to seek expert help support p5 we see more and more muslim elderly living on their own the children move away because of economic reasons or whatever but the imams ive spoken with said that if it gets to the point where you are struggling as carers and family carers then thats permissible seeking outside help the imam mentioned this in his khutbah sermon last friday actually and he used the word dementia directly which was groundbreaking i think for a mufti to do this and in the khutbah said that you are permitted to seek outside help according to islam p5 this gives hope that over time increasing engagement by imams will lead to an increased level of awareness and understanding in the community and a more nuanced understanding of a faithful islamic response to summarise the findings in this section at present it seems that the wider muslim community of british pakistani origin is not engaging with questions of dementia or providing much active support to assist carers of family members living well with it the underlying causes appear to be first a failure to separate the demands of islam from cultural assumptions so that the needs of carers are not taken into account and may even be suppressed and secondly that the wider lack of awareness and understanding of dementia in the community can lead to apathy stigma and secrecy most often imams and community leaders shared the same attitudes as the rest of the community but in a few notable cases imams showed a good degree of awareness and were able to provide teaching on the subject of dementia that had the potential to change attitudes and be a source of support this opens the possibility of enlisting the wider community in the support of people living with dementia and their carers by a programme of teaching and education barriers to accessing services as noted in the introduction people living with dementia from communities of south asian origin living in britain tend to access dementia support services more rarely than their white british counterparts and relatively late in the disease trajectory some contributing factors have already been identified in the low levels of overall knowledge and understanding of dementia within the community and the high religiocultural value given to care at home provided by a family member however additional barriers to access can be identified in the attitudes of muslim carers of british pakistani origin to these services and the character of the services being offered to them knowledge attitudes and understanding of the community about service provision as mentioned there is cultural pressure on carers not to seek support from outside the family this disincentive is compounded by ignorance of and anxiety about the available services participants described themselves as relatively ignorant of the services available to support their efforts to care for the family member living with dementia they also expressed some concern that the help offered would be religiously and culturally inappropriate i wasnt aware of any organizations that could help gp is always the first people that we go to or we go to an imam or a faith leader as muslims what happened was she was assigned to a partner gp p5 i dont think theres anything out there that is that islamically that theres a lot in the sense of materials to read to help you with building your faith but actually anything practical theres nothing there theres no group that i could go and theyre all muslim and who would probably understand theres nowhere where you can go and have that you could offload or build that support network where you could someone sharing that same experience so it reduces the isolation p2 432 perceived attitudes and understanding of service providers towards the communityspecific dementia care concerns and needs if there is hesitancy from carers participants also reported that it can be difficult to find service providers that can meet cultural and religious needs around dementia care and we couldnt find anywhere in the locality that would meet our cultural linguistic religious and dietary needs so we found one eventually p5 in addition service providers themselves may assume that the majority of care will be provided by family members so if you for example when one couldnt manage for mum the carer said that for me as a daughter in law as a muslim as a pakistani inaudible my job is to just get on with it and try and do the best that i can to support her rather than try to find a solution out of the house p7 discussion and conclusions this study identified factors affecting access to dementia care that are consistent with the existing literature on communities of south asian origin generally however it has also identified factors that are distinct to the religious beliefs and practices of the muslim individuals and how these influence dementia care positively andor negatively the data should be interpreted with caution because of the limitations of the study the sample size was unavoidably small and the methodology of interviews by remote means may have limited the freedom with which participants were able to explore their thoughts and feelings when compared with facetoface interviewing the use of a single interview conducted under covid19 restrictions without insight into the social or familial context provides a thin description of the current state of affairs that needs to be enriched with a thicker extended and ethnographically informed programme of research 51 in addition the decision to interview only in english and by remote means may have restricted our access to carers who were older more recently arrived in the uk or less integrated into society outside the british pakistani community it is noteworthy that only one participant was caring for a spouse and none were over the age of 60 despite these limitations this initial study yielded some suggestive insights in general we found that family carers of people living with dementia in this sample group do draw strength and support from their faith at an individual level it would be easy to overinterpret the data from a rather small sample but reviewing the interview transcripts it is possible to discern how this may be taking place structured religious practices structure the interviewees lives and social relations we anticipated that in turn the burden of caring would interfere with and possibly undermine the religious practice of the carers but this was not uniformly the case on the contrary practical difficulties were approached pragmatically and several interviewees spoke of the encouragement and support they received from the family member living with dementia this positive picture did not extend to relations with the wider muslim community where respondents talked of confusion between properly religious and simply cultural expectations of a lack of awareness and understanding of dementia leading to a negative experience of both community and leadership furthermore carers may be discouraged from seeking support from service providers because of the cultural expectation of familybased care concerns that the religious and cultural needs of the person living with dementia will not be understood or respected and poorly informed responses from service providers themselves there were however signs of positive change one key finding that emerged clearly from this research is that most of these difficulties are not entrenched and structural ones but arise from unpreparedness or ignorance that can be relatively easily addressed thus some carers spoke of knowing nothing about dementia at first but quickly learning others were making pragmatic and constructive adjustments to fulfilling their islamic duty for the family member living with dementia involving critical distinctions between traditional cultural expectations and religious requirements within the cultural context of the uk at the community level there was evidence that dementia awareness among leaders can make a difference and be a source of support for example in two cases religious leaders were found to be addressing the deficit of understanding of dementia within the community and providing advice on how to respond in an islamic way one imams contribution probably proved decisive in helping one family to accept that the best way to care for their parent was to ask professionals to do it and some service providers had clearly learned how to engage with the family in a responsive manner these findings suggest that there is scope to improve the service to muslims of british pakistani origin living with dementia and their family carers by betterinformed engagement with this community at the level of their beliefs values and practices carefully planned engaged welltargeted training of both carers and service providers could yield significant improvements in the pattern of access to support services from this community consequently to increase engagement between service providers and carers there is potential for development on three fronts first engagement with the community itself where the active debate on the distinction between religious expectations and cultural ones suggests there is room for development and change with the help of an engaged and sensitive programme of education by working with sympathetic religious leaders secondly there has been little thought or study devoted to the religious lives of carers which they all claimed as a source of motivation strength and support although the lazy notion that they look after their own has been used as an excuse not to engage with carers it remains the case that this is the context for most care taking the religious dimension of carers role seriously may help to establish lines of support that will enable them to fulfil their role more effectively and for longer whilst their own needs as carers are also not neglected finally service providers need to engage muslim communities both to learn from them where the religiously based anxieties and concerns lie and to reassure them of the commitment to religiously sensitive support author contributions conceptualisation pk dl nn at methodology pk dl nn at formal analysis pk dl nn at investigation nn data curation pk writingoriginal draft preparation pk writingreview and editing pk dl nn at supervision pk project administration pk funding acquisition pk all authors have read and agreed to the published version of the manuscript funding this study was supported with a research excellence grant from staffordshire university school of health sciences and wellbeing institutional review board statement the study was conducted in accordance with the declaration of helsinki and approved by the ethics committee of staffordshire university for studies involving humans data availability statement transcripts of the interviews can be examined by application to the corresponding author informed consent statement informed consent was obtained from all subjects involved in the study written informed consent has been obtained from the patients to publish this paper

this paper reports on a study that begins to address the paucity of research around the religious motivations of muslim carers of family members with dementia seven carers were recruited for interviews from the british pakistani muslim community concentrated in the midlands and north of england interview transcripts were analysed thematically using an iterative collaborative methodology the findings suggested that the muslim faith plays a pivotal role as a support mechanism for individual carers and their families but the wider faith community and its leaders did not typically offer support and could impede access to external care this was a result of cultural pressure and lack of awareness both among religious leaders and the community as a whole the study concluded that the inequality in access to dementia services may be constructively addressed if service providers engage with these faith concerns in the community and religious leaders to meet the needs of muslims of british pakistani origin

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introduction labour migration from myanmar to thailand began in the middle to the late 1980s because of the unstable political and economic situations 1 3 a survey among myanmar migrants stated that more than half of the migrants are married with 90 staying with their married partners in thailand most are of reproductive age with the highest number in the age group of 2534 years and the second highest in the age group of 1524 years 3 family planning is one of the main components of reproductive health family planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births it is achieved through the use of contraceptive methods and the treatment of involuntary infertility 4 in myanmar most pao people live in rural areas for agriculturebased livelihoods the public health sector in myanmar cannot fulfil the basic essential package of health services for the entire population 5 which causes fp service gaps for people living in rural areas including pao community due to resource limitations in promoting fp knowledge in the country of origin fp knowledge inadequacy persists when they migrate meanwhile the demand for fp methods has increased because of the transition from pronatal practices to a preference for downsizing the number of children owing to the unstable nature of migrant living and financial insecurity interactive discussions with healthcare providers regarding the informed choice of fp methods are hindered for pao migrants by language barriers in the land to which they migrated an informed choice of contraceptive is critical for successful fp informed decisionmaking means that users are provided with information on different fp methods with pros and cons health advantages risks and side effects enabling them to compare various methods 6 without a thorough understanding of fp methods users cannot make an informed choice among methods which could result in contraceptive discontinuation 7 followed by the risk of an unintended pregnancy and unsafe abortion 8 as such the pao migrant population in thailand is vulnerable as they come from an environment with limited resources for fp knowledge and services and face challenges in the host country to access quality fp counselling for informed choice when fp information and services are not accessible due to limited resources language and cultural barriers it could lead to increased numbers of unintended pregnancies and a sense of powerlessness over fp among the migrant population 9 who defines women with unmet needs for fp as … those who are fecund and sexually active but are not using any method of contraception and report not wanting any more children or wanting to delay the next child the concept of unmet need points to the gap between womens reproductive intentions and their contraceptive behaviour 10 the unmet needs for fp of myanmar migrant women living together with their partners in bangkok is moderately high with one in every six women having unmet needs for fp 11 low fp knowledge contributes threefold to an increased potential of unmet needs compared to adequate knowledge in women 11 approximately 48 of pregnancies in lowand middleincome countries are unintended and 61 of the unintended pregnancies terminated in abortion in 20152019 globally 12 further analysis of the contraceptive utilisation rate of myanmar migrants reveals that the increased contraceptive utilization rate does not positively correlate with the knowledge adequacy of fp methods thawu found that despite an 857 contraceptive prevalence among myanmar migrant women in samutsakhon province only 54 of participants knew all choices of contraception 13 soe et al reported 801 contraceptive prevalence in their study group of myanmar migrant women in phangnga province whereas only 74 had a high level of knowledge about contraception 14 the authors concluded that there is a gap between knowledge and utilisation although migrant women are using contraception many do not have correct and adequate knowledge for effective utilisation to achieve the desired outcome 14 several quantitative studies have focused on contraceptive prevalence rates the influencing factors of contraceptive utilisation unmet needs of fp and knowledge attitude and practice of fp among myanmar migrant women 11131415 however few qualitative studies have explored the information behaviour of myanmar migrant population related to fp there are three main myanmar ethnic migrant groups in chiang mai the burmese shan and pao among them burmese and shan have larger populations than pao with a prominent presence and are well known for their ethnically related public places such as wat sai mun the chin haw market and wat pa pao by contrast the presence of pao migrants in chiang mai is barely noticeable with a smaller population in terms of language burmese is a mainstream language among myanmar migrants the shan language has mutual intelligibility with thai hence shan migrants can understand and speak thai faster than other myanmar ethnic groups burmese and shan have more advantages in seeking information owing to the broader applicability of their dialects whereas paos unique language and smaller community networks restrict their help seeking behaviour the same ethnicity language and culture with strong social cohesion and interdependence create a small world for pao migrants chatmans theory of life in the round refers to a small world where community members have similar viewpoints and comprehend each other because they belong to a particular culture and language 16 ethnic minorities with small populations in a small world tend to seek information within their group and will not go beyond their small world for information 16 chatman claims that the social groups preference to confine themselves within their groups creates gaps in obtaining helpful information from other groups 17 the informationseeking behaviours of pao migrants could be affected by the small world effect for this reason this study was focused on pao ethnic migrants due to their higher vulnerability to information gaps from external resources and being a minority among minorities this study aimed to understand the information behaviour of pao ethnic migrants related to fp methods and influencing factors on their fp knowledge acquisition focusing on a specific ethnic migrant group provides a better understanding of how the cultural norms traditional practices and social networks of a given group relate to their information behaviours and the factors influencing their fp knowledge acquisition theory guiding the research the theoretical foundations of the study are premised on the structuration theory by giddens and the information behaviour models by wilson structuration theory explains the creation and reproduction of social systems through agency and structure structures can be abstracted as the rules and resources upon which the actors practices rely 18 giddens recognise agency with reflexive monitoring ability for reasonable daily activities and rationalisation skills to understand current activities within social structures 19 the study considered both structure and agency to understand the influencing factors on information behaviour of the study group wilson defines information behaviour and informationseeking behaviour as … the totality of human behaviour in relation to sources and channels of information including both active and passive information seeking and information use 20 p49 whereby the information seekers demand information from formal and informal sources to fill their information needs 21 people seek information to have more knowledge and to be able to make better and more informed decisions related to the situation in which they have to make a decision 22 the personal and situational factors influence individual information behaviour based on types levels and sources of information and seeking methods 23 s method a qualitative study utilising nonprobability sampling was conducted with 16 indepth interviews 3 focus group discussions and 7 key informant interviews in chiang mai inclusion criteria for idis and fgds were pao ethnic migrants who had lived in thailand for at least 2 years and were aged 1849 years snowball sampling was applied to identify the research participants following a twomonth participant observation at wat nong kham temple in chiang mai historically this temple has provided teaching and spiritual comfort for pao ethnic groups with the abbott and many of the monks being pao over two months the first author who shares the same ethnicity and language engendered rapport and trust with the pao migrant population by actively participating in various temple activities including sunday meal donation events and attending a funeral ceremony in preparation for the interviews and focus group discussions the first author developed an interview guide that facilitated a semistructured interview style that encouraged participants to share sensitive information as they felt comfortable prior to the start of interviews all participants and key informants were given an information and consent letter in either english or burmese language and the researcher explained in detail the objectives of the research and the voluntary nature of participation the interview guide was reviewed and updated after the pilot study in this way the primary data was collected whereby different individuals fp experiences based on the age gender marital status and fertility intention were explored following the data collection an inductive thematic analysis began with transcribing the interviews which were then reviewed and coded following this process the data were transferred to microsoft excel to categorise the coding into meaningful themes based on their relationship to each other the potential themes and thematic maps were developed and reviewed again for coherency consistency and distinctiveness detailed analysis for each theme began after developing the reasonable thematic map and the process was guided by the theoretical framework the research method was compatible with exploratory qualitative research with data triangulation from four data collection methods participant observation individual indepth interviews focus group discussions and key informant interviews this research was approved by the graduate school chiang mai university on 25 june 2021 all participants involved in this study provided informed consent the personal information and data shared by the participants was handled with confidentiality by using pseudonyms results the following themes emerged from the data 1 the information behaviour of pao migrants concerning information sources under this theme two subthemes became apparent from the findings active information seeking and passive receiving of fp knowledge both from formal and nonformal sources active information seeking from formal and nonformal information sources the first author discovered that the majority of pao ethnic migrants did not actively seek fp information and counselling services from health personnel for informed decisionmaking regardless of their current knowledge level among the participants of individual idis only one participant reported the experience of purposively seeking fp information from health professionals the others described practising contraception without consulting health staff i didnt consult with a doctor i bought the pills and took it by myself after getting married i went to the shop and said i want to have pills we took pills by ourselves after purchasing at the pharmacy no i just went and bought them at the pharmacy there was no consultation with doctors these interview excerpts show that pao migrant women developed their knowledge of contraceptives mainly from nonformal information sources such as their social networks and kinship relationships consisting of friends neighbours parents relatives and siblings the following responses are related to how they develop knowledge of contraception some people say like oh you get married then take pills there are shops that sell all types of pills there is no discussion about this among relatives because of family relationships some do not talk about this mostly these conservations happen among friends pao migrants felt more comfortable seeking information from nonformal sources which were convenient and costless however missing the step to acquire information from formal sources resulted in knowledge inadequacy of the fp method they were using contributing to method failure and unplanned pregnancy i was shocked to know i was pregnant i was shocked i did not want to have a baby yet i did not plan to have a baby at that time i did not have enough money i planned to take oral pills at the end of the month i didnt think anything would happen just skipping 4 to 5 days i thought it would be okay and i did not take the pills for just 4 or 5 days and i got pregnant passive receiving fp knowledge from formal and nonformal information sources health information was received not only through active exploration for a particular purpose but also via passive acquisition without intending to seek or use the information although active information behaviour from formal sources was less likely to occur among pao migrants passive information behaviour from formal sources occurred at postpartum followups those who gave birth at hospitals received fp counselling and information regarding available services from health staff during followup visits this could be a window of opportunity for informed choice because it enabled the pao migrants to access comprehensive fp counselling including information and services on longterm reversible and permanent contraceptive methods in thailand although postpartum contraceptive counselling promoted informed choice with increased service accessibility it was not beneficial for some individuals who strongly relied on information from informal sources for decisionmaking the knowledge from informal sources had a greater influence than the formal sources among pao migrants regardless of the information quality the doctors advised me that if i do not want to have a baby yet i could choose between injectables and taking oral pills i was about to take oral pills however they told me that i could only get pregnant after menstrual cycle appears after giving birth so i didnt take oral pills the doctor encouraged me to take injectable but i didnt do it although this participant attended fp counselling at her postpartum appointment her decision to take oral contraceptive pills was not implemented because she followed the information received from informal sources due to this action she was shocked when she was pregnant five months later besides inadequate knowledge of fp methods and fertility sole reliance on informal sources for contraceptive decisionmaking posed the risk of having unplanned pregnancies 2 structural influence on the information behaviour of pao migrants sexrelated cultural norms and accessibility to reproductive health education were the crucial structural factors influencing the information behaviour of pao migrants culturally seeking contraceptive information and knowledge was generally considered shameful as women everyone are shy to discuss it its still embarrassing to discuss it among women it is not convenient to go and ask elder people either man or woman they may give advice but we feel discomfort worry and shyness about what they will criticize when someone come and seek such information myanmar migrants came from a society that disapproves premarital sex with social punishment in several remote areas an unmarried participant perceived disapproval when seeking knowledge regarding fp from health care providers the social perception that contraceptives were only for married people influenced fp information behaviour it is kind of weird to ask it without getting pregnant like if we want to ask we can ask about it after giving birth it is not convenient just to go and ask after getting married i am not virgin anymore because of this i can consult more openly but before getting married i am too shy to ask about it similarly a male participant expressed shame to seek contraceptive information without a spouse i think it would be better to go and ask with your spouse as married couple should go together to see doctors or nurses i would not be comfortable to go alone it is a bit of shameful another cultural norm that impacted the fp information behaviour of pao migrants was agerelated in myanmar middleaged adults are expected to avoid sexual relationships and engage in religious activities a participant who became pregnant at 41 years shared her concern when she visited a hospital for antenatal care i went to that hospital i was worried like i had pregnancy at older age whether the health staff would take care of me or not interviewer why do you think doctors and nurses wont take care of you because i was scared of being scolded you are too old to get pregnant and why do you have a baby i used to hear such blame directed towards oldaged pregnancies in myanmar another interviewee shared a similar concern i think the doctors will scold me as i am too old to have a child i am about 40 i am getting old now i am afraid of being blamed for not consulting doctor beforehand besides culturalrelated structural factors another contributing factor was the accessibility to reproductive health education programmes there were limited formal resources to promote sexual and reproductive knowledge including fp methods for migrants in chiang mai although reproductive health education is integrated into the formal thai education system pao migrants are unintentionally alienated from these structural resources as majority of younger population did not attend formal schools a nongovernmental organisation staff who was working on migrant health projects shared the health literacy of migrants is not the same as thai citizens it is different because there are a variety of information sources and tools for thai people they can get information only when an ngo goes to their workplace such as a construction site… this one way only another reason is that their primary intention to come here is to earn money thats why they do not spare time for it when migrants were asked about the accessibility of health education sessions in chiang mai the response was there is less chance than myanmar since we are constantly working here our routine is just going from work to the rented room and rented room back to work a key informant responded to the question where can migrants access fp knowledge from formal information sources as the following ah…normally i would say its difficult but there are some ngos in thailand ngos working for health are sharing health knowledge i think they can get it only from ngos for thai citizens that topic is not strange to them for migrants they will not know that factors influencing the agency of pao migrants in information behaviour two significant subthemes linked with personal and situational factors emerged under this theme the lack of awareness of the right to information and barriers to seeking information lack of awareness of the right to information pao migrants had no tradition of actively consulting with professionals for an informed choice regarding contraception most pao migrants failed to practice their right to information due to a lack of supportive factors first they were unaware of the location of fp services and ways to access fp knowledge and quality fp counselling second they had no confidence in approaching health personnel for comprehensive fp counselling services as it was unfamiliar among this ethnic migrant group additionally they also had low awareness of the benefits of informed choice there is a reproductive clinic for premarital fp counselling burmese migrants rarely come for service just a few very few most of them do not know the services existence there are some people who come and ask about fp methods but those are just a few numbers they do not dare to ask normally myanmar people who work in chiang mai they usually attend the antenatal clinic however only a few couples use premarital counselling personal and situational barriers which influence pao migrants information behaviour personal and situational barriers hindered pao migrants practising agency for their information behaviour especially in seeking fp information the language barrier was expressed since i could not communicate in thai very well i was anxious to talk to doctors hospital is crowded with thaisalmost all they communicate in thai only burmese language is not used it was difficult since i did not know anything with limited knowledge on the meaning of words i could not communicate well furthermore previous negative communication experiences with healthcare providers hindered the migrants from seeking health information in the public health sector i was afraid of being scolded by the doctor the doctor did not scold me there were health staff who scold the patient at another hospital some migrants also expressed situational barriers in seeking information from healthcare providers such as the experience of long waiting time in public health settings they presumed that service providers might have little time for interactive discussions to develop their knowledge of fp methods even in the hospital they answer just what we ask they did not go beyond what we asked i have to queue there are many people waiting in front of you health care providers are busy and the clients are waiting in long queues and they dont have much time for each patient they respond only to what we ask and no time for consultation based on their selfreflection and rationalisation of the barriers in seeking healthinformation at public health settings most pao migrants perceive that seeking healthinformation from formal information source is challenging discussion this study indicates that active information seeking from professionals to make an informed decision on fp methods is not common among migrants instead migrants develop contraceptive knowledge based on the information acquired from nonformal sources although active fp informationseeking can be acknowledged as a positive behaviour to facilitate healthrelated decisions and practice the information source matters informed decision regarding choice of contraception by medical personnel should not be replaced by information from nonformal sources sole reliance on information from informal sources places the migrants at high risk of having unplanned pregnancies from method failure and unmet needs for fp this result concurs with that of a previous study which showed that inadequate knowledge and limited access to fp contributed to unmet needs for fp 11 the study also found that information behaviour for fp mainly occurs within informal settings several authors agreed that social networks including friend and kinship relationships play a significant role in searching for healthrelated information 9 24 25 26 this kind of informationseeking is more prominent among migrants due to language and cultural barriers in communicating with health staff 924 as it is more convenient to communicate with a sense of belonging 26 although the information from informal sources is sometimes mixed with subjective opinions derived from individualised experiences and knowledge they have more influence on pao migrants regarding the choice of fp methods according to low et al social network serves as a primary information source and exerts a remarkable influence on individual behaviour 27 culturally sex has been articulated as shameful in the pao migrant society and there is almost no space left to discuss it from a health perspective the absence of traditional practices for discussing fp from the aspect of reproductive health limits reproductive health informationseeking behaviour including contraception culture does not favour women to freely practicing contraception due to shame 9 religious beliefs and lack of partner support as well as social norms and pressure 24 sexual abstinence before marriage is a moral standard deeply rooted in the social perception under tradition culture and religious values therefore it is assumed that fp knowledge only concerns married persons and it is considered inappropriate to discuss this among unmarried people regardless of their sexual activity status social disapproval of premarital sex prohibits fp knowledgeseeking by unmarried persons our findings support the claim that unmarried people are more vulnerable to pregnancyrelated morbidity and mortality due to the limited availability and access to fp services 28 socially constructed agerelated cultural norm brings adverse social interaction toward pregnant women in their middle adulthood the social expectation to refrain from sex and devoting oneself to religious activities during middle adulthood has impeding effects on informationseeking behaviour the social practice of placing the blame for having pregnancies in middle adulthood causes older pregnant women to fear being blamed resulting in lack of confidence to seek fp information and services several authors agree that specific cultural norms influence the pattern of seeking fp information and utilisation by individuals 9242930 the study results were similar cultural norms related to sex marriage and age hindered the fp information behaviour of pao migrants hence culture as a structural barrier should be considered when designing migranttargeted health education programmes as another structural barrier the reproductive health education programme under the education system alienates migrants since most migrants especially firstgeneration migrants have no association with the hostcountry education system ngos are alternative sources for migrants to seek fp services and information however their reproductive health projects are mostly at the border areas of thailand and myanmar and only a few are in the metropolitan area of chiang mai it was found that pao migrants had less experience of receiving information education myanmar migrants need fp information education especially to know each methods side effects and correct misperceptions 11 public health education services including health consultation sms facetoface consultation and promotional materials significantly benefit the fp of the rural migrant populations 31 the situational and personal barriers that weaken the agency of migrants to practice the right to information were language barriers perceived perception of unfeasible situations for interactive discussions with healthcare providers and fear of being disrespectfully treated by health staff past experiences of negative communication with health staff increased hesitance to acquire health information which is a nuance factor obstructing active informationseeking in health settings healthcare settings should be a space that facilitate sexual and reproductive rights including the right to access fp information and services however pao migrants perceived that seeking fp information from health personnel is difficult they rely on friends parents and kinship networks as convenient sources of fp information they do not expect to undergo fp consultations with healthcare providers instead they seek easily available shortterm contraception from nearby gp clinics and pharmacies this contributed to knowledge inadequacy despite a high contraceptive prevalence rate accessing contraceptive services at gp clinics and pharmacies does not represent comprehensive fp counselling and informed choice the information they receive from pharmacy and gp clinics is specific to their predetermined methods furthermore their choices are limited to oral contraceptive pills and injectables due to the lack of opportunity to familiarise themselves with other contraceptive methods a study argued that having good contraceptive knowledge is different from accessing comprehensive fp information and the capacity to make informed choices 32 those depending on the shortterm methods are more likely to stop using them at some point compared to those who use longterm methods 32 this could lead to unmet fp needs this study has several limitations this study focused on ways of seeking information from information sources to understand how migrants construct their fp knowledge hence less emphasise was given to information utilisation furthermore it focused on the contraceptive aspect of fp and excluded the treatment for involuntary infertility despite the mentioned limitations this study explored the fp information behaviour with respect to information sources along with influence of structure and agency recommendations prolonged insufficient public health services with limited resources for fp information in the country of origin cultural barriers and lack of migrantfriendly fp resources in the migrated country were contributing to the fp information behaviour of migrants despite myanmar migrants having several deterrents to accessing fp information and counselling for informed choice the problem was understated public and private health facilities providing fp services and ngos should support and address the structural and agency barriers to ensure access to comprehensive fp counselling for the migrant population this study informs the behaviour and challenges which should be considered for the effective

the accessibility to quality family planning fp information and counselling for myanmar ethnic migrants in thailand is questionable inadequate knowledge and lack of informed choice to practice fp methods increase the risk of unmet needs and method failures in fp which could result in unplanned pregnancies and induced abortions this research aimed to understand the fp information behaviour of a pao migrant group as well as structural and agency influencing factors on fp knowledge acquisition in chiang mai a qualitative research based on the information behaviour model and structuration theory was conducted using participant observation indepth interviews focus group discussions and key informant interviews a nonprobability sampling method was employed and 31 respondents participated in the study the study found that actively seeking fp information from formal sources to make an informed decision was not common among pao migrants instead there was more reliance on informal information sources for choosing fp methods cultural norms related to sex marriage and age hinder migrant health informationseeking behaviour from formal and informal information sources pao migrants were alienated from structural resources limiting the opportunities to promote fp knowledge the personal and situational factors that significantly influenced the agency of migrants were lack of awareness of the right to information language barriers and perceived communication barriers with health staff limited resources of migrantfriendly health education programmes adversely affect migrant fp information behaviour reproductive health education programmes including quality fp counselling services should be accessible for marginalised migrants to ensure that their choices of fp are wellinformed

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introduction existing ethical issues and major decisionmaking models in japanese healthcare one prominent ethical issue that has emerged as a major social topic concerning modern medical practice in japan has been that of decisionmaking related to the treatment of serious illnesses decisionmaking is an act of choosing from multiple potential options in 2018 a female patient in her 40s with chronic kidney disease died as a result of a decision to withhold the introduction of hemodialysis one issue with this case was that the attending physician had initially recommended the withholding of hemodialysis as a treatment option to which the patient originally consented later the patient expressed her desire to rescind her consent but the physician ignored this as her condition worsened we would argue that in this particular case it was unlikely that an appropriate patientphysician relationship had been established and that decisionmaking based on authentic patient preference had taken place in 2019 two physicians were arrested after administering a lethal injection to a woman in her 50s who was suffering from amyotrophic lateral sclerosis as physicianassisted death the fact that they were not her regular physicians and that they received money from her for this are considered highly problematic not to mention the act of euthanasia itself this case brought to the forefront the discussion of whether the absence of a continuous patientphysician relationship is a serious problem in the decisionmaking process as for the former case accusations against the physician developed into a civil lawsuit the latter investigated as a criminal case that ended with the arrest of the two physicians for commissioned murder appears to have had a greater social impact and arguably more serious ethical implications some dialogue has progressed concerning ethical issues in cases involving treatment refusals such as lifesaving intensive care for a seriously ill baby blood transfusions for patients who are jehovahs witnesses and removal of an implantable cardioverterdefibrillator in japan a prominent gap remains in what is considered the patients best interest as defined by the medical side versus the patients and appropriate decisionmaking processes are difficult to establish in clinical settings many ethical dilemmas remain in modern japanese healthcare and establishing an appropriate decisionmaking process is an urgent task there are three main decisionmaking models paternalism patientinformed choice and shared decisionmaking the paternalism model fails to provide sufficient information to patients and thus fails to respect their selfdetermination meanwhile the patientinformed choice model does not adequately address patient comprehension of medical information places an excessive burden on patients to make decisions themselves and ignores changes in patient values because of these shortcomings the former two models are considered less ideal and the sdm model has been recommended as a better alternative introduction of shared decisionmaking according to brown and salmon sdm was developed to resolve the tension between patients who are entitled to make health care decisions and medical practitioners whose responsibility is to protect the patients best interest sdm theory ensures that decisions are evidencebased and that they align with patient interests proponents of sdm who implicitly assume patient willingness and capability to make appropriate decisions for themselves suggest that patients and medical practitioners negotiate decisions this sdm approach based on the negotiation between patients and medical practitioners currently dominates the literature on how to achieve patient participation sdm is often positioned between the paternalistic approach and the autonomybased approach it recognizes both physician beneficence and patient autonomy and respects protects and supports patient autonomous choices there is also the idea that being able to make selfdetermined choices is happiness as a natural nature of human beings furthermore people live interdependently in relationships with one another the concept of supporting patient selfdetermination and autonomy has developed as an ethical extension of the informed consent concept that said the provision of information alone does not ensure that patients make decisions that suit their preferences and intentions sdm is characterized as a complex intervention in which patients and clinicians form a partnership making decisions together using the best available evidence medical decisionmaking is approached as a shared process with shared responsibilities clinicians present the various treatment options benefits harms and probabilities and patients weigh the pros and cons and gradually arrive at their preferred decision the fundamental goal of sdm is to improve the patients ability to make autonomous decisions allowing them to make treatment choices that sufficiently reflect their individual and personal views of life experiences goals preferences and values indeed sdm has been recommended with increasing advocacy in japanese clinical settings in 2017 the japan medical association general policy research organization conducted a japanese medical awareness survey targeting japanese citizens four thousand adults from all over the country were randomly selected and an attitude survey on healthcare was conducted through individual interviews in total 1200 responses were obtained with a valid response rate of 30 when asked who would be the appropriate decisionmaker and what decisionmaking style they would choose if they suffered from a serious illness 509 of participants responded decide by myself after consulting with a doctor 245 responded listen to the doctors explanation and then agree with it 197 responded listen to the doctors explanation and leave the final decision to the doctor and 11 responded leave everything to the doctor without listening to hisher explanation the working paper of the japan medical association general policy research institute interpreted these results as the indication of the strength of japanese peoples independence in terms of healthcare choices although there were agebased differences according to nakayama these results indicate that 50 of respondents prefer the sdm model suggesting that they are aware of the importance of selfdetermination in healthcare he also pointed out that 40 of those aged ≥70 years chose the sdm model and that only 11 of respondents chose the paternalistic model if the above results truly reflect the opinions of the general population they suggest that japanese people have become more independent than they were in the past and wish to participate in sdm for healthcare decisions findings from research studies and clinical practice in japan also suggest that sdm as a decisionmaking method has become widespread with increasingly more active patient participation in decisionmaking in addition patient participation in sdm has been suggested to help reduce decisionmaking conflicts in patients expand their treatment options and improve longterm treatment satisfaction japanese healthcare professionals also recommend the use of sdm with decision aids problems concerning shared decisionmaking recent reports have described several theoretical and practical problems concerning sdm first the definition of sdm is not clearly established and there is disagreement about what sdm really is indeed according to some studies there are at least nine different definitions of sdm second there has not been enough time to implement appropriate sdm and competing clinical demands exist in clinical settings third levels of education and health literacy affect attitudes toward decisionmaking participation with a decreasing trend in intention to participate with decreasing levels of education and health literacy for example the most common factors for patients favoring sdm are female gender higher education and younger age on the other hand low levels of health literacy negatively affect patient understanding of relevant medical information however some claim that patients should be asked what role they want to play in the decisionmaking process and that various strategies such as literacyappropriate communication should be utilized fourth according to the latest review on the benefits of sdm although there are some data indicating that sdm improves patient satisfaction no evidence suggests its influence on actual clinical outcomes fifth studies have found that poor communication by physicians impairs sdm physician recommendations may be biased and that a substantial proportion of physicians have a negative attitude toward sdm and disregard it in their practice sixth in sdm patients and physicians should be equal when discussing treatment options to make final decisions inappropriate interventions lacking medical evidence are more likely to be selected by patients than physicians including options that are harmful to third parties such as the overuse of antibiotics finally some argue that differences in patient abilities to make decisions and the amount of support they receive to do so are the causes of inequality in the decisionmaking process the situation is complicated further by differences in the various understanding of personal autonomy which may be considered the eighth issue at least two kinds of autonomy are at playindividualistic autonomy and relational autonomy a highly individualistic view of autonomy regards patient preferences as clear firmly established and enduring on the other hand a less individualistic view assumes that patient preferences are often unclear unstable variable and dependent on the context and individual relationships ie similar to relational autonomy proponents of relational autonomy claim that all selfdetermination occurs in a context that is embedded within the society rather than being selfdetermined on an individual basis and that selfdetermination is influenced by the beliefs of society this concept has been used in questioning the tendency to overemphasize nonintervention against selfdetermination as mentioned above the fundamental aim of sdm is to improve patient ability to make autonomous decisions so that their treatment choices might fully reflect their individual and personal views on life experiences goals preferences and values however in addition to the lack of clear understanding of what sdm really is if there were serious discrepancies in the understanding of fundamental concepts such as autonomy value and preference how and to what end sdm should be carried out would remain undetermined and controversial in addition distrust among stakeholders and irreconcilable differences in values would make sdm more difficult and sometimes impossible to achieve it has also been pointed out that some ethical issues exist regarding sdm processes for example patients may fear being labeled a difficult patient if they explicitly express their desire to participate in sdm other issues include an unequal power balance between patients and physicians inappropriate family interventions physicians having a strong influence on patient decisions decisional burden patients changing values biased and irrational decisions by stakeholders and involuntary consent psychological cultural and social tendencies in modern japan we are concerned that the abovementioned issues surrounding sdm which are difficult to solve would also become serious obstacles in practicing sdm in japanese clinical settings in addition when considering the ideal sdm in modern japanese society it becomes important to gauge the impact of psychoculturalsocial tendencies on its implementation in light of this the following section explores some of the issues we consider to be important from the psychoculturalsocial perspectives psychoculturalsocial tendencies have been used by many critics in japan to describe japanese people today those include surmise selfrestraint air peer pressure and community it is very important to discuss how these tendencies may affect the ideal practice of sdm in japanese clinical settings and for japanese health care professionals to be aware of the adverse effects that these tendencies might have on sdm surmise selfrestraint air and peer pressure are often brought up in the context of recent political scandals in japanese society as well as being predominant public behaviors amid the covid19 pandemic we argue that these tendencies associated with social characteristics could have nonnegligible impacts on medical practice community can be regarded as a platform where people behave according to these tendencies potential ethical implications of all five tendencies especially their negative impacts on sdm need to be thoroughly examined definitions and brief explanations of the five tendencies are provided in table 1 these five tendencies as summarized in table 1 are interrelated overlapping and are not mutually exclusive for instance kokami claims that air is a fluidized version of community some also consider air to be the cause of surmise people who are good at reading the air are subject to peer pressure while those who ignore the air are regarded as individuals who do not surmise also peer pressure may be completely external or internalized and in the latter case the individual unconsciously surmises or refrains from doing what they truly want to do surmise is an action and selfrestraint is an omission however it is a persons actions based on their common consideration for both others and heteronomy peer pressure is an intervention by community upon individuals and air can be the content which peer pressure imposes on people community appears to generate a certain air with normative power and this air forces people to act in a certain manner through peer pressure individuals read the air and practice selfrestraint or surmise some say that surmise selfrestraint and peer pressure as well as behaviors to read the air all result from ones consideration for how others might evaluate them and that all are deeply linked to the mental structure of japanese people although these five tendencies have yet to be established as academic terms what they all have in common is that they do not use clear and explicit words for communication there is also a view that it is the japanese spirit to be concerned about the emotional reactions of others around them despite their similarities and close associations each of these five words has independently and separately been in japanese society it should also be noted that an increasing number of reports have mentioned these psychoculturalsocial tendencies in the last 5 years reading the air recognizing the superiors intentions in advance and deciding ones actions accordingly there is a system in japan in which people excessively surmise the wishes of ones boss surmising can occur in any organization in japan and this is due to the psychology of selfprotection desire for approval fear of being hated by or upsetting others and the effort to avoid being excluded from ones organization some claim that surmise is based on ones consideration for others as the japanese are always halfunconsciously taking note of other peoples moods and feelings behaviors according to surmise are speculative and have no rational basis originally the word sontaku was used to mean guessing the hearts of others but in recent japan it has been used to refer to a set of actions that one takes to read the mind of ones superior and regarding the superiors wishes as rules to obey selfrestraint selfrestraint or selfregulation is the voluntary refraining from doing things when one wishes to do them it is argued that japanese people would quietly and gently refrain from engaging in a certain behavior even if refraining is optional and lacks coercion or penalties simply as a result of reading the air japanese people do not say no easily in the culture of i dont want to bother people around me one tends to be hesitant about exercising selfdetermination it also seems that modern japanese people tend to refrain from expressing their own true hopes from the beginning of their lives many japanese people are consistently told at home that they should not bother others air an invisible force that keeps people from doing what they want to do a very powerful and almost absolute criterion of judgment concerning ones actions a community with a strong air tends to exclude socially those who resist the air as heretics air is a vague difficulttocontrol rule for which no person is in charge or is a decisionmaker but for which sanctions will be issued to those who disobey or ignore however it is often ambiguous as to who is given the order or what kind of rules they are expected to obey peer pressure the power that implicitly forces a minority or dissident to act like a majority the pressure that everyone must be the same an order to obey the air of a majority or mainstream group while japan is reportedly a country with outstandingly high peer pressure it is also argued that peer pressure is a ubiquitous force worldwide it is also argued that peer pressure is increased by the closedness of japanese society a homogenization norm the undifferentiated nature of individuals and the small size of the community even the attitude of it is a voluntary activity but everyone must participate in it is accepted in a japanese community in japan people tend to be accused of both making individual decisions and taking unique actions some say that brainwashing is being carried out in the field of education establishing firmly in the mind of children that obedience is a good thing that said there are also young people who do not give in to such pressure community seken refers to a community formed only by people who are related to each other now and in the future examples are companies schools and neighbors some argue that community is the dynamic that often occurs when japanese people form a group in such a group there are specific rules including giftreciprocity the class system in the order of seniority absence of individualism groupism exclusion of foreigners equality commontime consciousness which are obeyed due to peer pressure it is said that japanese people have historically been bound by community for more than 1000 years some also point out that community is regarded by its members as the reference group against which each individual judges their decisions or actions the eyes of others become the code of conduct individuals are concerned about others evaluation within their community worried about being locked out of it and are aware that they are required to be in tune with or obey community rules 2021 itakura 2021 in this paper we use surmise and selfrestraint as independent concepts because of the following differences surmise is an act of both selfdefense and selfbenefit such as promotion and there is no surmise police as in the case of selfrestraint surmise is an action whereas selfrestraint is an omission in some situations this difference could ethically lead to different personal responsibilities for the consequence in these situations the norm of not causing trouble to their community may mainly lead to peoples selfrestraint the power of air has frequently been mentioned as the cause of the japanese navys defeat in world war ii air which refers to the normative content of peer pressure is the term from which the buzzword ky has been derived the content of air may vary but the presence of peer pressure is persistent in japan community appears in the waka read by the famous poet okura yananoue over 1000 years ago in japan community is sometimes called sekensama with the honorific title sama and is regarded as an entity having a kind of superior personality ohta claims that japan has japanesemade communitarianism a community in a general sense is a form of human communal life based on bloodrelated territorial or emotional connections and it is a group in which mutual aids and mutual regulations exist due to communality communitarianism in general is a value system that considers the community as desirable both emotionally and ideologically and actively maintains and strengthens its existence some argue that the japanesemade community is one that is characterized by strong closedness a homogeneity norm and the undifferentiated nature of individuals therefore it tends to aim for a situation in which all members are united and solidarity is regarded as a golden rule in other words the ultimate goal of the community is a complete union of its members in this sense japanesemade communitarianism can be regarded as seken communitarianism generally emphasizes common social customs and cultural traditions the common good is considered a substantive concept of a good way of life which defines the way people live in the community the common good of the japanesemade community may be that all people live in the same way as a group in a common time frame sharing the common past present and future in other words harmony solidarity and homogeneity are the most important values or goodness in such a community members are required to act or not act according to surmise selfrestraint air and peer pressure moreover the members of this community follow the homogeneity norm so that they can be accepted and respected by other members they may exist in other groupist cultures similar to japan at any rate in terms of how these trends affect sdm in japanese healthcare as discussed in the next section it is less important whether or not these trends are unique to japan instead what matters most is the possibility of them having adverse effects on sdm in contemporary japan in the following we will briefly describe the relationship between the abovementioned five tendencies and japanese cultural characteristics previously discussed in the literature the tendency to surmise may be attributed to respect for or obedience to authority both surmise and selfrestraint could be the product of heteronomy air is a vague difficulttocontrol rule for which no person is in charge or is a decisionmaker ambiguity has long been regarded as a dominant japanese cultural character and air clearly is a form of ambiguity in that no explicit order or suggestion is implied by it peer pressure which implicitly forces a minority or dissident to act like a majority orders everyone to be the same and easily achieves the state of harmony no matter what people want in the community the eyes of others become ones code of conduct it forms the otheroriented tendency in which one regards both the members of the community as well as the community itself as collective guidelines against which one judges ones own actions finally it is the japanese spirit of caring for and worrying about the emotional reactions of others that makes japanese people cooperative or willing to avoid conflict community in this sense has clearly evolved on the basis of familygrouporiented approaches notably those five tendencies do not appear to include explicitly the elements of dependence and entrusting however according to these tendencies person a could expect that person b would not do anything against as interests just as a could surmise bs wishes and interests this may be referred to as reverse surmise or mutual surmise in this context we argue that surmising and dependenceentrusting are quite similar as pointed out by japanese psychiatrist wada in relation to the covid19 pandemic japanese peer pressure is so strong that japanese people cannot express individual opinions out of fear of criticism they have no real appreciation of the importance of freedom and gently obey the government policies while also believing what the mass media reports without any doubts in summary while it may seem that japanese psychoculturalsocial tendencies are incompatible with the idea that independent individuals decide what is most important for them and live freely without the influence of others or community traditions it can also be said that a clear direct and lowcontext communication method is not generally appreciated and has not been adopted in japanese society moreover the position that individuals should be able to make the best decisions for themselves based on their own personal values has not been popular notably however some claim that the myth that japanese are collectivist and westerners are individualist has no scientific basis and is a bad cultural stereotype and such a notion has been denied in various psychological studies this claim is based on the results of several empirical studies which primarily conducted psychological experiments and laboratory analyses in subjects who were mostly university students in japan and the usa those studies however aimed to compare general groupism and individualism traits between japan and the usa and did not address patient attitudes actions or decisions in clinical settings moreover no studies have looked into the effects of surmise selfrestraint air and community as sekentendencies that concern us according to takano some experiments have been conducted on tuning but peer pressure was not directly investigated or clarified based on these facts although those studies are very valuable in the field of academic psychology their results are unlikely to be generally applicable to japanese clinical settings to clarify the aim of this paper is to highlight the cultural tendencies that may negatively impact the practice of sdm to this end we do not question how many people actually have these tendencies we think that dividing the east from the west for cultural categorization would be too simplistic within any country differences exist among individuals generations families and regions even within the same culture some aspects may change over time while others remain constant certain aspects may also be shared across different cultures at the individual level as well personal and cultural perspectives can significantly change during ones lifetime speculative arguments concerning potential adverse effects of modern japanese psychoculturalsocial tendencies on shared decisionmaking the aforementioned psychoculturalsocial tendencies could have a strong influence on the practice of sdm in japanese healthcare thus far however no empirical studies have tested this assumption and no academic papers exist on this matter therefore in the following section we will consider how sdm might be affected by the five psychoculturalsocial tendencies in clinical settings in relation to the previously described japanese social characteristics the arguments that follow although clearly lacking in scientific evidence present our purely speculative claimsour doubts concerns and worries about what might happen in japanese clinical settingsfrom the perspective of bioethicists and clinicians facing japanese patients in clinical practice this paper is not one that reports descriptive ethics work with objective data rather our points are based on ethical arguments that we believe to be important for those working in clinical settings as well as being ethically important from the standpoint of a precautionary principle generally speaking the core elements of the sdm processregardless of the multiple definitions and varying implicationscould be summarized as follows both the patient and physician participate as a team in making the best choice for the patient both are equal partners in their relationship the physician should provide information and recommend reliable options in an easytounderstand manner the patient or patient and family weigh the benefits and disadvantages of options while also knowing that they are in a situation with no single best option the patient makes a healthcare decision based on their own values and concerns the physician should examine the patients understanding and expectations and the patient and physician should negotiate and make a shared decision in the discussions that follow we simplify our points by assuming that sdm takes place among the patient family and physician and present our concerns doubts and questions regarding the ongoing and future practice of sdm in japanese clinical settings from an ethical perspective again we are aware that individual differences exist even within the same culture or group and emphasize that we have no intention to argue that the following applies to all japanese people first is it even possible for relevant parties in japanese clinical practice to establish an equal partnership among themselves forming the basis of sdm japanesemade communitarianismcommunity is highly authoritarian the physician may be perceived as an authoritative figure by the patient there is also no guarantee that all family members have equal say in these matters or that the patient is immune to strong opinions or intentions of influential members such as an older male or main provider it may also be difficult for stakeholders to form an equal partnership as independent individuals as it has been pointed out that individuality is not valued in japan rather the physician would develop a relationship with the patient not as an independent individual but as one of the family members this makes it difficult for the patient and physician to exchange opinions freely as equal independent partners second would the patient willingly reveal their true opinions and intentions to the physician japanese people usually find it difficult to say no to others especially to their superiors whom they perceive as an authority the patient may try to surmise the physicians thoughts and express their wishes while taking into consideration what the physician might want the patient may also refrain from expressing their preferences due to the selfrestraint tendency at the same time given their highcontext cultural background and the psychological tendencies of dependence and entrusting they may tend to think that what they want to say or do can be communicated and understood without words thus the patient may hesitate to tell the physician that they have doubts or disagree with the physicians recommendations the patient may even refrain from asking questions even if they do not understand what the physician is saying because of the desire to avoid confrontation and keep a harmonious patientphysician relationship the patient may leave their real opinions ambiguous or unspoken third would the patient carefully and willingly weigh the benefits and risks of each treatment option on their own heteronomous otheroriented and dependent tendencies of the patient may lead them to leave crucial decisions to the physician and family alternatively the air created by others may lead them to make treatment decisions rather than through wellfounded rational balancing of merits and drawbacks concerning treatment choices it is also necessary for the patient and family to pay attention to the cognitive bias of all stakeholders involved especially that of the physician moreover it is doubtful that family members could calmly and carefully consider the merits and demerits of options and the future situation due to emotional instability and burdens fourth we are very concerned about the kind of decisionsharing that might take place in the sdm process in japanese clinical settings where a real equal partnership is unlikely to be achieved we fear that proper decisionsharing would not happen in situations where the patient surmises the physicians intentions and refrains from expressing their wishes to the physician and family members reads the air created by people involved and feels coerced to follow it or receives peer pressure indicating that an ordinary patient usually listens to the physicians opinions and accepts them in any way sdm would also not work for the patients autonomy and best interest if the communitys idea ie a patient in a certain condition usually chooses a certain treatment and never disagrees with their physician has been internalized if the patient surmises the physicians intent refrains from expressing their wishes and involuntarily accepts what the air expects them to do in the first place it is unlikely that the patient willingly participates in sdm and collaborates with the physician to make shared decisions on an equal footing as they might consider their participation meaningless or a waste of time the patients attitude toward participation in decisionmaking also depends on their personality and emotional state as well as their relationships with the physician and family members therefore no one can tell what is going on in the decisionsharing phase from the outside due to the complicated psychoculturalsocial tendencies and highcontext communication style prevalent among the japanese collaborative processes under the norm that everyone should be united and homogenized would be far from an approach that considers the patient an individual with personal values and beliefs even the physician and family members may exert pressure on the patient to obey the air if the patient is unwilling to follow fifth would the patient make the final decision for themselves some people may not want to make decisions based on their otheroriented tendency while others may give up making their own decisions when confronted by physicians or family members the air that carries stakeholder opinions may generate the final decision in the absence of the final decisionmaker some may care more about what others want them to do than what they really want to do or expect physicians to decide for them yoichi miyashita a japanese journalist who has worked overseas for a long time wrote that he was against the legislation of voluntary active euthanasia in japan given the ambiguity of society he argued that japanese family relationships are under the influence of the social climate and people are supposed to read the air in given situations and feel compelled to respect harmony with others he was concerned that some patients may decide to end their lives by physicianassisted suicide just so they could avoid bothering their family in the process of medical and nursing care even if they want to live longer family members with unclear boundaries between self and others may impose certain principles for some patients the family serves as the reference group against which they make judgments about right and wrong finally what does mutual agreement in sdm really mean in circumstances dominated by surmise selfrestraint air peer pressure and community in which harmony solidarity and homogeneity are valued is the agreement a true agreement when all people concerned want to avoid being considered the disturber of harmony or a difficult patient would not the wishes of vulnerable patients be ignored in the name of unanimity would not the final agreement itself become the ultimate goal justifying manipulation with much concern and doubt it is possible that the patients final consent is not purely voluntary but rather represents the involuntary or reluctant agreement made in line with the intentions of those in a stronger position moreover what is regarded as good in the community may differ from what the individual patient considers to be good for themselves hence the potential adverse effects of psychoculturalsocial tendencies in modern japan on sdm are very worrisome and we cannot afford to ignore them conclusions this paper discusses the certain risk of sdm being adversely affected by japanese psychoculturalsocial tendencies and argues that sdm in japanese clinical settings might fail to achieve its goal although sdm is a good model in and of itself and is necessary for improving decisionmaking processes in japanese clinical practice we are concerned that sdm requires a closer relationship among stakeholders and more frequent communication which may increase the influence of health care professionals on patient psychology and the likelihood that the japanese psychoculturalsocial tendencies become too marked close relationships and frequent communication are undoubtedly preferable but the shared nature of sdm can make authentic patient decisionmaking difficult to ensure healthcare professionals including physicians should try to identify patients authentic preferences free from surmise selfrestraint air peer pressure and community this task may be quite difficult and timeconsuming and will require building a patientphysician relationship with openness and mutual trust it goes without saying that in order for the sdm model to work well in reflecting patient understanding and values health care professionals need to be supportive of and sensitive to the individual preferences and needs of patients during sdm processes because the decisional burden is heavy and patient values are not fixed finally in present japan health care professionals should be aware of the influences of surmise selfrestraint air peer pressure and community on patients even in situations where they tend to the patient alone japanese healthcare professionals should also be aware of the fact that they too may be falling subject to the unwanted influences of the japanese psychoculturalsocial tendencies in conclusion we emphasize that there is a possibility that the abovementioned psychoculturalsocial tendencies present in japan could strongly influence the practice of sdm in japanese healthcare we argue that efforts should be made to eliminate these negative impacts on sdm and furthermore to conduct rigorous empirical research to establish trustworthy evidence in the future only with such efforts can we make more plausible arguments and claims based on convincing psychoscientific data

in japan where a prominent gap exists in what is considered a patients best interest between the medical and patient sides appropriate decisionmaking can be difficult to achieve in japanese clinical settings decisionmaking is considered an act of choicemaking from multiple potential options with many ethical dilemmas still remaining establishing an appropriate decisionmaking process is an urgent task in modern japanese healthcare this paper examines ethical issues related to shared decisionmaking sdm in clinical settings in modern japan from the psychoculturalsocial perspective and discusses the ideal decisionmaking process in present japan specifically we discuss how five psychoculturalsocial tendencies surmise sontaku selfrestraint jishuku air atmosphere or mood kuuki peer pressure or tuning pressure dochoatsuryoku and community seken which have often been referred to as characteristics of presentday japanese people may affect the ideal practice of sdm in japanese clinical settings we conclude that health care professionals must be aware of the possible adverse effects of the above japanese psychoculturalsocial tendencies on the implementation of sdm and attempt to promote autonomous decisionmaking thereby allowing patients to make treatment choices that sufficiently reflect their individual and personal views of life experiences goals preferences and values

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introduction selfrated health as a commonly used indicator of health status and quality of life has been given a lot of attention by researchers who aim to identify determinants of healthy aging and risk factors of agerelated disorders as the percentage of the worlds older population is growing rapidly the solutions for increasing life expectancy in good health are of major interest of the gerontological studies along with the aging population the problem of elder abuse and neglect is growing more and more people have specific care needs which are not met 1 this fact has implications for health and quality of life of older adults however scarce is research investigating the association between neglect and selfrated health among older adults especially in eastcentral europe this paper is an attempt to gain an insight into this important topic elder neglect prevalence and its implications for health elder neglect is defined as intentional act or omission of care occurring in a relationship of trust which causes harm or serious risk of harm to an older adult or deprives an older adult of basic needs or failure to meet the elders needs by a responsible caregiver 2 neglect is the most unreported yet not the least important type of abuse throughout the world 34 the current worldwide prevalence of elder neglect is estimated by the world health organization at 32 which is the third most frequent type of elder abuse 4 in some countries the problem is even larger as reported by some researchers eg 76 in usa 5 158 in china 6 16 in spain 7 242 in israel 8 424 in egypt 9 in poland elder neglect was considered to be a serious social problem by 581 of social workers and healthcare professionals according to a study by tobiaszadamczyk et al 10 neglected people are generally subject to lower quality of life and poorer selfrated health 11 serious physical and psychological consequences of neglect should prompt researchers to search for identification and minimization of the impact of neglect on older adults lives 1 11 12 13 14 15 factors associated with selfrated health and neglectwhat we know from the literature there have been a relatively large number of studies investigating the association between selfrated health and different sociodemographic or healthrelated factors for instance aguilarpalacio et al 16 demonstrated that female gender and low educational level among other factors presented the strongest association with low selfrated health marital status is also related to srh in a populationbased study by lindström 17 the never married and the divorced have significantly higher ageadjusted odds ratios of poor selfrated health than the married group however a study in china by cai et al 18 indicated that married or single respondents were less likely to report good selfrated health in a large crosssectional italian study researchers observed that low perceived income adversely affected subjective health 19 also some studies revealed that religiosity is related to srh older adults in colombia who consider themselves more religious were less likely to perceive their physical health as poor compared to those who are less religious 20 similarly kent et al 21 stated that religionspirituality is associated with selfrated and mental health and krause 22 indicated that the way in which older people view their health may be traced in part to the virtues that are part of most faith traditions dong et al 23 suggest that the main determinants of srh among elders include social support and health status poorer health condition is highlighted by many researchers as a key predictor of poorer selfrated health a recent study by yang et al 24 indicated that poor selfrated health among older adults was associated with chronic diseases poor mental health and poor social relationships according to van der linde et al 25 selfrated health is strongly associated with cardiovascular disease events after adjustment for sociodemographic clinical and behavioral risk factors esteban y peña et al 26 demonstrated that srh was considerably poorer among adults with diabetes vs those without diabetes another recent study by peleg nudelman 27 indicated that depressive symptoms predict selfrated health among older adults in a crosssectional study by abu et al 28 older adults with higher multimorbidity and worse physical frailty more often rated their health as poor loneliness is another significant contributor to poor srh in a longitudinal study by nummela et al 29 never or seldom experiencing loneliness was a strong predictor of good srh among older adults increased risk of poor selfrated health was also confirmed in a large danish study among lonely middleaged and older adults 30 as far as elder neglect is concerned it has been demonstrated that sociodemographic characteristics such as gender age education income as well as social support and health status are associated with en and so they should be considered as potential confounders in the analyses 31 32 33 34 in a study realized by ron acierno et al 35 among adults aged 60 years and more poor income poor health and lack of social support were indicated as predictors of neglect another research on a large sample demonstrated that elder neglect was associated with younger age and lower education level among others 5 garreolmo et al 7 in a research carried out in spain found that social isolation and lack of contact with trusted persons increased the risk of neglect among adults aged 75 years and more sooryanarayana et al 31 highlighted the association between elder neglect and depression furthermore the researchers indicated that en was more frequent among older adults who suffered from at least one chronic disease 31 also the results of a study by chokkanathan lee 36 confirmed the association between elder neglect and depression and generally lower satisfaction of life additionally the study revealed that women experienced neglect more often than men 36 some factors can be associated both with selfrated health and neglect little is known about the potential role of neglect in the association between previously identified determinants of srh and srh the knowledge about these potential correlations might be helpful in better understanding of the broad context of elder neglect in order to develop instruments for an efficient improvement of older adults health and quality of life aim of the study the aim of the study is to find out what is the actual association between neglect and selfrated health among older men and women taking into consideration the selected confounding variables the study also aims to verify if neglect mediates the association between selected factors and selfrated health materials and methods study design a crosssectional study titled elder neglect and selfneglect challenges for formal and informal caregivers and the medical and social professional care system was conducted in lesser poland in 2017 the analyses were based on facetoface computerassisted personal interviews conducted with 2001 randomly selected communitydwelling individuals aged 65 years and more a structured questionnaire measuring different aspects of health and quality of life was used to collect data the data were weighted to generalize the study sample to the older polish population a detailed study design was described elsewhere 37 measurements selfrated health was assessed with the following question compared to other people in your age would you say that your health is… and a 5point likert scale ranging from very good to very poor neglect was assessed with the selfreported neglect scale the scale has two 2factor structure which covers basic needs and psychological needs dimensions the scale score can be interpreted as the level of selfreported neglect which occurred within the last 12 months 37 higher scores mean higher level of neglect the percentage of nonzero values of the srns score makes it possible to estimate the prevalence of persons at risk of or suffering from neglect thus for descriptive statistics we also considered neglect as a dichotomous variable by categorization of the results into yes signs of neglect and no no signs of neglect sociodemographic characteristics such as age marital status education and income were selected as other independent variables based on their association with selfrated health andor elder neglect demonstrated in previous studies the number of residents in the household and the number of people whom the respondent can count on were used to determine social networks frequency of church attendance was assessed with one question how often have you attended church within the last 12 months excluding such occasional events as weddings or funerals the response categories were from everyday to never this variable can be considered as indicator of social participation on the one hand and as a measure of religiosity on the other hand 3839 presence of cardiovascular diseases cancer andor diabetes which were selected as the most frequent causes of death among older adults in poland 40 was measured with selfreported information in order to evaluate health condition respondents were asked whether they suffered from these diseases diagnosed within the 12 months prior to the interview being at risk of depression was measured with the shortened 15item geriatric depression scale 41 higher scores indicated more depressive symptoms reported by the respondent the feeling of loneliness was assessed by the de jong gierveld scale 42 scores range from 0 to 100 where higher scores indicate a higher level of feeling of loneliness loneliness has been reported in previous studies as strongly correlated with poor health and quality of life in old age 2930 will to live was measured with a 6category scale from no will to live to very strong this variable was considered as potential confounder due to its strong correlation with depression poor satisfaction of life and general wellbeing negatively impacting selfrated health 4344 depression loneliness and will to live were measured as psychosocial variables statistical analysis the profiles of men and women according to selfrated health and different variables were determined based on the chi2 test or u mannwhitney test to verify the association between neglect and selfrated health multivariable linear regression models were performed in the first step sociodemographic characteristics were considered as confounding variables secondly variables related to social relationships and health characteristics were added into the model finally psychosocial variables were added additionally the sobel test of the indirect effect to assess the significance of the mediation effect of neglect was used 45 the mediating effect of neglect was verified according to the models considering all independent variables neglect as mediator and selfrated health as outcome at first unadjusted models were made for every independent variable in case of variables for which significant mediation effects of neglect were found further adjusted models were carried out to investigate the potential mediating effect of neglect on the association between independent variables and selfrated health three pathways were used path a evaluated the relationship between independent variables and neglect path b measured the association between neglect and selfrated health the effect of neglect on the link between independent variables and selfrated health was assessed through path c path c evaluated the total effect of the independent variables on selfrated health we considered the value of p 005 as significant statistical analyses were conducted with the mplus base program v 70 results the characteristics of the groups of men and women according to selfrated health and different variables revealed a statistically significant association between srh and education diabetes and cardiovascular disease for men in the female group the tests showed a significant association between srh and cancer as well as between srh and neglect income number of people whom the respondent can count on frequency of church attendance will to live age depression and loneliness were found to be associated with srh for both groups the results of a multivariable linear regression analysis allowed to verify some of the relationships as far as neglect is concerned the results of the linear regression models revealed that higher level of neglect was significantly associated with poorer selfrated health only in men not in women the results were statistically significant after controlling for sociodemographic variables the association did not remain significant after further adjustment for social network variables as well as health and psychosocial characteristics additionally we observed an association of diabetes cancer cardiovascular disease and depression with srh for men marital status was also associated with srh even after controlling for social support and psychosocial variables married men evaluated their srh better than the never married income was found to be associated with srh in both men and women a higher number of people whom the respondent can count on was found to be a strong predictor of better srh in model 2 in both groups finally will to live correlated strongly with srh in both groups after adjustment for sociodemographics social networks and other psychosocial factors at the final step of the analyses we verified if neglect mediates the relationship between the considered independent variables and selfrated heath the results of the mediation analysis demonstrate that a significant indirect effect of neglect was found in men when the association between marital status or frequency of church attendance and selfrated health was taken into account in case of marital status widowed men in comparison to the married presented a higher level of neglect which is significantly associated with poorer selfrated health in case of frequency of church attendance it correlated negatively with neglect which was also associated with selfrated health in women neglect was not found as mediator for the association between any of the considered independent variables and selfrated health the indications of the paths in the table correspond to indications on figure 1 path a independent variables → neglect path b neglect → selfrated health path c independent variables → selfrated health path c independent variables → selfrated health table 4 presents a further analysis of the mediation effects of neglect on the association between the variables for which the effect was significant in unadjusted models and selfrated health we verified if the mediating effect of neglect for the two variables was still significant after controlling for other variables added subsequently in the models as in table 2 age marital status education income number of residents in the household number of people whom the respondent can count on frequency of church attendance depression loneliness and will to live in case of marital status the indirect effect was statistically significant after controlling for age education and income but was not found significant after further adjustment to social network health and other psychosocial factors similar results were obtained with regard to frequency of church attendance the indirect effect was statistically significant only in case of adjustment to sociodemographic characteristics table 4 results of the mediation analysis with confounding variables where marital status and frequency of church attendance are independent variables neglect is considered as mediator and selfrated heath is a dependent variable discussion in the study we demonstrated that selfrated health was associated with elder neglect as well as with age marital status chronic illnesses income social support and will to live among men furthermore we found that neglect mediates the association between frequency of church attendance and srh as well as between marital status and srh as far as women are concerned srh was significantly associated only with income number of people whom the respondent can count on diabetes and will to live a mediating effect of neglect among women was not observed for any of the variables the fact that neglect is associated with srh among men but not among women might be related to gender differences which can be considered from different perspectives there have been many studies demonstrating various subjective health assessments among men and women yet comparisons in the context of neglect have been lacking previous studies confirm that perceived social support social network size the quality of social contacts and their effects on srh differ between older men and women indicating that the positive effect of social networks on health was more relevant for men than women 4647 on the one hand man and women differ in perceptions of the signs of an illness and its consequences for health 48 men tend to refer more often to physical functioning and assess activity limitations more heavily than women 49 also men and women differ in health behaviors which play an important role in subjective health assessment 50 finally differences in evaluation might depend on the life stage some studies demonstrate that women evaluate their health better as they age 50 a possible explanation is that womens social roles are less demanding and generate less stress in older age which allows them to invest more in their health and might improve their health perceptions 50 on the other hand gender differences in srh can be explained by the influence of social networks generally women seek company and support from other people more often than men 48 consequently they have larger and more varied social networks as well as closer relationships 4651 in our study the mediating effect of neglect on srh among men not women can find explanation in the berkmans conceptual model of social networks and health 52 berkman et al 52 demonstrated that health behaviors as well as psychological and physiologic pathways impacting health are directly influenced by the mechanisms related to social network according to berkman et al 52 social network influences physical and mental health mainly through social support it is acknowledged that active daily contact with friends andor family is positively associated with better srh among older adults 51 caetano et al 46 state that low social support and reduced social network result in less frequent use of health services poor functional capacity somatic health problems and unhealthy behaviors which are all factors influencing health assessment conversely social connectedness can protect against stress and illnesses 47 previous studies have demonstrated that the benefits of marriage are not equal between women and men generally the positive association between health outcomes and being married is greater for men than women because women find social support more easily than men outside marriage whereas for men marriage is more often the only source of support and care 53 women lead a healthier lifestyle and have a more significant family role in making emotional connections 53 when a female spouse dies the widower is more at risk of social isolation and neglect which can have impact on his srh 48 as far as church attendance is concerned it has been demonstrated that membership in formal or informal networks such as religious groupscommunities can benefit health as they foster trust selfesteem and cooperation 46 the study by caetano et al 46 indicated that nonparticipation in group activities appeared to be an important aspect of social life that negatively affected srh in older men participation in religious activities such as church attendance is a form of social engagement that protects from isolation or neglect as it provides company and support from the community of faith 54 in our mediation analysis the effect of church attendance on srh was significant for women but it was not mediated by neglect for men the effect of neglect appears to be more meaningful as the association between church attendance and srh was only significant when explained by the influence of neglect taking into account the aforementioned considerations we can assume that older men attending church might receive support protecting them from the risk or impact of neglect which consequently improves their srh conversely lower frequency of church attendance might result in smaller social network less support and less potential caregivers which can lead to neglect and via neglect to poorer srh a strength of the study is that it was relatively large and based on a representative sample of older people from the general population of poland we used valid and reliable scales to measure such variables as neglect depression and feeling of loneliness moreover the study was conducted in the central european region where studies about elder neglect are scarce as far as limitations are concerned the crosssectional design of the study does not allow us to establish any causal relationship furthermore the data collected on neglect and health conditions were selfreported which might have led to misclassification finally the study was conducted among noninstitutionalized individuals thus those with the worst health status were rather unlikely to be included in the study conclusions the current study demonstrates that elder neglect is significantly associated with srh in men and that it is an important factor mediating the effect of marital status and church attendance on srh as far as other variables are concerned the mediating role of neglect was not confirmed in response to the publichealth need to identify potential determinants of healthy aging our study indicates the role and the importance of prevention of elder neglect in addition to this the study underlines the role of social networks and social engagement as factors which might protect against neglect and thus improve selfrated health of older people nonetheless further research is needed to explore more closely the interrelationships between neglect and different factors influencing subjective health assessment data availability the corresponding datasets of this study are available from the corresponding author on reasonable request authors contribution all authors contributed to the study conception design or analysis conceptualization tg and bta methodology preparation of the material data collection and analysis as kz and bw writing original draft preparation as writing review and editing as kz tg supervision tg all authors read and approved the final manuscript compliance with ethical standards and informed consent the study was approved by the bioethical committee of the jagiellonian university krakow poland written informed consent was obtained from each participant of the study abbreviations en elder neglect srh selfrated health

the aim of this crosssectional study is to examine if neglect is associated with selfrated health srh and if neglect mediates the association between selected factors and selfrated health among older men and women the analyses were based on facetoface computerassisted personal interviews conducted with 1632 randomly selected communitydwelling individuals aged 65 years and more from among the general population of lesser poland the regression models analysis revealed that elder neglect was associated with selfrated health and the mediation analysis demonstrated that neglect mediates the association between frequency of church attendance and srh as well as between marital status being a widower vs being married and srh among men these observations can be helpful in better understanding of the broad context of elder neglect in order to develop instruments for an efficient improvement of older adults health and quality of life in addition to this the study underlines the role of social networks and social engagement as factors which might protect against neglect and thus improve selfrated health of older people

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organizing whether political social or governmental it is a space of both planning and spontaneity of silent coexistence and explicit conflict and therefore offers abundant empirical and methodological opportunities it is surprising that the street and the experiences it brings with it have remained largely outside the scope of organization studies we suggest that organization scholars take to the street and offer recommendations as to how to do so specifically we explore the tensions that become apparent when organizing happens in and through the street introduction the organization studies field is almost ignorant of the one place that for centuries has been the most common site for organizing the street on the street people walk talk drive exercise interact transport trade navigate traffic beg consume fight attack steal riot protest evangelise and advertise people increasingly also use the street to conduct telephone calls and to read and compose correspondence some listen to podcasts conduct walking meetings or simply enjoy the pleasure of walking to facilitate the generation of new ideas the street we would argue is both a longstanding location for organizational activity and a relatively new setting for the contemporary organization of work we also argue that inherent in the historical development of the street is a tension that is frequently encountered in our field at large in europe for example the street both as a physical setting and as a concept has been something that must be controlled or managed as well as a space that facilitates the unexpected and spontaneous the roman empire introduced infrastructure to mobilise armed forces and resources through its territories making roads a constructed indicator of control at the same time people have also constructed their own experiences of their surroundings during the medieval period peoples sense of belonging centred not on cities or boroughs but rather on sites such as castles churches and cemeteries space was experienced as a set of poles and places to be transversed in time in fact the word spatium emerged in the middle ages and indicated a lapse in time a good example that illustrates how streets reflect both attempts at control and the freedom of experiencing space is provided by the traboules of lyon france traboules are medieval short cuts which emerged between the fourth and fifteenth centuries in lyons saintjean neighbourhood during this time the city experienced a shift in how space was managed with streets and other passages transitioning from shared spaces to either public or private spaces the word traboule comes from the latin transambulare meaning to move through the word itself already indicating an action or an experience traboules were antidotes to the topdown approach to organizing space as a traboule does not follow the logic of the city avoids official roads royal streets or long detours a traboule links shores establishes bridges shortcuts the city and links parallel streets which for geometrical reasons should never meet traboules are liminal spaces in the sense that they were neither private property nor under the citys jurisdiction they are shared but not public those who use themlocal merchants then tourists noware permitted to move through but cannot claim ownership the short history of the traboule exemplifies the ambiguous status of many types of urban space which over time fluctuated between public private and somewhere in between streets are for shared use but the extent to which people can claim access or ownership depends on current regulations as well as the identity and status of the individual in question processes of exclusion define the street as do claims to its shared nature interestingly the tension between formal organized space and shared informal space is also evident in the etymologies of the different words for street the english word street comes from the old english stret or straet which in turn is derived from the late latin strata used elliptically for via strata a paved road these origins allow us to see the street as an artefact or a tool something created for the purpose of guiding and managing movement by contrast the french word for street rue comes from the latin ruga meaning wrinkle rue connotes not a tool but rather an assemblage of ways houses and inhabitants wrinkling itself into an urban landscape our field is also characterised by a continuous investigation of the relationship between what is given and what emerges or between organizing as a verb and organization as a noun much like the different types of streets that existfrom the haussmannian boulevards of paris which gave the army room to manoeuvre its vehicles through the city to other types of historical and everemerging short cutsorganizing and organization embody a continuous oscillation between that which is given or planned and the instantaneous or the improvised nevertheless organizational scholars apparently continue to favour the comfortable quarters of furnished centrally heated and often privatelyowned organizational spaces even if our field has developed a strong interest in liminal transitional or boundaryspanning places these spaces still tend to have four walls and a ceiling much of this may have to do with the origins of organization theory and its focus on questions of control confinement and restriction the minutiae of which tend to be more easily scrutinised in closedoff spaces where variables can be controlled and manipulated the street we would argue is an interesting focal point at which to examine the situated nature of organizing and organization the aim of our essay is to make explicit the constantly changing modes of relation between organizations organizing and the street we identify four such modes organizing that takes place on the street organizing through the street the organizations entry onto the street and finally the streets entry into the organization we argue here that it is precisely the cooccurrence of both the symbolic and the material that in different ways provides avenues for thinking through the relationships between the organization organizing and outside spaces the street as a site for organizing the street is not unidimensional but rather acts as shorthand for open outdoor spaces in urban or suburban environments that are accessible to different types of users indeed we concur with scholars in science and technology studies who have emphasised that common conceptions of urban space should be decentred and that the streets social aspects should be investigated in light of new developments for instance by considering how the development of new technologies such as selfdriving cars can turn the street into a laboratory the everchanging social nature of the street does not carry the same meaning to everyone as new and continuously improving connectivity allows some to turn their commute into efficient work time and others to be on call as members of the precarious cohort of ubiquitous service providers such as uber drivers in adopting this nonessentialist and historically situated understanding of the street we can explore its relationship to organizing and organization returning to the work of weick the term organizing connotes practices and processes it has also been defined as the connecting of heterogeneous actors and is often used with an adjective eg temporary organizing or alternative organizing understood in this way the street is replete with organizing for street vendors buskers doortodoor salespeople taxi drivers police agents postal workers employees of waste removal companies homeless people and maintenance workers the street is an integral part of their economic activity and the ability to predict its rhythms is part of everyday organizing streetbased work is associated with casual labour as well as with illegality and danger for example in the drug trade and in sex work these associations are not the result of any true nature or essence of the street but rather stem from the specific material qualities the street may offer such as the preservation of anonymity with digital technologies accessible in the street online platforms and messenger services are reconfiguring much of the gig work happening on the street giving us the opportunity to investigate what streetbased organizing means for those on either side of these transactions as well as for our understandings of the relationship between the street and the organization the street as a mode of organizing one important way in which the street and the organization have often been thought together is the streets role as an integral part of political organizing invoked in the expression taking to the streets in a way blocking a street at its centre impedes all movement of the city one need only look at the mass protests of the last and current centuries to see that political change an organizational endeavour is often achieved through a presence on the street as well as an engagement with the street as a concept for example not only did the global protest movement occupy wall street do exactly that but in its spread across the globe the wall street address became a metonym for the institutions and mechanisms that the activists opposed in fact during the protests that took place in paris in 1968 the street was a place in which to gather but also symbolised the controlling measures put in place by those in power we may cite for example the slogan sous les pavés la plage the street does not only feature as both tool and object of political protest but it has also played a key role in the emergence of the image of the modern reflexive individual associated the independently thinking individual with urban space the close relationship between the street and the individuals independence is also evident in hip hops associations of the street with status and intelligence further examples are myriad such that in many contexts the practice of moving around the city on foot immediately indicates a state of solitary reflection perhaps the clearest intertwining of individual creativity and streetdwelling is found in the dérive a technique of seemingly purposeless urban dwelling developed by the mid20th century parisbased collective of artists and marxist intellectuals known as the situationist international the tradition is currently kept alive by british literary writers and artists such as sinclair keiller and self and the dérive continues to exemplify the political potential of a solitary roaming of the streets in response to this tradition here have also been calls to understand the political organization of the street from a nonwestern viewpoint or in the context of workingclass immigrant communities others have critiqued the romanticised perspective on walking the street alone an activity that for many is not without risks for example a woman alone on the street has classically been connected to promiscuity evident in the term streetwalker in the realm of contemporary fine art qualmann and sharrockss walking women brought together female artists who engage with the gendered experience of navigating the street numerous further examples could be given many of which emphasise that for women the street offers freedom as well as danger hence we espouse the view that the street is not necessarily a harmonious space for equal exchange and tranquil reflection but is also the realm of agonistic encounters in which different and potentially conflicting social groups exist alongside each other noteworthy exceptions to the general absence of the street in our field have observed this political or conflictridden aspect to the street and have as such recognised it as what may be termed a mode of organizing in an organizational study at street level fernández studied an activist movement active on the streets of buenos aires focusing on the practice of putting roadblocks all over argentina the study focuses on the cooperatives decision to move the locus of their action back to their own neighbourhood they normalise their resistance by organizing the streets for instance by inviting a banking service to take up residency on the main street in their area in contrast to transformative attempts islam zyphur and boje see in the street the potential to preserve local culture their study concerns a carnival group parading in the annual krewe du vieux float two weeks prior to new orleans worldfamous mardi gras parade the authors analyse how the krewe du vieux float in which people walk or use donkeycarts is more in touch with the street than the institutionalised tractorpulled floats parading during mardi gras here also the street is not only a setting but the act of being on the street is an inherent part of the point being made and can be read in line with earlier work on the classdimensions of carnival also drawing attention to the politics of the local courpasson investigates how mundane gestures become subversive when performed in the workplace here the street is a space away from work that offers a break to people who choose to have lunch there we escape and we walk for five or ten minutes together to go to another place these walking minutes are great because we are nowhere to be controlled again the street is more than a setting walking along the street instead of the office hallways even if only for several minutes can allow people to shift to a different mindset furthermore in a study of a swedish suburb some 20 kilometres from stockholm barinaga found that the creation of mural paintings became a tool in challenging the stigma of the area in her study the street is approached as a canvas for artistic murals but working on the street also becomes a means of rearticulating the sociospatial dynamic much in line with the idea of a mode of organizing barinagas study sees public outdoor space as constitutive of a specific organizational phenomenon other research has also revealed that the street is not merely a setting but also acts as a mode of organizing and forms an inherent part of the phenomenon at hand a study of the annual edinburgh fringe festival has revealed how performance artists use different parts of the street in the inner city thereby constituting new types of space similarly a study of a volunteer organization in montréal emphasised how walking children to school in a group challenged existing boundaries between organizations and social groups while a study of a purposefully unplanned section of pavement behind amsterdams central station revealed how cyclists and pedestrians are required to engage in selforganizing while the settings and specificities of these studies are widely varied each concludes that the situated and embodied ways of being on the street matter nonetheless all these studies frame the street as a setting and do not theorise the street we believe that framing the street as a distinctive mode of organizing is the first step toward considering the political potential of organizing not just on but with the street organizations entering the street while the previous sections have focused on instances of organizing we also observe an increasingly busy intersection between the street and formal organizations the latter seeming to make it their business to enter and engage with the street one need only look at the history of jaywalking which became a punishable offence as a result of automobile manufacturers efforts or the ways in which commercial firms have taken up space on the street through advertising in many urban environments billboards posters and animated screens colonise the street in increasingly advanced ways the street then becomes an organizational or even bureaucratic space where rules are made more visible than in any other societal contexts traffic signs pedestrian crossings and speedbumps amongst other things make social regulations material and explicit formal organizations such as forprofit actors can now also capture more of peoples attention and effort through their smartphones and mobile devices public wifi laptops and smartphones facilitate work on the street or outside the place of work assembled under the umbrella term smart city these new technological possibilities also help governments to plan the organization of cities on the levels of public transport waste removal or crowd control citizens engage in open or critical mapping projects and community architecture to regain a sense of control over their immediate urban environment but such democratic or selforganized initiatives often also entail an infiltration of street life by more professional practices or entities manifestations of firms on the street raise issues of locality and simultaneity that question the definition of an organization by its physical location only when an organization is exposed to outdoor spaces we observe an imbrication of situated encounters actions processes and experiences happening outside of those practices usually considered to scale up to organizations as a result formal organizations seep through into various streetbased social processes we believe that the reverse may also be observed and wish next to discuss the increasingly streetlike nature of some types of formal organizations these two mirror images should be considered in relation to one another prompting us to wonder whether organizational members become more welcoming towards streetlike elements entering their organizational spaces because their mobile devices have already allowed them to take parts of their work life outside to the street the street entering organizations how are the street its aesthetics or its presumed principles incorporated in formal organizations companies try to encourage more movement within the walls of their offices often through policies of hotand flexdesking openplan offices and spaces designed for flexible use however we argue that organizations do not merely encourage movement and encounters but also incorporate streetlike features such as mural paintings in street art fashion benches in hallways and food trucks and barista corners transforming the entrance halls and foyers of companies into landscapes that evoke street life we also think that with some imagination the metaphor of the street may be extended to encompass the ongoing flexibilisation of labour in many countries job security for highly educated workers has decreased and in particular those who seek to execute knowledgeintensive cultural or creative work are compelled to accept projectbased work and selfemployment leading to the emergence of what some have termed a new precarious class while those with somewhat creative or intellectually stimulating jobs may at least take pleasure in a more bohemian lifestyle scholars have also argued that the new precariat is partially characterised by boredom the lack of permanent employment opportunities within organizations has led to the emergence of work environments catering specifically to independent precarious workers many of whom are not precarious by choice in fact scholars have recently started to acknowledge how flexible and creative workplaces such as coworking spaces business incubators and creative hubs may help to conceal or reinforce inequalities for example by giving people the opportunity to appear content and busy in the absence of dependable work if using the image of the street to signify the emergence of the gigeconomy and the new middleclass precariat may seem too much of a stretch we need only consider that many urban spaces typically aimed at consumption are now in fact populated with independent workers carrying their laptops from café to café this phenomenon may be characterised as both the street entering organizations and the organization entering the streets since freelancers may also be found conducting their work from urban places such as parks and public benches where practices of leisure and consumption may coexist alongside their working activities although the spatial turn in organization studies has brought to the field greater awareness of the material aesthetic affective and symbolic elements of organizational spaces to date no investigation has examined the manifestations and consequences of that which we now call the colonisation of the street by formal organizations and the increasingly streetlike appearance of formal organizations for example if the street can indeed act as a mode of organizing organizational scholars should ask whether this mode of organizing also enters organizations when they become more streetlike in terms of their aesthetics and spatial layout moreover while some scholarship has examined highskilled employees mobility and experiences of disorientation as a result of working in transit this research has focused mostly on nonplaces which typically convey a generic atmosphere and aesthetic by contrast research into workersonthego might specifically investigate the role of the street in their rhythms and experiences of work as well as looking not only at elite but also at precarious andor lowskilled mobile workers and the darker side of street business researching on and with the street to present our suggestions for research at the intersection of organizations organizing and the street in a more structured and extensive manner we now offer an example of a performance art piece that the first author attended we chose this piece which took place on the street as a means of illustrating the different tensions that may be identified in the intersection between street organization and organizing these tensions are each related to the first observation that the street as setting and as concept is characterised by formal as well as informal elements identifying these tensions with the help of our short example will help us to suggest ways in which organization scholars can engage with the street which we believe offers ample methodological and epistemological opportunity to this we will propose an agenda with research questions and designs for organizational scholars rather than designing a typology that is intended to capture reality these tensions are aimed at orienting the reader and linking our observations to wellestablished discussions in organization studies pertaining to issues of structure practice and experience the performance piece in question entitled home was created by hilde tuinstra a artist active in the netherlands and germany home consisted of a theatrical audiotour around buikslotermeerplein in amsterdam a large square next to a shopping centre in a traditionally workingclass area in the citys northern district tuinstra worked on this project for over a year engaging in a type of artistic ethnography with the neighbourhood immediately surrounding the shopping centre during this time she was interested in the upcoming changes that the neighbourhood was about to experience in particular the longanticipated construction of a new underground train line offering amsterdams northern district a much quicker connection not only to the city centre but also to the citys financial district home can be seen as both performance art and participatory art to offer some brief background in the fields of fine art and theatre the 1960s and 1970s witnessed a movement that mimicked or led the much widerspread need for democratisation of public institutions much like the student protests many artists no longer wished to cater to the demands of what they felt were hermetic and hierarchic institutions and took their practice outside sometimes to the streets furthermore bringing artistic work into the ongoing flows and interactions of everyday life is often recognised as having political potential because it offers people the possibility of adopting a new perspective according to rancière aesthetical practices and judgements are always political because they promote an order or a hierarchy of valuation aesthetics are thus also capable of challenging existing orders and can be used productively in protests and social movements as well as in other interventions in existing organizational contexts hence we should ask not what certain artworks are but rather what they do here art can be understood as a system of action and an affordance for social encounters or individual contemplation this to our minds offers clues to the potential benefits of taking the organization outside the example of tuinstras performance discloses a set of tensions that exist in the street and disrupt the flow of work and organizing in ways that invite theorising and for a start a set of research questions put briefly these tensions cohere around formal versus informal an indepth investigation into an environment that was open and undefined tuinstra finally constructed a multimedia theatrical tour around the neighbourhood the artwork can thus be seen as consisting of both the experience that tuinstra eventually offered her audience and the research and social ties that were created along the way the artwork plays with the tension of routine versus improvisation via the headphones the participants in home were present in the immediate physical environment and enveloped in a virtual world the feeling was comparable to the sensation of navigating the street while listening to ones favourite music wrapped in a solitary blanket of private sounds yet utterly enchanted with the surrounding world at some moments it seemed as though the music was telling the story of the trees cars and people passing by your thoughts are your own but they are amplified by the immediate uniqueness of this moment this place the music may be interrupted by a call that streams through the same headphones and enters your personal space should you respond to this immediate demand or remain encapsulated in the moment when you leave your house or place of work to attend a meeting do you stop to look at graffiti signs or do you travel in an uninterrupted straight line as if traversing a void encounters with strangers may pull you out of your thoughts and into the here and now of ordering something or responding to a request for directions these questions relate to the tension of presence versus absence that often characterises work and communication on mobile devices while in transit taking organization studies to the street we propose that the street is not merely a setting for research nor an object but argue that it has value as a methodological and epistemological device and wish to offer several directions for conducting research on and with the street the street has long been a site and a mode of organizing furthermore formal organizations are increasingly intertwined with street life as lamastra haefliger 2012 provides an opportunity to revisit these theories navigating the tension between formal and informal structures individuals can explore various paths of consuming and producing earning and spending hence organization scholars may study the street as a location for novel forms of crowdbased organizing and liquid consumption for example people come up with ideas set up shop or review products with a few touches on the screens of their smartphones while on the go for knowledge workers with flexible work hours and locations mobile information technology and improvements in public transport are turning the street into a more attractive place to work away from boredom and amidst the flow of public life fresh encounters and better coffee at the same time particularly in western cities the street and its adjacent spaces are carefully planned and monitored when do we amend space and make it our own structures can be subverted and practices may follow a straight path or take a detour we must study and reflect on the situatedness of these modes of connecting and interacting and conceptualise these as aspects of organizations that happen beyond the traditional temporal and spatial boundaries conducive to different types of experience which are increasingly mediated through various modes of connectivity in conclusion we believe that exploring the street helps understand some of the tensions pertaining to and constituting work and organizing processes today planned routes with room for adjustment wellestablished practices for coexistence with the possibility of surprises and a continuous oscillation between presence and absence through mobile device use all make the street a setting that exemplifies the issues and phenomena relevant to organization studies

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introduction anxiety is one of the most common emotions in the field of education including learning socialisation frustrating experiences and peer conflict 1 in chinese education research parental education anxiety refers to the complex emotional state of tension anxiety worry and annoyance about parental education 2 in order to reduce educational anxiety the general office of the cpc central committee and the general office of the state council of china issued the opinions on further reducing the burden of homework and offcampus training on students in compulsory education in july 2021 3 the policy consists of double reduction the first reduction is to reduce the excessive burden of homework and offcampus training on students the second reduction is to reduce family education expenses and the anxiety and burden of parents the double reduction policy was a major education reform however according to a survey conducted by china youth daily 273 of parents said that their educational anxiety had not been alleviated after the implementation of the double reduction policy 4 in the context of the double reduction policy scholars have explored the causes of parental anxiety in different ways most of the existing literature used interviews and questionnaires to understand parents anxiety after the implementation of the double reduction policy 5 6 although previous studies have explained the causes of parental anxiety they have not connected them with theories therefore this study will use theory to explain the causes of the phenomenon of parental anxiety the research question in this study is how to explain the causes of the phenomenon of parental anxiety using an interdisciplinary theory this study used a literature research method to summarise 57 relevant texts and 9 relevant newspapers and news articles next the study selected theories that are more relevant to the characteristics of parental anxiety in china family capital and intensive mothering this research first briefly explained the reasons for choosing these theories then used the theories to explain the causes of parental anxiety in education by collating and summarising previous research the main contribution of this study is the interdisciplinary approach which draws on knowledge and theories from the fields of education psychology and sociology in addition this study enriched the research in the area of double reduction policy and parental education anxiety understanding the causes can help to alleviate anxiety which will provide a new perspective on the management of educational anxiety 2 literature review the double reduction policy the objectives of the double reduction policy are to regulate outofschool training reduce the burden of homework on students in compulsory education and reduce the burden of outofschool training 3 in particular compulsory education is the education that all children and adolescents of school age must receive 7 compulsory education includes primary and junior high schools and is free of tuition and miscellaneous fees the main elements of the double reduction policy include reducing the total amount and length of homework upgrading afterschool services in schools regulating outofschool training improving the quality of education and teaching and strengthening support and governance 3 educational anxiety to explore educational anxiety from a theoretical perspective one needs to first clarify its definition according to the definition from the nhs anxiety is a feeling of mild or severe unease such as worry or fear 8 educational anxiety as a branch of anxiety can be understood as peoples excessive worry apprehension and even fear of education 9 to understand educational anxiety it is first necessary to categorise it although different schools of thought differ in their understanding of anxiety most agree on the concept of anxiety anxiety includes chronic anxiety and state anxiety 10 this suggests that state anxiety is a transient emotional state that is reflected in a particular moment or event causing immediate or related physical and psychological reactions 10 educational anxiety is anxiety that arises because of the specific event of education and should be classified as state anxiety exploring educational anxiety in terms of the practical application of anxiety educational anxiety can be studied from the perspective of disciplines educational groups and attributions firstly educational anxiety in terms of disciplines refers to the anxiety presented when faced with different disciplines common ones are maths anxiety foreign language education and outdoor activity anxiety 11 this is because mathematics foreign languages and sports are difficult for some people therefore people resist and become anxious about the subject this study is biased towards taking a holistic view of subject anxiety this is because in compulsory education students mainly learn the basics and the differentiation caused by different subjects is not obvious enough second from the perspective of the educational community students parents and teachers as important parts of the education system all experience anxiety about education parental educational anxiety which is studied in this study is a particular part of this parents are more worried about their childrens future than teachers are yet are unable to take charge of their own future in the same way as students parents are in an uncontrollable state of worry thirdly educational anxiety is thought of in terms of attribution which means explaining the causes of educational anxiety attribution is the process by which people seek the internal motivating factors of their behaviour from the results of their own behaviour 12 individual attributions can generally be categorised as internal and external stable and nonstable 12 this study will build on previous research and experience to explain the causes of parents educational anxiety taking into account both internal and external causes at the same time the research will incorporate relevant theories to categorise the causes into attributions parental anxiety parental education anxiety is a parents anxiety about the students performance and future and jin suggests that the characteristics of parental education anxiety lie in the identity of the parent 13 parents help their children to complete their education are indirectly involved in their childrens education build their childrens character and influence their childrens development because of this special emotional connection it is normal to feel anxious about the child li adds that parental anxiety stems from overwhelming anxiety about educational issues 14 chen xiao make a similar point that parental anxiety is a result of fear and stress in the competition for scarce resources in society 2 concerns about the quality and cost of education have evolved into a common symptom of parental education anxiety currently scholars have different views on parental education anxiety some scholars believe that it is a negative social mindset and that parental anxiety can hinder the healthy development of young people 13 on the other hand moderate anxiety can urge students to learn and thus enhance their learning effectiveness therefore appropriate anxiety is necessary in areas with sufficient educational resources and moderate competition for talent appropriate anxiety can promote better student achievement however when resources are scarce improved performance does not equate to getting into a good school getting a good job or gaining adequate social resources parents anxiety is exacerbated by concerns about the future as this study examines parental anxiety in china in the context of the double reduction policy the first negative perspective is more applicable in this study given the tightness of educational resources and excessive parental anxiety in china furthermore wang ru also share the same view as this study viewing educational anxiety as a problem that needs to be alleviated 15 educational anxiety is not only a common psychological state of the general public but also a social mindset issue analysis of the causes of the phenomenon of parental education anxiety the double reduction policy reduces the anxiety of students and parents to a certain extent by reducing undue competition from training providers enhancing school management and reducing the pressure of students inschool work and outofschool training however the double reduction policy has failed to completely address parents educational anxiety influenced by family capital parents increased investment in education generates financial pressure comparisons with others limited access to information and cognitive biases which exacerbate parents educational anxiety on the other hand the intensive relationship with the child also influences parental educational anxiety this is reflected in parents developing higher expectations and concerns for their children expecting educational returns engaging in selfdeprivation and role overstepping this study will explain the above in detail through a literature research approach family capital influences the development of parental anxiety family capital includes economic cultural and social capital 17 economic capital refers to the familys wealth and income cultural capital includes family education before entering the schooling system and social capital is the integration of actual or potential resources that individuals have acquired through their social networks 16 in relation to education in china economic capital is the investment that families spend on their childrens education this includes purchasing school district properties hiring family tutors and enrolling in extracurricular classes among other things school district properties are properties near good schools and residents children can attend schools for free and without examination although subjectbased training institutions have been banned after the double reduction policy was enacted however families with sufficient financial capital will invest in subjectbased education and shift to hobbybased training for example swimming calligraphy and dance based on this parental anxiety arising from economic capital can be summarised as concerns about whether the investment in their childs education is sufficient and whether others are investing more in their childrens education 17 second cultural capital within the family determines the childs abilities this study focuses on concrete and physical cultural capital which includes parents educational background language work culture 16 bourdieu suggested that families preinvested cultural capital develops childrens abilities and talents 17 families with a strong culture are more likely to produce highly capable children furthermore the prerequisite for cultural capital is within the family and the theory is weakened if the cultural capital of poor families is not sufficient to support the development of their childrens abilities china completes full poverty eradication by 2020 and its society is structured with a relatively high proportion of lowermiddle income people as a result cultural capital has a weaker capacity to influence chinese society in the context of the double reduction policy the lack of cultural capital can lead to parents limited ability to educate their children rationally in addition parents with limited cultural capital have limited cognition and are more easily influenced by those around them parents may feel the bandwagon effect of if others enroll their children in extracurricular courses i will enroll my child too thus increasing parents anxiety about their childrens education the main influence on social capital is social networks following the double reduction policy teachers are not allowed to engage in paid tutoring however parents with relationships can find teachers for their children privately 17 parents who lack social capital do not have such resources concerns about the quality of schooling and the articulation of junior and senior secondary curricula add to parents educational anxiety family capital as reflected in previous research through literature research this study finds that economic capital in family capital is the main cause of parental anxiety this is because economic capital constrains educational investment educational budgets and influences family financial stress and educational quality which in turn affects educational outcomes moreover as mentioned above economic capital has more distinctive characteristics and is easier to compare than cultural and social capital furthermore economic capital can directly influence the cultural and social capital of a family parents with limited economic capital have difficulty in accessing differentiated and quality educational resources in chinas highly competitive educational landscape therefore the more restricted economic capital is the more anxious parents are likely to experience the points from previous studies can well support the argument of this study limited economic capital can cause parental anxiety for example huang suggests that limited budgets make it difficult to find good tutors and improve the quality of education 4 duan adds that parents are easily influenced by the marketing of training providers creating a bandwagon effect and enrolling their children in extracurricular training leading to a tightening of the familys financial budget 18 li and yang also suggest that a lack of economic capital can make parents panic about the unknown and more likely to worry that the quality of education is lagging behind 18 furthermore the chinese slang phrase lets not let our children lose at the starting line emphasises the mindset of parents who worry about their children falling behind others this comparison with others is also a comparison of capital between different families it leads to increased anxiety for parents with limited capital finally huang adds that some parents overemphasise the importance of subject education neglect their childrens physical and mental development and spend too much on subject tutoring putting too much financial pressure on the family 4 secondly cultural capital influences parents interpretation of the double reduction policy their cognitive scope their ability to nurture their children and their choice of whether to think rationally follow the herd or stick to their own views parents with limited cognitive levels are limited by cognitive biases and are more likely to feel anxious as they are unable to judge events objectively and fairly cultural capital becomes a tool for uppermiddle income families to create educational disparities further exacerbating the anxiety of parents who lack cultural capital this is supported by the following studies firstly parents with limited cultural capital are prone to the bandwagon effect and are easily influenced by others making them feel anxious 6 secondly parents lack a scientific and rational understanding of their childrens development 9 thirdly parents are vulnerable to the misconception that tutoring can improve performance fourth parents with low educational attainment have a limited cognitive level and are more likely to be anxious in addition social capital influences the educational resources that parents can find for their children and the information that parents can access social capital further exacerbates the degree of difficulty in accessing educational resources and enhances parents anxiety huang adds that parents do not have enough capacity and connections to access the few qualities educational resources after the implementation of the double reduction policy 4 in addition yu and yao suggest that parents who lack cultural capital have weak information screening skills limited access to information and are prone to misunderstandings and anxiety about their understanding of education 19 under the influence of the double reduction policy outofschool tutoring institutions are regulated and inschool educational resources tend to be equitable however outofschool hobby classes and oneonone tutoring still exist outofschool resources need to be acquired through capital and relationships and family capital has become a major influencing factor affecting access to resources as a result the inequalities hidden behind family capital persist this includes unequal budgets for education differentiated levels of family education and unequal resources for education parents who are unable to break the capital barrier are forced into a vicious cycle of educational anxiety 18 intensive mothering influences the development of parental anxiety intensive mothering refers to the intensive parentchild relationship between child and parent which is characterised by a childcentred approach in which the mother spends a great deal of energy time and resources on childrearing 20 intensive mothering is considered to be a characteristic of most families following the modernisation and transformation of the family parents will prioritise their childrens material and emotional needs demand greater emotional commitment and have higher expectations of their children 20 in addition the high cost of raising a child translates into expectations of educational rewards and parents will place greater emphasis on rewarding utilitarian education although the double reduction policy has reduced childrens academic burdens parents worries about their childrens future remain in the context of limited educational resources and fierce competition for resources at the same time parents irrationally high expectations for their children and the high investment of family capital are hardly rewarded as expected intensive mothering in previous studies through literature research this study finds that intensive mothering can lead parents to have overly high expectations of their children this includes setting excessive goals for their children and hoping that education will yield tangible benefits however education struggles to meet the utilitarian mindset of parents and parents whose goals cannot be met can develop anxiety in addition some parents may experience selfdeprivation and role overstepping selfdeprivation refers to parents sacrificing their career plans to return to their families for the sake of their childrens education or boosting the education budget causing financial pressure on the family role overstepping is when parents develop an overly intimate relationship with their children and an excessive desire to control their childrens lives in terms of excessive expectations wang and ru refer to parents desire to achieve class mobility through education 15 parents overemphasise educational outcomes believing that entering university is a necessary option for success second some parents see education as a commodity 14 parents believe that the more they invest in education the more they get in return and overemphasise the instrumental value of education yu and yao cite the proverb a good scholar who studies with relative ease can become an official in which parents expect their children to have a higher social status through education 19 in addition some parents develop selfdeprivation in giving to their children for example parents increase their investment in their childrens education by cutting back on daily living expenses 18 such behaviour is irrational deliberately reducing the familys quality of life and putting hopes on the child gives the child a sense of pressure that parents are doing this for you which is not conducive to the childs development gao et al add that parental selfsacrifice includes cutting back on personal entertainment or original career plans in order to better educate the child 21 parents expectations of their childrens education become more difficult to meet and anxiety increases finally some parents can develop role overstepping for example the educational outcomes of their children are linked to the success or failure of their parents lives a child getting into a good university and getting a high paying job equates to parents achieving success some parents overinterfere with their childrens time friendships and even hobbies 21 for example they expect their children to devote all their time to study and not to be friends with classmates who do not study well the result of this role overstepping is conflict between the child and the parents and the child becoming bored with school parents expectations of their childrens education become more difficult to be met and anxiety increases although parentingintensive anxiety has been somewhat alleviated with the implementation of the double reduction policy the double reduction policy does not allow schools to ask parents to correct homework and parents do not need to accompany their children to subject tuition classes however childrens afterschool time requires higherquality parental companionship more emotional commitment from parents and parents have to make tradeoffs between work and family life highquality parenting and companionship squeeze parents time and space and parental education anxiety is difficult to alleviate conclusion this study has attempted to use theories of family capital and parenting intensity to explain the causes of parental anxiety in china this research is discussed by interpreting the theory collating previous research linking previous research to the theory and in the context of the double reduction policy in general the original intention of the double reduction policy was to reduce the burden on students and reduce outofschool tutoring before the implementation of the double reduction policy parents investment in their childrens education and comparisons with others can lead them into educational anxiety after the implementation of the double reduction policy the economic capital in family capital cannot be used to invest in extracurricular training in subjects and parents education anxiety is somewhat alleviated however the cultural and social capital of family capital is beginning to reveal its importance parents with limited family capital find it difficult to invest in interestbased training personally tutor their children and access more educational resources and become more anxious in the competition for education in addition from a parentingintensive perspective parents find it difficult to fulfil their responsibility to educate their children and pour their expectations into the international conference on interdisciplinary humanities and communication studies doi 105425427537048520220573 schools and outofschool tutoring institutions parents high expectations of their children and their utilitarian mentality towards the rewards of education remain unabated when high expectations are not met parental anxiety remains pervasive secondly changes in education policy will not completely change the status of parental anxiety and its causes as anxiety does not result from a single factor in addition it takes time for policies to be implemented and evaluated and there is room to expand the data and information on the double reduction policy the causes of educational anxiety in the context of the double reduction policy need to be studied in more depth

china introduced a double reduction policy in 2021 but the survey found that parental education anxiety has not been sufficiently reduced in order to reduce anxiety the causes of the anxiety phenomenon need to be traced through documentary research this study collated and summarised previous research and connected it with family capital theory and intensive mothering theory to explain the causes of anxiety it is found that the limited economic cultural and social capital in a family can cause parental anxiety parents anxiety is also affected when limited resources are confronted with parentingintensive parents high expectations of their children and utilitarian expectations of educational returns

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methods study design setting and sample the study used data from the baseline wave of the health and ageing in africaa longitudinal study in an indepth community 26 in brief haalsi is a longitudinal cohort study which recruited individuals aged ≥ 40 years who are enrolled in the agincourt health and demographic surveillance systems and resident in the bushbuckridge subdistrict of rural mpumalanga northeast south africa haalsi aims to describe biological social and economic determinants and consequences of health and ageing in rural south africa 26 the agincourt hdss which is hosted by the south african medical research councilwits university rural public health and health transitions research unit has since 1992 collected longitudinal populationlevel data on vital demographic events and other key health social and economic indicators in the agincourt study site 26 out of a total number of 12875 eligible individuals from the agincourt hdss population 6281 were randomly selected to participate in the haalsi study and 5059 completed the baseline wave data from all 5059 enrolled participants were analysed in our study study visits collection of data for the baseline wave of the haalsi study took place between november 2014 and november 2015 trained fieldworkers visited participants in their homes and collected data on sociodemographic variables and selfreported health status and risk factors using computerassisted personal interviews and performed clinical assessments including blood pressure and pointofcare biomarkers dried blood spots were also collected for assessment of hiv serostatus and viral load the survey instruments were translated from english into xitsonga the local language and responses were back translated into english to ensure reliability translation was performed by experienced members of the unit staff with further minor modifications by the fieldworkers who conducted the interviews to ensure the language used was in keeping with the vernacular 26 study variables sociodemographic variables sociodemographic variables were selfreported and included age marital status employment status educational attainment marital status number of individuals living in household and principal component analysis was used to create a wealth index from household characteristics and asset ownership 27 chronic illnesses and measurements body mass index was calculated from objective measures of weight divided by square height and who bmi categories were used 28 a total of 8 chronic illnesses were included in our study and defined by both objective measures 29 and selfreport presumptive diagnosis of hypertension diabetes and dyslipidaemia was through the existing selfreport of the diagnosis of the conditions additionally objective measures were used to verify this hypertensionmean systolic blood pressure ≥ 140 mmhg or mean diastolic blood pressure ≥ 90 mmhgwas calculated from the second and third of three consecutive measurements during the home visit 30 for those not on hypertension treatment those on hypertension treatment were classified as hypertensives regardless of the blood pressure measurement results at a home visit diabetes mellitusfasting glucose ≥ 7 mmoll or random glucose ≥ 111 mmoll on pointofcare testing during the home visit 31 and dyslipidaemiatotal cholesterol 621 mmoll highdensity lipoprotein 119 mmoll lowdensity lipoprotein 41 mmoll or triglycerides 225 mmoll on pointofcare testing 29 anaemia was defined as haemoglobin 12 gdl in women and 13 gdl in men on pointofcare testing 32 individuals were considered hiv positive if dried blood spots were positive on screening and subsequent confirmatory tests dried blood spots from individuals who tested positive for hiv were then tested for hiv1 rna angina was defined using the rose criteria 33 and chronic bronchitis was defined as a selfreported daily cough productive of phlegm for at least 3 months per year for at least 2 successive years 34 participants were classified as having depression if they identified three or more symptoms on the centre for epidemiological studiesdepression scale 35 while posttraumatic stress disorder was defined as a score ≥ 4 on the breslau scale 36 multimorbidity with hiv and multimorbidity without hiv about a third of the participants in this study were living with hiv as such in this study and the previous studies from the same cohort have classified multimorbidity into hiv multimorbidity and multimorbidity without hiv 37 participants were considered to have hiv multimorbidity if they had two or more of these chronic illnesses including hiv 293839 we further classified the subset of individuals who presented more than one of the listed conditions but did not have hiv as one of their chronic conditions as having multimorbidity without hiv the chronic illnesses included were selected to ensure comparability with health and retirement survey sister studies as well as to obtain further data on conditions which are prevalent in the agincourt hdss study area 26 statistical analysis data management preprocessing and analysis was conducted using stata v170 the continuous variables were categorised the bmi was categorised according to who classification 28 and all analyses were stratified by sex descriptive statistics were computed and reported as frequencies and proportionsthis was done for sociodemographic factors alcohol use patterns and the prevalence of chronic conditions the chi 2 test was used to assess the strength of the association between individual sociodemographic and household factors and multimorbidity age body mass index wealth asset index and educational attainment were considered as a priori confounders and sex 40 41 and therefore added in the multivariable modified poisson regression models regardless of the univariate pvalues all other variables were entered in the multivariable models if they had a pvalue 020 from the univariate analyses furthermore we have reported the direct acyclic graph on causal associations of alcohol use and multimorbidity we reported adjusted relative risk and their corresponding 95 confidence intervals any factor with a pvalue 005 was considered statistically significantly associated with the outcomes of interest ethical considerations results study population characteristics the haalsi study randomly selected 6281 participants 40 years and older from the agincourt hdss a total of 5059 were reachable available consented to take part and were enrolled in the baseline wave of the study from them 2345 were male and 2714 were female the more frequent age group was between the ages of 5059 years old a third had a normal bmi and three quarters were not working almost half of them had no formal education and lived in a 36person household a fifth of them belonged to households with the poorest wealth status while the rest consumed it at least once a month the overall prevalence of multimorbidity with hiv was 596 and was similar in both males and females the prevalence of multimorbidity without hiv was 525 and was similar in males and females alcohol use and hiv multimorbidity reported alcohol use was associated with hiv multimorbidity specifically those reporting ever using alcohol had 5 increased risk of hiv multimorbidity compared to those who had never used alcohol before this was similar in males and females the reported current alcohol use was associated with 3 lower risk of hiv multimorbidity among all participants and among females and 2 lower risk of hiv multimorbidity in males but these were not statistically significant other factors associated with hiv multimorbidity among all participants other factors that were significantly associated with hiv multimorbidity among all participants were bmispecifically the overweight category had a 10 higher risk and the obese category had a 12 higher risk compared to the normal weight category marital statusespecially in those reporting being separated or divorced and widowed in comparison to those who had never been married before on the contrary the following factors were found to be protective against hiv multimorbidity educationspecifically those who reporting completed secondary education or more had an 8 lower risk when compared to those who had no formal education and individuals living in a 36person household who had a 5 lower risk compared to those living alone among females among females other factors that were significantly associated with hiv multimorbidity were marital statusthose reporting being separated or divorced had a 14 higher risk whereas educational level had protective effect with those who completed secondary level or more having a 10 lower risk among males among males factors that were significantly associated with hiv multimorbidity were bmithose in the overweight and obese categories had 10 higher risk and 15 respectively compared to normal weight category marital statusthose who were widowed had a 19 higher risk and those who reporting currently married had a 14 higher risk and wealth indexthose in the richest category compared to those in the poorest wealth category however protective factors included individuals living in a 36person householdwho had an 11 lower risk alcohol use and multimorbidity without hiv reported alcohol use was associated with multimorbidity without hiv specifically those reporting ever used alcohol had 5 higher risk of multimorbidity without hiv among all participants and this was similar in males and females the reported current alcohol use was associated with 3 lower risk of multimorbidity without hiv among all participants and those who were currently married had a 12 higher risk among females among females other factors that were significantly associated with multimorbidity without hiv were agethose aged 5059 years had an 11 higher risk 6069 yearsolds and 7079 year olds both had 14 higher risk and those aged 80 years had 18 higher risk bmiamong those in the overweight and obese categories and marital status those separated or divorced had 21 higher risk and those who were widowed had a 15 higher risk among males among males other factors that were significantly associated with multimorbidity without hiv were age6069 years olds had 17 higher risk 7079 year olds had 19 higher risk and 80 year olds had 34 higher risk bmiamong those categorized as overweight and obese specifically the overweight had 17 higher risk and being obese had 22 higher risk and wealth asset index the richest category had 9 higher risk sensitivity analyses we performed a sensitivity analysis to assess the association between alcohol use and multimorbidity using these reported alcohol use frequency categories never ever at least once in the last 30 days and at least once a week similar results were obtained for both hiv multimorbidity and multimorbidity without hiv this was done to determine the impact of alcohol dose frequency on multimorbidity and findings were similar to the presented alcohol use categories discussion we sought to determine the association between reported alcohol use and multimorbidity in a population of individuals aged ≥ 40 years in rural south africa in this analysis we found that reported alcohol use was common with almost half of the population reporting ever used alcohol also the reported alcohol use was modestly associated with hiv multimorbidity and multimorbidity without hiv the observed prevalence of reported alcohol use in this study was 446 which is similar to the who reported estimate of 43 among those aged 15 years and above in africa 242 in this study across all alcohol use categories males reported higher and more frequent alcohol consumption than females alcohol consumption is an activity dominated by males with a prevalence reported to be 54 in males and 32 in females and mainly attributed to cultural roles of males and females 43 the prevalence of multimorbidity with hiv in the study population was higher than that of multimorbidity without hiv that is partly explained by the interaction of hiv with various ncds the overall prevalence of multimorbidity in this study is within the range of the previously reported prevalence of multimorbidity among older adults in south africa and in lowand middleincome countries 4445 reported ever use alcohol was associated with both multimorbidity with and without hiv in this study population as well as only in females this may have resulted from a visible doseresponse of prior alcohol use that was ceased possibly due to efforts made by individuals to manage multimorbidity 25 previous studies on alcohol use and multimorbidity reported that alcohol use was associated with multimorbidity 112546 and ncds 131447 especially in the elderly 111464849 that could be mainly due to the toxic biochemical effects of alcohol 25 the association between reported alcohol use and both multimorbidity with and without hiv in males was not statistically significant other studies from high income countries reported a significant association of alcohol on ncds in males and slightly beneficial for femalesowing to the beneficial effect of light to moderate alcohol consumption on both diabetes and ischaemic disease 47 these contradictions raise concerns to the accuracy of reporting of alcohol use in our study population pointing towards the likelihood of underreporting due to social desirability 50 although nonsignificant a more protective association was observed across the entire population of individuals who used alcohol in the last 30 days and both multimorbidity with and without hiv this could be due to underreporting of alcohol use 50 findings of this study should be interpreted with caution considering the following limitations social desirability bias caused by underreporting of alcohol consumption patterns commonly occurs in multimorbid individualswhich although uncertain may have been the case in our study if this was the case this may have resulted in the underreporting of ever alcohol use by participants who were told to stop alcohol consumption due to the development of multimorbidity these incidences of underreporting may have either biased the results towards the null or caused an overestimate of the effect it is therefore critical to validate reported alcohol consumption using a biomarker especially in chronic diseases management settings the crosssectional nature of this study could not allow us to determine the directionality of causation between alcohol use and multimorbidity overall alcohol use is a significant problem in rural south africa and globally alcohol use has been associated with chronic conditions and odds of having more than one chronic condition at a time in rural south africa and elsewhere in africa despite that there has been no coordinated alcohol intervention response with fragmented strategies being implemented across different governmental levels and departments 51 two scoping reviews reported on the lack of individual level interventions and integration of such interventions in primary health care settings in subsaharan africa 910 conclusion reported alcohol use and multimorbidity were common among adults in rural south africa ever used alcohol was associated with both multimorbidity with and without hiv current alcohol use was not associated with multimorbidity potentially due to underreporting because of social desirability there is an urgent need to integrate alcohol interventions in the management of ncds and multimorbidity and such interventions should include an objective assessment of alcohol consumption data availability data are available in a public open access repository any additional data requests could be directed to the haalsi baseline data are publicly available at the harvard centre for population and development studies programme website haalsi org data competing interests the authors declare no competing interests

we assessed the prevalence of reported alcohol use and its association with multimorbidity among adults aged 40 years and above in a rural transitioning south african setting findings could potentially inform alcohol interventions integration in the prevention and treatment of chronic conditions we analysed data from the first wave of the health and ageing in africaa longitudinal study in an indepth community haalsi nested within the agincourt health and demographic surveillance systems conducted between november 2014 and november 2015 n 5059 we computed descriptive statistics and performed univariate analysis to determine factors independently associated with multimorbidity age body mass index education sex and household wealth status and variables with a pvalue 020 in univariate analysis were included in multivariable modified poisson regression models any factors with a pvalue of 005 in the final models were considered statistically significant the first wave of haalsi was completed by 5059 participants aged 40 years and above and included 2714 536 females the prevalence of reported ever alcohol use was 446 n 2253 and of these 519 n 1171 reported alcohol use in the last 30 days the prevalence of hiv multimorbidity was 596 30145059 and for multimorbidity without hiv 525 26575059 alcohol use was associated with hiv multimorbidity among all participants rr 105 95 ci 102108 and separately for males rr 105 95 ci 100110 and females rr 106 95 ci 102111 similarly alcohol use was associated with multimorbidity without hiv among all participants rr 105 95 ci 102109 and separately for males rr 106 95 ci 100112 and females rr 106 95 ci 101111 reported alcohol use was common and associated with hiv multimorbidity and multimorbidity without hiv among older adults in rural northeast south africa there is a need to integrate screening brief interventions and referral for alcohol treatment in the existing prevention and treatment of multimorbidity in south africa

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introduction globally in 2017 approximately 39 million youths were infected with hiv 1 and it was increased by 30 between 2005 2016 12 in subsaharan africa young and adolescent are particularly vulnerable to hiv and other sexually transmitted infections of all youth women living with hiv worldwide 80 of women live in ssa 3 4 5 in 2017 the national hiv prevalence in ethiopia was estimated to be 116 6 currently in ethiopia 62 of the total people living with hiv were female 7 onethird of the ethiopian total population are young peoples and approximately half of them were females 7 youth and adolescents are extremely affected by hivaids and other sexually transmitted infections 68 but the majority of youth did not know their hiv serostatus therefore undiagnosed hiv infections are still high among sexually active segments of the population 9 identifying 90 of the people infected with hiv was the first and crucial goal established by the ethiopian ministry of health in 2016 because of the increasing number of new hiv infections 1011 the goal will be achieved by improving hiv testing practice 12 timely hiv testing is crucial for early diagnosis and enrollment to hiv chronic care which reduced the probability of transmission and hivrelated mortality 1314 it is also important to promote hiv prevention among the negatives 9 the majority of youth in ssa including ethiopia have not been tested for hiv past evidence revealed that only 3255 of youth have been tested for hiv in their life 15 16 17 18 similarly a recent populationbased survey in ethiopia showed only 40 of women previously tested prior to the survey 8 which implies a significant number of hiv seropositive people did not know their hivpositive serostatus therefore identifying the barriers and enablers to uptake hiv testing is crucial to improve hiv testing practice among population groups who participate in highrisk behaviors previous studies have identified age residence education status wealth index used condom at last sex consistent condom use access to general medical care access to hiv testing knowledge of hiv and substance use 19 20 21 22 23 24 25 as factors that affect hiv testing but the identified factors vary from population to population and from country to country most of the studies in ethiopia have focused only on pregnant mothers whose hiv testing practice and healthseeking behaviors were different from the young and adolescent populations therefore information regarding barriers to hiv testing specific to the youth population was limited in ethiopia 8 most of the previous studies did not assess the effect of discriminatory attitudes towards plhivon hiv testing practice except a study done in kenya reported as an obstacle to hiv testing 26 the current study also tried to answer this information gap furthermore nationwide information regarding hiv testing is needed to accelerate progress towards the three 90s goals in the country therefore this study aimed to identify barriers and facilitators for hiv testing practice on youth women in ethiopia using data from a nationalbased household survey to inform future policymakers for designing gender and agespecific interventions materials and methods data sources and study population this analysis used secondary data from the 2016 edhs data were obtained from the dhs program website in 2016 edhs five questionnaires were used the household questionnaire the womans questionnaire mens questionnaire the biomarker questionnaire and the health facility questionnaire however in this analysis the authors used only womens data in 2016 edhs 15683 reproductiveage women have participated in the survey after excluding women beyond the youth age group we restrict our analytical sample to 6401 women aged 1524 years a detailed explanation of the methodology of 2016 edhs is found somewhere else 8 description of 2016 edhs in 2016 edhs the sampling frame was the 2007 ethiopia population and housing census the census consists of 84915 enumeration areas one enumeration area was covering on average 181 households during 2016 edhs ethiopia has nine geographical regions and two administrative cities the sample of 2016 edhs was selected in two stages each region was stratified into urban and rural areas yielding 21 sampling strata samples of enumeration areas were selected independently in each stratum in two stages all reproductiveage women who were either permanent residents or visitors who stayed in the selected household the night before the survey were eligible to be interviewed study variables and measurements the main outcome variable was hiv testing practice age residence educational status wealth index media exposure internet use substance use condom use at last sex number of sexual partners selfreported history of sexually transmitted infections hivrelated stigma and comprehensive knowledge on hiv were the independent variables submit in 2016 edhs comprehensive knowledge on hiv aids was measured using the following five items 1 having just one uninfected faithful partner can reduce the chance of getting hiv 2 consistent use of condoms during sexual intercourse can reduce the chance of getting hiv 3 healthylooking person can have hiv 4 hiv can be transmitted by mosquito bites and 5 a person can become infected by sharing food with a person who has hiv having a comprehensive knowledge of hiv was defined if respondents responded to all five questions correctly access to media was classified depending on the answer to how often women read a newspaper listened to the radio or watched television women who answered at least once a week to any of these media were considered to have access to media substance use was measured based on the response to whether or not participants chew chat drink alcohol or smoke cigarettes hivrelated discrimination was computed from two questions would you buy vegetables from a vendor with hiv and children with hiv should be allowed to attend school with children without hiv women who respond yes for the above two questions categorized as nonstigma and discriminatory attitude and who responded no or i dont know for one or more questions categorized as have stigma and discriminatory attitude statistical analysis participant characteristics were summarized using frequency and weighted percentage a multivariable logistic regression model was used to determine the predictors of hiv testing uptake all possible variables were included in the final regression model regardless of the pvalues at the bivariable regression model adjusted odds ratios with 95 ci were used to measure the association between the independent and outcome variable all statistical techniques used a complex sampling design applied in the 2016 edhs results participant sociodemographic characteristics from the total participants about 55 were found in the age group between 15 and 19 years the majority of respondents were rural residents within this sample 430 of youth women were orthodox religion followers about 57 were single in marital status and 20 of youth women did not attend formal education nearly 90 of youths women ever chewed chat only 243 of women had a comprehensive knowledge of hiv and only 75 of youth women used the internet hiv testing practice the magnitude of hiv testing uptake in youth women was 377 among hivtested women the majority were in the age group between 20 and 24 years and 65 were from rural residents nearly twothirds of hivtested participants had media access but only onethird of women had a comprehensive knowledge of hiv barriers and facilitators for hiv testing marital status wealth index level of education media exposure comprehensive knowledge of hiv and discriminatory attitude were significantly associated with hiv testing in the multivariate analysis model in this study the odds of being tested for hiv were 5 times aor47 95 ci higher among married women 62 times aor616 95 ci higher among divorced than single the odds of being tested for hiv were higher among women with a primary level of education aor 24 95 ci and secondary level of education aor40 95 ci when compared to those with no formal education women found in the richer wealth index group were 23 times at higher odds of testing for hiv as compared to the lowest group similarly women found in the richest level of wealth index were 3 times more likely to be tested for hiv youth women with a lack of media access had a 31 reduction in the odds of testing uptake aor 069 95 ci similarly participants with poor comprehensive hiv knowledge had a 32 aor 068 95 ci lower probability of hiv testing as compared to their counterpart similarly women who have discriminatory attitudes have lower hiv testing practice aor07995 ci compared to those who have no discriminatory attitude discussion using national survey data we found that only onethird of women were tested for hiv in their lifetime which is similar to previous studies in africa 1527 hivaids research and palliative care 202012 submit your manuscript dovepress 965 but much lower than a study done in zimbabwe 18 the current study is restricted to youth women age 1524 years which may account for the differences in findings most of the hiv testing programs in ethiopia targets key populations which include adolescents and young age groups although youths were identified as a target group for hiv testing in ethiopia the current finding suggests that a substantial number of youth women were unaware of their hiv status persons with unknown hiv status might enhance ongoing hiv transmission to accelerate progress toward achieving the three 90s goal the ethiopian ministry of health and its partners should increase hiv testing coverage in communities particularly in the adolescents and young population 966 comparable to prior research from zimbabwe and uganda 1828 married women had a higher probability of being tested for hiv than never in a union in ethiopia hiv testing before marriage for couples has been introduced as one approach to improving hiv testing coverage prior to the 2016 edhs this might initiate married women to know their hiv status better than single in addition women who are married might be tested during pregnancy finally it might be because women with relationships might perceive their own risk of being infected with hiv in this study educational attainment is an important facilitator of hiv testing a high educational level is associated with good hiv testing practice because of continued exposure to hiv prevention information that is more freely available in the school system than in the community 2229 educated women were found to be more knowledgeable on the benefit of testing like prevention of mothertochild transmission 30 which might initiate women to be tested for hiv finally education might improve testing practice through improved recognition of the significance of knowing ones hiv status and greater control over the decision to test thus hiv testing approach should be emphasized among uneducated youth women existing evidence has recommended that wealth index is vital in influencing hiv testing practices 31 good economic status might be related to improved awareness of risks and reduce financial barriers to testing this study also revealed that the highest wealth index was associated with an increased likelihood of testing for hiv even if the test was free of charge in all government health institutions in ethiopia youth prefer private health institutions for their confidentiality 8 lack of money might be a barrier for hiv testing in private health institutions as pointed in the past evidence 32 the other important finding is that good media access is positively associated with hiv testing which is supported by previous studies done in east africa 3334 media exposure increases awareness about the importance of hiv testing and improves the understanding of the prevention approach which might initiate women to be tested for hiv this finding points to the need for governmental and nongovernmental organizations to use several types of media in convincing youths to constantly learn about the benefit of hiv testing and to know their hiv status the current finding also showed that women who have no comprehensive hiv knowledge were less likely to be tested for hiv this suggests that creating awareness about hiv in societies leads to an increase in the practice of hiv testing this finding was supported by previous studies done in different parts of the world 303536 in opposite to this there was no association in a previous study conducted in zimbabwe 18 as previously documented this study shows that women who had a discriminatory attitude were less likely to be tested for hiv 837 the attitudes and perceptions related to hiv mode of transmission can be an important barrier to hiv testing and can operate on an individual level and institutional levels such as in healthcare services 3038 the current study has several strengths such as a large nationally representative sample size availability of detailed data on confounders and standardized and highquality data collection tool however there are several limitations to consider first we cannot assign causality because the data were crosssectional secondly in the original survey data were collected based on selfreport which might result in social desirability biases conclusion in ethiopia hiv testing for the youth population is a public health priority as the new infection is significantly high among this age group however hiv testing practice among youth is still low in our study being married secondary level of education and high wealth index category were facilitators for hiv testing lack of media access lack of comprehensive knowledge about hiv and having discriminatory attitudes were the barriers to hiv testing practice therefore promotion of education improves hivrelated knowledge strengthens mass media awareness campaigns and minimizes discriminatory attitudes may be the possible means to increase hiv testing practice in ethiopia future researchers should consider institutional level factors like lack of staff training and maintenance of confidentiality data sharing statement the data can be available from the corresponding author and dhs database abbreviations aor adjusted odds ratio cor crude odds ratio edhs ethiopia demographic health survey hiv human immunodeficiency virus plhiv people living with hiv spss statistical package for social science ethical approval and consent to participate the investigators have accessed the edhs survey data from the dhs program website gramcom and then the researchers have maintained the confidentiality of the data consent for publication not applicable disclosure the authors declare that they have no competing interests dovepress publish your work in this journal hivaids research and palliative care is an international peerreviewed openaccess journal focusing on advances in research in hiv its clinical progression and management options including antiviral treatment palliative care and public healthcare policies to control viral spread the manuscript management system is completely online and includes a very quick and fair peerreview system which is all easy to use visit to read real quotes from published authors

background in developing countries youth women are most at risk of hiv infection center for disease control recommends that people who participate in highrisk behaviors get tested for hiv at least annually in 2016 the ethiopian ministry of health set goals to identify 90 of the people living with hiv by 2030 but undiagnosed hiv infections are still high in the country to alleviate the problem it is vital to identify the factors that hinder hiv testing practice therefore this study aimed to identify the facilitators and barriers of hiv testing practice among ethiopian youth women methods the analysis was done on 6401 women aged 1524 years using data from the 2016 ethiopia demographic health survey edhs the main outcome variable was selfreported hiv testing practice multivariable logistic regression was used to identify the facilitators and barriers of hiv testing practice results in this study 377 95 ci 336 391 of youth women were tested for hiv in their life being married aor47 95 ci 367 601 divorced aor62 95 ci 398954 having primary level of education aor2495 ci 179313 and secondary level of education aor40 95 ci 287563 being rich aor2395 ci 139391 and being in the highest wealth index catagory aor2695 ci 130516 increase the odds of hiv testing however lack of media acccess aor 07 95 ci 054087 lack of comprehensive hiv knowledge aor 068 65 ci 053086 and having discriminatory attitude towards plhiv aor07995 ci 064097 decrease the odds of hiv testingthe practice of hiv testing among youth populations was low as compared to national recommendations lack of media access lack of comprehensive knowledge about hiv and having discriminatory attitudes were the barriers to hiv testing practice marriage secondary or higher education attainment and high wealth index category were the facilitators for hiv testing improving hivrelated knowledge improving media access and minimizing discriminatory attitudes are strongly recommended to promote hiv testing practice

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introduction the novel confessions of an old boy by kam raslan tells the story of a young malay boy who is brainwashed by the colonial ideology he obtains his early education in malaya receiving an english education as an adolescent he enters the malay college kuala kangsar an allmale elite college known as the eaton of the east the british education that this character receives has a strong influence on his thinking and his way of life as an adult working as a civil servant with the ruling government his visits to europe geneva london and paris make a further impact on him he acquires the english customs and values the protagonist dato hamid who according to kam raslan really did exist was born in the 1920s during the time in which the british rule in malaya was at its peak as this character gets older he finds it even more difficult to bring himself back to his malay roots this novel depicts the struggle of the colonised people to liberate the self from colonial influence hence at the end of the novel the assimilation and adaptation of the european culture leaves the native to reform his way of life this paper begins its analysis by looking at the noun confessions in the title of kam raslans novel confessions of an old boy the dato hamid adventures the merriamwebster online dictionary defines confession as an act of confessing a disclosure of ones sins in the sacrament of reconciliation or a statement of what is confessed a written or oral acknowledgment of guilt by a party accused of an offence the word confession is synonymous with autobiography merriamwebsters encyclopaedia of literature defines autobiography as either real or fictitious in which intimate and hidden details of the subjects life are revealed thus this novel can be considered autobiographical in nature as it reveals ones life experience feelings and thoughts in routledge encylopedia of narrative theory herman and his coeditors define confession as confession as opposed to memoir for instance implies that the speaker or writer wishes or even needs to reveal something that is hidden possibly shameful and difficult to articulate confession is predicted on selfawareness and the search for selfknowledge in light of these definitions one can deduce from the title confessions of an old boy that the story is a detailed account of the protagonists life furthermore as the story is in the firstperson narrative the novel can be categorised as what herman and his coeditors term a confessional narrative which they suggest can either be memoirs letters diaries or footofthe gallows of confessions of a crime thus the novel confessions of an old boy the dato hamid adventures can be regarded as an articulation and revelation of the self but filtered through the writers perspective ambivalence of the anglophile subject according to michael foucault knowledge and power permits the coloniser to construct the image of the colonised as part of their strategy in discourse the coloniser has created the image of the colonised as the other these derogatory images of the colonised world have become embedded in the minds of some people to the extent that although colonisation has long ended mental colonisation continues among some sections of the previously colonised peoples the colonised have tried to free themselves from this binary worldview by adopting western values which are deemed by the coloniser as superior to the local values this means that colonialism has in fact led to cultural assimilation as a british colony the natives of malaya were exposed to the english culture many embraced western traditions and as a result became hybrid identities in postcolonial studies the key concepts ashcroft griffiths and tiffin define hybridity as the creation of new transcultural forms within the contact zone produced by colonization the authors state that hybridisation takes on many forms linguistic cultural political racial etc in malaya those who became anglophile subjects were mostly from the upperclass as they had experienced the british education system it was apparent that british education had shaped their worldview thus the malay anglophile subjects are mostly those who are intellectual elites occupying high positions in the society it is this formation of the hybrid anglophile identity and the factors that contribute to its formation that this study seeks to highlight postcolonial scholars state that the anglophile individual not only faces an identity crisis but is also ambivalence in hisher perception of the self and other this hybrid subject looks at the west as superior while perceiving the east as inferior it is the postcolonial writer according to boehmer who tries to dismantle and resist colonialist perspectives a study of kam raslans anglophile character dato hamid provides an insight into the ambivalence and double consciousness faced by the hybrid subject ambivalence is a prominent concept in postcolonial studies it is becoming an increasingly important subject of study as we step into the world of globalisation according to ashcroft griffiths and tiffin ambivalence was first used in psychoanalysis to describe a continual fluctuation between wanting one thing and wanting its opposite a simultaneous attraction toward and repulsion from an object person or action it is this fluctuation of interest between wanting one thing and wanting its opposite at the same time that invites bhabha to use this term in his analysis of representation in colonialist discourse bhabha defines ambivalence as attraction and repulsion that characterises the relationship between the coloniser and the colonised thus he develops the concept of ambivalence of the colonialist discourse the notion of ambivalence is to prove that the relationship between the coloniser and the colonised is constantly unfixed and that the sense of ambivalence also destabilizes the claim for absolute authority or unquestionable authenticity between the colonial master and the colonial slave bhabhas concept of ambivalence in colonialist discourse states that the idea is developed by the colonised subjects who reproduce the colonisers habits and values through mimicry the reason as bhabha states is that mimicking is seen as an effective strategy of colonial power by becoming mimic men the colonised subject will no longer be his self but turn into a replica of the coloniser however this also threatens the status quo of the relationship between the coloniser and the colonised by mimicking the coloniser the subject becomes almost the same but not quite the main agenda behind colonialist discourse was to exercise power and control over the colonised bhabha argues that through such control of representation in discourse the colonised peoples became the subject of the coloniser these writings were also full of hybrid identities like the mimic mennatives who imitate western values in the novel confessions of an old boy the dato hamid adventures the portrayal of such identity is apparent although the lead character is attracted to the european culture at times he feels otherwise therefore this sense of ambivalence becomes a threat in perpetuating the colonial discourse marics article entitled postcolonial readings of identity in arundhati roys the god of small things and kiran desais the inheritance of loss ambivalence and mimicry discusses the issue of identity of the anglophile and states that the construction of the colonial subject does not reside in an overt opposition but in the inherent ambivalence of the dominant colonial discourse which needs but simultaneously rejects its colonised other the characters in both narratives papachi in the god of small things and the judge in the inheritance of loss contest their local identity as a result of victimisation and subjugation by the coloniser pappachi has so internalized the values beliefs and ideologies of the colonizers that he cannot countenance criticism or question anyone he sees as representative of that system the judge on the other hand has rejected his own culture and later joined the indian civil service that adapted the british ruling system hence it shows how both characters struggled to rethink their lost identity in a similar work bhabhas notion of mimicry and ambivalence in vs naipauls a bend in the river kumar focuses on anglophile ambivalence faced by the diaspora who exhibit mixed feelings through the essential dichotomies marking the lives of émigrés the dichotomies such as lovehate relationships contradictions between self and other nativealien clash of cultures are all portrayed in the novel and discloses the representation of ambivalence in colonial discourse salim the protagonist in the novel says i wanted to break away to break away from my family and community also meant breaking away from my unspoken commitment… this connotes his preference for the colonial culture as he tries to desert his own cultural roots however the severe act of mimicking the janusfaced lovehate attitude of the mimic men according to bhabha gives rise to the mimicry that presents itself more in the form of menace than resemblance more in the form of rupture than consolidation he states that mimicry is a sign of double articulation and the effect of mimicry on the authority of colonial discourse is profound and disturbing for the emergence of the colonial is dependent on its representation upon some strategic limitation or prohibition within the authoritative discourse itself… so that mimicry is at once resemblance and a menace the menace is greater than the resemblance in short severe mimicking is detrimental to the speakers fluency and true competency mimicry is defined as the exaggeration and repetition of language culture and manners with a difference in defining mimicry taylor takes bhabhas stand where he defines mimicry as similarity or resemblance with a difference it is never a perfect copy and here in lies its power to create anxiety on the part of the colonized this suggests that mimicry does not indicate a hundred percent similarity by mimicking the coloniser the colonised becomes almost like the coloniser but retains some elements of difference and by mimicking the cultural norms of the colonizer the colonized contest s the colonial subjects construction mimicry according to bhabha is a form of resistance of the colonised that destabilises the domination of the colonial discourse bhabha writes resistance is not necessarily an oppositional act of political intention nor is it the simple negation or the exclusion of the content of another culture as difference once perceived but the effect of an ambivalence produced within the rules of recognition of dominating discourses as they articulate the signs of cultural difference the act of mimicking is also seen as disrupting the colonial authority in the essay of mimicry and man bhabha defines mimicry as one of the most elusive and effective strategies of colonial power and knowledge however at the same time bhabha acknowledges that mimicry creates ambivalence and uncertainty when he argues that mimicry is the most negative effect resulting from cultural imperialism quoting jacques lacans essay the line of light of the gaze bhabha states mimicry reveals in so far as it is distinct from what might be called an itself that is behind the effect of mimicry is camouflage… it is not a question of harmonizing with the background but against a mottled background of becoming mottled exactly like the technique of camouflage practiced in human warfare the concept of mimicry suggested by bhabha is relevant to fanons black skin white masks which portrays a mimic man who tries to behave like an englishman but his looks fail him he is not accepted as english bhabha puts this very aptly as to be anglicized is emphatically not to be english this notion of mimicry is also portrayed in kam raslans novel where the protagonist gives preference to the colonisers culture and rejects his own ancestral values mimic men eternalise english values these characters imitate the ways of the colonisers in their dressing socialising the consumption of alcohol as well as lifestyle a eurocentric lens is commissioned in every aspect as the standard of judgment the reason behind this is to get recognition from the white man this desire to be white according to fanon exists in the coloniseds soul fanon states out of the blackest part of my soul across the zebra stripping of my mind surges this desire to be suddenly white i wish to be acknowledged not as black but as white this brings to question the instinct and intention of human beings perhaps there is always the desire to be what one is not for example for the dark complexioned to have fair skin and for the fairskinned having the desire to be tanned the question of what a man desires is very fittingly dealt with in kam raslans novel confessions of an old boy the dato hamid adventures mimicking the white culture is clearly eurocentric and shows a form of western hegemony eurocentrism and western hegemony are two central issues that cannot be ignored in the study of postcolonialism eurocentrism a term introduced by the italian scholar antonio gramsci is fundamental to this study of hybrid characters in kam raslans novel the term can be understood as the conscious and unconscious process by which europe and european cultural assumptions are constructed as or assumed to be the normal the natural or the universal in postcolonial studies eurocentrism or privileging and placing the european culture at the centre of all things led the way for the establishment of european systems and values as inherently superior to indigenous ones mimic men or the colonised people inhibit dual roles and a dual identity simultaneously position themselves as both the coloniser and the colonised thus the mimic men who embrace the white culture relegating all other cultures including his own would find himself living in the state of double consciousness the mimic man who is almost the same but not quite constitutes only a partial representation this means that the colonial culture is always potentially and strategically insurgent thus mimicry is the sign of double articulation a complex strategy of reform regulation and discipline which appropriates the other as it visualises power and acts as a sign of the inappropriate a recalcitrant who colludes with the dominant strategic function of colonial power intensifies surveillance and poses an imminent threat to both normalised knowledge and disciplinary powers since he is now well versed in the world of the coloniser and potentially capable of falling back on his native leanings another important perspective in studying ambivalence is that it is also a recurrent feature in discussing the exile and displacement concepts experienced by diasporic individualswriters rabbani and singh illustrate the ambivalence of the diasporic identity in vs naipauls the mystic masseur which rose from psychological transformation resulting in displacement and exile the protagonist in the novel ganesh ramsumair is depicted as a character entrapped between two worlds and two cultures indian by origin but having settled in trinidad a caribbean island and under the british colonial rule and thus twice ambivalent this highlights that living in two different cultural upbringings can cause one to live in an ambivalent state furthermore double ambivalence can take place in the case of a diasporic individual who lives in exile in another country and in the state of a once colonised nation in the following section confessions of an old boy the dato hamid adventures is analysed in light of bhabhas concept of ambivalence of the anglophile subject in his perception of himself and of others the discussion exemplifies instances showing that the ambivalence of anglophile subjects disrupts colonial authority in the discourse analysis of confessions of an old boy in confessions of an old boy the dato hamid adventures kam raslan mainly discusses the effects of educational and cultural encounters on the anglophile subjects and how it contributes to their ambivalence the following discussion examines how dato hamid has become ambivalent in his perception of himself and also of others the analysis highlights how different encounters and glorification of the white culture transforms the subject into an ambivalent state ambivalence as faced by the anglophile subject can be seen to relate to several factors the protagonist becomes a hybrid personality when he receives an english education during the colonial rule in malaya to be more precise he received a colonial education from malay college kuala kangsar zawiah asserts that the introduction of the cambridge school certificate english literature syllabus have incongruously transplanted and produced a hybrid that has tended to bend westwards in search of light similarly we see that as a result of his english schooling background dato hamid speaks dresses and behaves like a white man the english education that he receives plants in him the seeds of imperial ideology and as the story progresses we witness how this character becomes so mesmerised by the british that he loses all sight of his native culture and tradition accordingly this anglophile subject adopts a eurocentric perception of the world around him the influence that the english education has on dato hamids mindset relates to what ashcroft griffiths and tiffin have to say in the postcolonial studies reader education becomes a technology of colonialist subjectification in two other important and intrinsically interwoven ways it establishes the locally english or british as normative through critical claims to universality of the values embodied in english literary texts and it represents the colonised to themselves as inherently inferior beings wild barbarous uncivilized kam raslans novel confessions of an old boy the dato hamid adventures depicts a character who is mentally colonised resulting from the british education he received dato hamid looks up to the colonisers culture to the extent that even his friend comments youre an englishman mid according to edward said these individuals look at the european identity as a superior one in comparison with all the noneuropean peoples and cultures dato hamid loses his self in his effort to become english this leaves him in a state of ambivalence thus it can be observed that the relationship between the coloniser and the colonised is not merely within the context of master and slave but extends beyond that it is a relationship that involves assimilation kam raslan who himself is of mixed lineage british mother and malay father portrays this identity conflict and a search for a sense of belonging with a change of mindset in the colonised native the natives culture is automatically affected according to ngugi wa thiongo english education brought about the destruction and distortion of the coloniseds cultures thiongo states where his own native languages were associated in his impressionable mind with low status humiliation corporal punishment slowfooted intelligence and ability or downright stupidity nonintelligibility and barbarism… if that kind of perception happens the result could be disastrous to top it off because employment with the british government of malaya meant honour dignity and achievement the colonised people were further made to revere the english culture and values the excerpt from kam raslans novel clearly portrays the aforementioned scenario in those days joining the civil service and working for the government was the highest badge of honour and who were selected to work us the educated ones qualified and experienced the aristocrats the malay elite the group of people who are always willing to accept changes… we knew what we were doing but we were always willing to accept new blood we also observe in the novel that the admiration for the english culture coupled with a british colonial education gives rise to a group of people termed the anglophile confessions of an old boy portrays the anglophile subjects awe for the english in many aspects such as language dress code behaviour relationships and lifestyle the novel reveals how the colonised anglophile subjects had embraced the colonising culture into their daily lives and glorified all that was english as dato hamid is an ambivalent anglophile subject the attraction of london life makes him want to settle there the night life the liberated women free thinking as well as boozing mesmerise him it was a wonderful hazy memory of cheap champagne busty girls laughter and late late nights in london basement and alleys aidan gives dato hamids character a bad boy tag for living an unislamic life as the story unfolds we learn of dato hamids extramarital relations with western women his first lover was anna who dato hamid planned to marry in geneva in 1949 dato hamid informed anna of his plan as they entered the barn and thought to himself ill never forget that moment… the smell of the hay… at which point she leapt onto me and we soon discovered such ecstasy as we had never experienced before the next woman was alexandra who dato hamid flirted with dato hamid through an anglophile lens looks back at these relationships proudly and thought to himself as i sat there amidst the warm glow of three generations of the fruit of my loins … what my grandson might call a love machine dato hamids affairs with western women can be seen as what bhabha regards as the troubled structures of sexuality which is in itself a metaphor for colonial ambivalence desire of hybridity in other instances dato hamid embraces the english way of life in dressing and socialising to him all that relates to the english or england is a sign of grandeur this can be seen from his favourite beverage choice of reading material dressing sense and his entertainment preferences he hates air sirap and bandung both of which are local malayan beverages i hate sirap… it stands to reason that if i hate sirap then ill hate ayer bandung he is more comfortable socialising with liquor imported from the west in many of the occasions eventually the wife admitted tiredness and went to bed while the grandson and i listened to las nighttime soundtrack of police sirens and helicopters over a delicious cognac dato hamid was familiar with different brands of wine which he loved to drink fortunately the vichyssoise and a cheeky white wine managed to help settle my sense of shame that night i uncorked a bottle of hautbrion as far as his readings are concerned he reads only english materials read english novels… do you like mark twains huckleberry finn its amusing what does huckleberry finn have to do with anything i read about it in the business times and for entertainment he prefers the orchestra and opera and western music what are you doing at the opera… in the orchestra stalls and thats how i found myself at the dorchester standing on the balcony of my wonderful room overlooking the hyde park nursing a delicious twelveyearold single malt whilst reception was busily trying to get me a ticket to see the magic flute at the royal opera house and as far as dressing goes he thinks that the english attire is the best this is exemplified when he says a gorgeous doublebreasted gieves hawkes wool pinstripe suit precisely the english cut that i adore but i see you had the foresight to bring your tuxedo to london its called black tie and you know that i never go anywhere without it as a result of dato hamids admiration and imitation of the west the anglophiles native culture is marginalised the novel reveals how a colonised anglophile subject assimilates the colonising culture into his daily life and glorifies all that is english all this was possible because western hegemony had made the colonising culture synonymous with modernity and civility according to bhabha the idea of civility does not lie in modernity itself but in the history of the colonial moment … discourse of civility is defined as the doubling moment of the emergence of western modernity thus the political and theoretical genealogy of modernity lies not only in the origins of the idea of civility but in this history of the colonial moment it is to be found in the resistance of the colonized populations to the word of god and man christianity and the english language thus one can observe how modernity linked to western culture is another factor that led the colonised subject to embrace the colonial values becoming in turn not white but a hybrid mozaffari adds that modern technology is another factor that encourages people to become hybrid identities he states that the introduction of modern technology such as the computer and the internet as globalisation progressed led to the realization that there was a sufficient disjunction between past and present to require a new descriptive vocabulary modernisation in the field of technology which originates from the west is a source of attraction in kam raslans novel for instance we witness that dato hamids grandson is attracted to the advanced western technology and therefore chooses to migrate to the united states and work there he is now a highly skilled computer animator in the motion picture industry of los angeles instead of feeling a sense of loss as malaya needs these young talents dato hamid is proud of his grandsons decision to migrate in another part of the novel he says my grandfather used to watch perahus come from aceh and now my grandson works with computers im your only living link to that time this statement reveals the ambivalence of the anglophile subject although the character is happy about the modernity that his grandson aspires it is apparent that he still holds on to the memories of his forefathers by perceiving himself as a link to the past this ambivalent perception as faced by the anglophile subject is due to the attraction and simultaneous repulsion that the colonised native has for the coloniser it can be deduced that factors such as modernity as well as physical and spiritual dislocation are pivotal factors that contribute towards the anglophiles state of double consciousness in the context of kam raslans novel dato hamids desire to assimilate into the white culture and break away from his native self causes him to be in a state of double consciousness there is evidence in the text that depicts his double vision at one point he states i have two lovesmy country and paris and in another instance he says malaya brings back bad memories for me these statements are contradictory he clearly cannot makeup his mind on whether he loves his homeland or paris this shows how dato hamid struggles with his identity the double vision experienced by dato hamid disrupts his thought process he states that bygone sense of excitement was lost and i found myself absentmindedly following a group of longhaired malaysian students… here we find the protagonist facing an inner conflict his love for england perhaps even the hippie society brought by the americans made him look for long haired boys in his own native community the hippie group consisted of youngsters who often dressed in casual folksy clothing and headbands and kept their hair long it is a known fact that to be a hippie was fashionable during the 1960s in england and since the protagonist no longer found england interesting he began to feel lonely and nothing to do in london he says to be honest i was beginning to run out of things to do in london consequently he now subconsciously tries to discover his interest within the malay society the feeling of alienation unhomeliness and living inbetween consumes dato hamid and deters his effort towards selfidentification this is evident in the novel when he tells his friend nik in la i realized what it was that i was feeling i was feeling exiled in fact nik feels the same way after spending so many years in london and longs for his homeland malaya to overcome this feeling of homesickness he sings old malay songs and talks in malay nik feeds us and sings old malay songs… and we all just sit around and talk in malay till dawn its like being back home it is evident that kam raslans protagonist feels the loss of identity and develops a sense of unhomeliness when away from his homeland in addition to the loss of identity and unhomeliness experienced by the protagonist the profound and disturbing effect of mimicry which bhabha highlights is also portrayed in kam raslans protagonist dato hamid who goes all out to mimic the english and glorify the west despite his adherence to british supremacy dato hamid as observed in the novel is no trophy to the coloniser in trying to get the colonised peoples to adopt english values on the contrary he seems to be an uncertain and confused personality who loses all sense of direction to be honest i was beginning to run out of things to do in london… i walked back to the hotel i wondered whether london had changed or maybe i had changed the colonial agenda and its ideology are disrupted when elements of overquestioning pertaining to presence and representation of oneself is consumed by the mimic man as it poses a threat to colonial authority in relation to this bhabhas conviction about the ambivalence of colonial authority begins when a subject starts to question his own existence the desire of the colonised native to become english also results in the subject to experience attraction as well as repulsion and ambivalence towards his own identity we witness in the story that although dato hamid initially looked up to the west when the glitz and glamour wore off and no longer held his attention he began to see the shortcomings of the english culture i left england to get away from all that rubbish… the glitz and glamour of london cosmopolitan life failed to grab dato hamids attention to fully embrace the white culture and values apart from the glitz and glamour that attracts the native towards the western culture the english language also has a huge influence in the creation of hybrid anglophile personalities confessions of an old boy depicts how dato hamids fluency in the english language draws him towards the english culture as zawiah states t he english language is more than just a language of communication but it has great utility value as an instrument of propaganda to perpetuate ideology and reinforce its hierarchical structure of power not by military might but through an army of metaphors deployed in a rhetoric of persuasion of democracy the protagonist dato hamid who received an english education has a very good command of the english language the love that dato hamid has for the language can be seen when he says i always get a nosebleed if i speak anything other than english tweed from kam raslans narration we observe how love and admiration for a language draws one closer to the culture of that language however the admiration and mimicry of the colonial culture as exemplified poses a hidden threat to colonial authority in the end although the protagonist in kam raslans novel tries hard to mimic his new culture and his new master he retains his malay name hamid and insists not to change it to sound like a white name this is unlike the judge character in desais novel who changes his name and prefers to be called james peter peterson in replacement of jemubhai popatlal patel to mobilise his colonial identity thus the act of an individual wanting to be white but refusing to change his name to a western one is seen as an act of attraction and repulsion in mimicking the coloniser resulting in colonial ambivalence which disrupts colonial authority conclusion this paper investigates the ambivalence of the anglophile subject in malaya in light of malaysian postcolonial studies it is undeniable that the british occupation in the mainland and the systems they had brought along with them particularly its educational system underscored the factors in shaping the western character of the people who glorify the values and culture of the coloniser however the malayan anglophiles feel a sense of ambivalence towards the imitated culture the rapid influence of western values was arguably through its education system the western values were implicitly instilled through the education system and gradually practised by the society and become part of the societys way of life in fact one can still see remnants of the british education in malaysias schooling system embracing the western culture and values by a colonised society has coincidently produced a group of people known as the anglophiles this group of people not only give preference to the values and traditions of the western culture over their local culture but they also mimic the western lifestyle hence they become hybrid individuals in their own country the anglophile subjects continue to adapt and adopt the western culture this adaptation and adoption have continued for a period of time with the departure of the british colonisers from the country and the ambivalence of the anglophiles towards the western culture they find themselves in a dilemma and in a state of conflict of identity ambivalence hybridity and mimicry are among the popular concepts in postcolonial discourse these concepts describe the ways in which colonised people resist the power of the coloniser and yet at the same time emulate and envy the trappings of wealth as well as cultural and political superiority of the coloniser works cited

this paper focuses on ambivalence a prominent concept in postcolonial studies and a recurrent theme in an anglophile subject in kam raslans novel confessions of an old boy the dato hamid adventures 2007 as a result of ambivalence the anglophile subject feels alien in his perception of himself and also towards others the subject is also ambivalent towards his own culture using this framework this article focuses on kam raslans protagonist dato hamid as an ambivalent anglophile subject the findings reveal that reverence for the english culture coupled with a british colonial education is what gives rise to such characters it is the british education that has indoctrinated english values into the natives life the admiration of the anglophile towards the english culture can be seen in many aspects such as language dress code behaviour relationships lifestyle etc all these elements become traits and characteristics of the anglophile the study reveals the adoption adaptation and assimilation of english traits and characteristics by the anglophile subject which has caused a sense of ambivalence in his perception of himself and towards the other

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background the house ball community is a community that since its inception more than 70 years ago in harlem new york has consisted of predominantly african american and latinx sexual gender and ethnic minorities of low socioeconomic status since then the hbc has expanded rapidly to major us and international cities the community consists of houses or familylike networks led by mothers and fathers who are more experienced members of the community houses host elaborate balls that serve as community events where members compete in performative categories and celebrate their sgem identities the social meaning of family has been central to this community since members have not been historically privileged with supportive biological kin or other support networks in their communities of origin therefore the hbc fulfills a need for young people many of whom consult with their house parents and siblings on issues related to health that they may not typically discuss with their biological kin the hbc has been impacted by the hiv epidemic for decades with new yorkbased researchers first documenting a prevalence rate of 17 in the community with 73 being unaware of their serostatus in 2004 researchers in los angeles found hiv rates of 6 in a venuebased sample taken at balls while 27 of those surveyed in the san francisco bay area selfreported living with hiv reflecting the demographics of the local hiv epidemic which more heavily impacts black and latino msm additionally hivrelated risk behaviours including condomless anal intercourse multiple sexual partners substance use exchange sex and low rates of prep uptake have been observed in the hbc across multiple cities these risk behaviors are not solely associated with membership in the hbc but reflect the lived experiences and structural vulnerability of low income sgem to hiv such as limited formal employment opportunities and dense sexual networks in addition social factors such as hivrelated stigma present challenges to reducing sexual risk behaviours among those who are hivnegative and engagement in care and treatment for those who are living with hiv previous studies have demonstrated that the hbc serves as a mechanism of hivrelated social support for both hiv positive and negative members hbc networks provide hivrelated social support that correlates with hiv testing condom use and being aware of hiv medication like prep these forms of intravention are naturally augmented by formal services located at communitybased organizations such as hiv testing preppep linkage to care and peer support for living with hiv however cbos can also be vulnerable to structural factors such as gentrification which threatens their ability to rent space and provide services to the community the impact of structural factors such as gentrification on the wellbeing of marginalized communities can be detected in the current demographic trends in the san francisco bay area san franciscos low corporate taxation policy has led to a growth of tech giants and created an overheated housing market that has reduced affordability for longtime tenants who are forced to leave as low rent socially marginalized areas of urban centres are remade to accommodate professional middle to uppermiddleclass citizens fewer existing working class ethnic minority residents remain in the area while gentrification attempts to integrate existing residents by creating new job opportunities people living with hiv can be negatively impacted as housing prices increase plwh in san francisco have had to spend a higher portion of their fixed household income on rent rather than on food and a reported 12 of plwh in california are homeless or unstably housed nelson sundback and kaine 2017 the hbc has traditionally consisted of the people who are most vulnerable to gentrification low income african american and latinx communities the bay area median monthly rent increased by 40 between 1990 and 201l and the proportion of african americans in all oakland neighborhoods a historically black city that is home to the hbc decreased by nearly 40 over the same period with many residents moving to more distal cities such as vallejo to find affordable housing business corridors within oakland have also seen dramatic changes with local mom and pop businesses being pushed out in favor of larger commercial retail outlets that cater to the needs of a more affluent and educated residential population gentrification and higher rents have also impacted cbos that have provided hiv prevention services to sgem pushing them out of centrally located business districts to more distal areas of oakland that are not as well served by public transit in this article we explore the changes experienced by the hbc and the cbos that have provided safe space and services to its members as the san francisco bay area experiences vast demographic shifts and changes in the context of gentrification methods data collection took place between august 2016 to december 2017 we conducted 45 indepth interviews with hbc leaders house members and gay family members who attended balls a team consisting of a white female anthropologist and two gay men of color research assistants conducted the interviews eligible participants were part of a house or a gay family gay bisexual transgender or otherwise nongender conforming identified sexually active as measured by anal intercourse with a man in the past year bay area residents and at least 18 years old interviews lasted 60120 minutes and were recorded and transcribed topics included history of housegay family involvement and dynamics support available through families hivrelated stigma and hiv prevention suggestions questions included tell me about your experience being in the ball community or in a gay family what have you heard from your house about hiv and tell me about a time when you got support from your house or gay family interviews took place in private offices at the university of california san francisco the california prevention education project a communitybased organization in oakland ca that collaborated on the project or at a private location of the participants choosing interviews proceeded until theoretical saturation was achieved with no new themes emerging in our analysis study participants all provided verbal consent and received 4000 to compensate for time and travel all study procedures were reviewed and approved by the ucsf institutional review board in addition to indepth interviews one research assistant was trained to conduct regular participant observation that took place at balls dance studios gay pride events nightclubs bars art museums and other community spaces and generally lasted between 46 hours on a weekly basis during these events he would identify himself as a researcher participate in activities engage in informal conversations and take jottings to record his impressions of the social interactions and environment fieldnotes detailing interactions community norms and other social cues were written up immediately following each observation activity and saved on a secure server fieldnotes and interview transcripts were then uploaded to an online qualitative data analysis programme dedoose to explore our data we followed procedures from thematic analysis developing and defining thematic codes to capture data segments related to gentrification health services house ball socialization and social support themes were developed using a deductive and inductive approach to characterize the data meeting regularly the authors organized the thematic areas into a defined set of codes we then applied the codes to a subset of transcripts until code application was consistent across coders the research assistant then coded the remaining transcripts and he and the senior author conducted crosscase comparisons across the entire data set to ensure consistency of the coding structure analytic memos summarized meeting discussions and coding decisions participants are identified using pseudonyms results several dynamic shifts took place within the hbc as the broader bay area experienced significant structural changes under gentrification first we describe the historical character of the ballroom scene in the bay area up until the closing of a local cbo sexual and gender minority youth in the east bay that hosted balls and provided sexual health services to hbc members then we discuss the demographic and social changes taking place in oakland due to gentrification and the challenges these pose to maintaining safe space for sgem youth next we describe a more commercialized form of vogue that is currently appreciated and performed by middleclass consumers or the new residents of gentrifying oakland and san francisco finally we examine how sgem are learning to adapt to these changing times in order to rebuild the hbc and return to a sense of family and health promotion efforts the intertwined history of the bay area hbc and sagmy until 2015 sagmy an oakland cbo served as the gathering point for lesbian gay bisexual and transgender identified and other sexual minority youth of color serving an especially vulnerable population in the bay area sagmy provided hiv prevention education and testing case management mentoring and hosted ballroomrelated activities for participants who went to the centre for many of our participants sagmy was a safe space where they could feel comfortable receiving essential health services when they were young a lot of people who live in oakland we all grew up with sagmy as the only real gay outlet… thats where a lot of people grew up going to afterschool…it would be a place where you could openly be yourself…a lot of people grew up knowing each other from sagmy so the gay scene out here is really small… sagmy was a big place with a lot of rooms a lot of counselors a lot of people who did hiv prevention but it was a center they had community they hosted health classes… it was just something that we went to everything so freely sagmy also fostered a culture where youth could socialize and be introduced to the hbc multiple participants cited learning about ballroom from practicing their categories with house members at sagmy and from the balls that sagmy often hosted these balls were essential for house parents to recruit newcomers celebrate their respective houses and build community jamila discussed how essential that sense of belonging and acceptance was during a turbulent time in her life i went to sagmy when i was like 19 it was just like the ballroom it was so more… like over the top… it was really like a safe haven for all the kids that didnt have family and friends and stuff when i was approached i was mainstreaming out of foster care i had no idea about oakland no idea about who youd be able to trust looking for a strong sense of acceptance jamila had switched from a youth organization in san francisco to sagmy in oakland because the cultural racial and economic demographics of sagmys staff mirrored her community she wanted to affiliate with those who could better understand her experiences when we were going to sagmy it was kind of like its a lot more of color kids here and were able to actually get along and not have to feel like were being judged so much from like the counselors just because we come from like places like that we grew up from multiple participants expressed that it was because of sagmy that they were exposed to role models and house leaders in the hbc who transformed them into more confident individuals alex now a house leader described how these gay affirming spaces were especially necessary given the homophobic environment where he grew up i have several role models i mean in the ballroom scene…i didnt really have confidence before i came into the ballroom scene so actually walking balls it helped build pride…they kinda helped that creative side come out in me…i was not really accepted being gay…i had to act straight at school and then i would leave and i would come down to like sagmy and then i formed friendships with like all these people most of our older participants who joined the hbc as youth came from economically underserved african american and latinx communities that often were homophobic and transphobic through sagmy they received services and support not otherwise available and gained access to the hbc where they would develop a sense of family and confidence that would be passed down to the next generation the loss of sagmy and deterioration of affordable housing sagmy was damaged by a fire in 2012 and then officially closed in 2015 when the leadership could no longer afford to rent space near its previous location in downtown oakland leaving few spaces for sgem youth in oakland to socialize or to receive hivrelated services because sagmy previously hosted balls and provided practice space for houses its closure led to fewer balls which translated to decreased participation in houses as well by the time sagmy closed several prominent african american leaders in the hbc were also being displaced by rising housing prices in oakland and were moving further inland to communities such as vallejo antioch and even sacramento in order to find affordable housing overall losing a stable sense of community and home was difficult for participants many participants who grew up with sagmy felt a sense of nostalgia describing the resource being central to their mobilization as a community a publicly funded agency sagmy was especially important in facilitating conversations around health issues such as hiv here alex shares his concerns that the next generation of sgem youth will not have the same resources available to him growing up in oakland sagmy was all we had and all the kids had…now they have like nothing to do theyre just like really on the street…i think that the community is dying because of it … sagmys lost their funding and we havent had any kids come to mizrahi or really to the scene but im starting to see like a lot of kids graduating from high school that are gay and stuff like that i know theyre out there but theres no sagmys i dont know where they hang out at i dont know where to find them our house members have cut in half we dont really discuss the hiv thing anymore without sagmy being there to educate while sagmy had the public funding to sponsor ballrelated events an elder in the community explains that the cost of building community requires a personal investment west coast ballroom is not a moneymaking opportunity where it might be on the east coast it has to be from the love of ballroom there have been fewer opportunities to foster the hbc because its members who typically come from marginalized backgrounds and struggle themselves with obtaining basic essential needs cannot shoulder the additional costs of a ball without additional institutional sponsorship along with the loss of cbos dedicated to the hbc and its health participants also cited the high cost of living as a significant barrier to remaining present in oakland and staying together as a community living here is really expensive … i think about moving but i think about the community that i have here …and you cant really put a price on that… t hey didnt have a place to stay so i let them stay at my place… infiniti member a has been displaced and so has infiniti member b and infiniti member c didnt have a place for a while and ugh i think infiniti member d might be homeless soon too…a lot of affordable places are getting shut down… infiniti member b got evicted because they were living in the warehouse…theyve been like couch surfing for 3 months … im holding onto it as much as i can…i actually lost my job because they closed the restaurant that i worked for… the thing is like people like us come to the bay for refuge…thats really heartbreaking if you think about it because historically speaking thats what san francisco has been and you know a lot of us a lot of them moved to oakland because its more affordable but now…its kind of like damn where the fuck do we go participants also recognized the effects gentrification has on the demographics of the hbc stewart who is not originally from the bay area discusses his perspective there are still people that are left over in oakland whereas in san francisco its just gone whats gone the black communities and the ballroom scene…ive only ever seen one ball while ive been here … thats just the way it is when the black people are gone the black peoples art form goes with it broader economic circumstances especially housing instability affected the community and social practices of our participants as they experienced the loss of safe spaces yet we learned that key hbc members were forging new paths to preserve their community and its practices the resiliency survival and evolution of the hbc house membership and activism the evolution and survival of the bay area hbc is characterized by the commercialization of vogue the inclusion of a variety of sexual gender and ethnic identities increasing numbers of participants who do not join houses also called free agents an emphasis on ballroom performance as a form of artistic expression and mobilizing houses as a vehicle for social change in response to the lack of publicly accessible space to practice and host balls in we found that the hbc members had begun to offer vogue classes at private dance studios around the bay vogue femme is one particular category in ballroom competitions and is often associated with a more femininized type of performance although butch queens also compete in the category classes cost from five to sixteen dollars at the door consist of an ethnically mixed demographic and focus on teaching specific elements such as duckwalk catwalk hands floorwork spins and dips current house leaders explain the elements similar to any other dance class teachers include white gay men gay men of color and cisgender women of color classes represent a new avenue for recruiting and maintaining house membership with less established local houses taking the lead they also provide a viable source of income for house leaders who teach them neil a new hbc member provided their perspective about joining i became a member of house of prolific a year ago when the house leaders were doing workshops inviting people to come and train with themand if they wanted to to actually become a member so i did…a year ago was when i started dancing a year is when i started vogueing…ive been in house of prolific since it started…weve had photoshoots of the house just to have these family portraits out of us dressing up together doing different vogue performances in different parts of the city…i feel like theres lots of people who vogue who might not necessarily have a house theres lots of like free agents running around the presence of vogue at pride events local art celebrations and dance studios reflects multiple participants view that vogue is on the rise again the increasing number of free agents also indicates that the culture is becoming more mainstream than years prior when sagmy was open as less established houses find their footing in san francisco and traditional houses from earlier years move out of the area the cultural meaning of house membership and belonging to the hbc is changing as the hbc has adapted the demographics of the scene have become inclusive of all people willing to participate these newcomers to the bay area hbc vary in socioeconomic status racialethnic identities and place of origin social groups that would not have performed nor been part of a ball in years prior jayden expressed excitement around seeing diverse people participating in a ball in oakland to see other people of color not just africanamericans participating in the ballroom scene was great to me since we live in such a melting pot of people in the bay area to see them all coming out the whites the asians and actually taking part and not just looking from a distance was great to me events like the way bay ball at the berkeley art museum and pacific film archive reinforce this point as this fieldnote describes i see many people who look like they are berkeley students since many were wearing their berkeley attire there is a total of maybe about 150200 people here there are straight men and women trans individuals many gay men there are people of all ages here a few of the participants are creatively dressed with facial effects and costumes… people who were just trying it out were allowed and welcomed to participate i see like 20 white 30 black 30 hispanic 20 asian…i certainly think that the majority of community members appreciate the presence of having these at a venue like the museum and just being able to put it on people did have to pay 13 which is a concern and barrier to being able to access the space but they do keep it all about community sass living your authentic self and having fun while some members of the community belong to houses many free agents just dance and perform recreationally jayden attributes the decline in house membership to the growing acceptance of sexual and gender minorities as a community we are growing as far as acceptance in the world a lot of youth…dont need the hbc in the same way… their biological daddys okay with them now so they dont need another daddy…they never quite experience the need of the extended family in the same way as in the past…in the past it was needed nonetheless our participants saw the hbc as an outlet for freedom in sexual and gender expression which is not typically embraced in mainstream spaces jose discussed a sense of confidence in their ethnic sexual and gender identity that they found through ballroom learning vogue has opened my world my expressivity my sense of power empowerment in my feminine body and affect…it helped me find and work out some of the biggest insecurities i had around gender i am gender nonconforming i have always failed at masculinity…just seeing that there are so many categories that one can be and inhabit and win at a ball and be celebrated not just by winning but by being snapped up…is just like a whole new world just basically just the simple context of being of your of your own gender performativity and being applauded thats super empowering… i want the heart of fierceness to arise within us i want the heart of the queer brown and black community and its power and potential to really pop off jose reflects the belief that ballroom remains a unique and safe space for sexual and gender minority youth to thrive lastly in this historical moment of progressive resistance emerging houses have established their collectivity as a vehicle for social justice embracing all who come from marginalized backgrounds new houses are aiming to mirror their critical awareness of the world with their actions jonathan discusses using his houses art as a way to uplift their community and to remember where they come from were doing social justice for black lives matter social justice for the pipeline were doing activism for the native americans we have a couple of indigenous people in our house and were there for them…were across the board like dancing for the mission womens building and raising money for dance mission its a nonprofit so well like work with kids and work with the community…we also want to get what we stand for as far as like hey shits going down and i need everyone to be woke and aware of whats going down the evolution of the ballroom scene perhaps mirrors changing social and economic conditions despite sweeping economic changes in the bay area community members remain resilient and have learned to respond in a collective way that allows them to survive in a space where they belong a return to family and health promotion leaders in the hbc see the changing scene as an opportunity to rebuild the community and have continued to build on traditions of providing hivspecific social support to their children for example diana a leader of an emerging house who is openly living with hiv explains how she integrates hiv into her conversations with her kids something may come up for somebody but its usually because i live with this disease every day im usually the person that will be like this or this around it because i just saw my doctor and ill come to my kids and say hey my doctor wants me to change my meds what do you guys think about that and ill tell them why and how long ive been on a certain medication and i dont think i should change because im afraid of the side effects or whatever…if a person is curious and they want to know their status they are encouraged to go and get tested and what i say to them is my story always comes up ive lived my life by not knowing and now when i found out i had 66 tcells if you have a feeling like you need to get tested ill go with you well go get you tested ill hold your hand and you know whatever the outcome may be you know youll be alright cuz im alright and if i can bounce back from 66 t cells all the way to being undetectable to 800 and something t cells now i know that you can come back and youll be okay jonathan continues to feel nostalgic for sagmy and notes the impact it had on the community and on him he appreciated how the agency married ballroom culture and health to more easily facilitate conversations around hiv prevention now an emerging leader he feels a sense of duty to give back to his community in the form of bringing back the culture and health awareness first we started off with my house father and myself we started doing balls in like 2010 we always wanted to like bring back the ballroom culture because i grew up around the ballroom culture or just going to a couple of balls back in the day when i was 16…that was like the start of my journey being aware of hiv and what it means and how you can prevent it…so were trying to bring that back because its kind of died down so i felt like it was my duty as a dancer as a vogue instructor to bring back the ballroom community jonathan has helped organize many of the kiki events and miniballs and has served as the emcees several times in addition to being consistently vocal about his pride in social justice causes he is affirming of anyone who tries to walk in balls to show that these events are all about love he recognizes how the overlapping timelines between sagmys closure and outmigration hurt the communitys ability to thrive but remains dedicated to bringing back the hbc as he once knew it hbc leaders want to be a part of the necessary coalition building process to continue to make ballroom a relevant part of sgem youth lives and health particularly around hiv discussion in this ethnographic examination of the impact of gentrification on the san francisco bay area hbc we found that participants are both struggling and finding creative means to preserve their community hbc elders reminisced about the sense of family and community that sagmy provided during their adolescence including easily accessible hivrelated services while gentrification may not have been the immediate reason for sagmys closure its loss contributed to the fraying social fabric of the hbc the inability of the agency to secure new space in the wake of the fire along with the relocation of other cbos and hbc members themselves from central to more distal locations has ruptured social relationships as well as the ability to access hivrelated services as youth moved and cbos closed or relocated house participation ebbed and remaining houses experienced challenges in providing support around hiv prevention and care with the loss of sagmy and safe space the hbc now recruits members by offering classes in rented dance studios recipients of this new landscape spoke of how ballroom gives them freedom in gender and sexual expression not obtainable anywhere else although some participants may be privileged by virtue of their educational attainment and economic status they still feel empowered by the sense of queer liberation that ballroom provides like the participants who grew up with sagmy these newcomers to ballroom cherish the ability to express oneself be affirmed and be surrounded by community however vogue classes cost money and take place in an urban area catering to middle to upper class residents hbc leaders continue the tradition of providing hivrelated support to their children however they remain concerned about continuing to reach low income sgem youth who would most benefit from the safety and support that the hbc provides there is a public health need to provide safe community spaces that are accessible to sgem in urban centres cities provide opportunities for members of subcultures especially sexual and gender minorities to interact and feel supported by their community developing social capital that has been shown to have positive effects on an individuals wellbeing and health when people are pushed out of safe spaces and familiar neighborhoods they may lose the social ties that can create social and economic opportunities as well as the health services and hivrelated support that are vital to their health and wellbeing safe spaces have been shown to reduce vulnerability to hiv among gay youth and transgender women of color when these spaces are lost through gentrification community members experience fear and mistrust of public institutions leading to challenges with engaging services indeed it is becoming increasingly clear that public health professionals must advocate vociferously for preserving community space as a way to address health disparities among those who are socially marginalized while urban renewal has historically displaced and socially segregated vulnerable populations it can also catalyze community building among those who remain we saw this in the offering of private vogue dance classes and informal hbc events as the community adapted to the changing landscape mixed experiences of gentrification are also seen in the literature with one study reporting that gentrification was positively correlated with collective efficacy a form of social capital that allows community members to better coordinate to achieve collective goals in our study we noted that local hbc members were more connected to broad social justice causes and empowered to advocate for their collective rights previously the hbc focused on achieving underground fame within a marginalized population the recent mainstream emergence of the hbc may provide opportunities to strengthen the social networks of community members which may lead to more social and economic opportunities and perhaps improved health outcomes while dance classes may challenge the ability of lowincome people to access the hbc it may be the most realistic way for the community to maintain safe space for segm youth and resist gentrification through creative means emerging houses are also using their art to give back to the community by donating ball proceeds to lbgt youth organizations so that they may continue to keep their doors open and provide services the hbc is a constantly evolving culture that can flourish within its particular urban region we see this reflected in the nimbleness of kiki houses as younger members develop new traditions with changing times despite the closure of publiclyfunded agencies such as sagmy the hbc remains resilient as community members adapt and create new forms of family and performance the more casual inclusive kiki events bridge between poor and middleclass members and overall may strengthen the community membership and resources significant research has explored the development and testing of hiv prevention interventions to facilitate behaviour change amongst people impacted by and living with hiv however our study points to the importance of preserving safe space and communities in order to effectively implement interventions hiv prevention efforts must consider supporting the hbc itself given its ability to build resilience among those whose lives are marked by racist and queerphobic forms of exclusion and displacement recognizing the structural factors that underpin and drive inequity in health the preservation of space as a means of disease prevention cannot be overlooked as more urban spaces experience gentrification public health professionals may struggle to find community spaces to actually deliver interventions and connect individuals to resources publicly funded spaces like sagmy foster communityled efforts around hiv prevention through strong social networks culturally and linguistically competent services and fun communitylevel events local cbos facilitate the gathering of community members that are so crucial to delivering effective interventions and remain a key piece of the prevention landscape as hbc elders continue to provide hivrelated support to help individuals connect to care and services limitations this was a purposive sample we deliberately recruited both house parents as well as house children to elucidate the dynamics of house relationships and hivrelated social support it was not a probability sample while gentrification may be occurring in other urban areas we do not know if other hbc members have reacted similarly to those in the san francisco bay area similarly while we documented concerns that segm youth may experience isolation without connections to houses or local cbos we were not able to directly document this phenomenon as our participants were hbcinvolved gentrification itself is not unique to the san francisco bay area and we believe that some of the patterns we document are common to other places experiencing similar economic and social changes conclusion if we aim to end the hiv epidemic the impact of structural factors such as gentrification must be considered without advocating for safe space and affordable housing only the wealthy will be able to afford to live in urban cities with close proximity to health services the most vulnerable members of urban communities such as sgem youth who participate in the hbc will continue to relocate or even lose housing as will the agencies tailored to serve them these changes may in fact exacerbate the hiv epidemic as people lose their support networks and proximity to health promotion programming and services a sobering reality check despite calls to end the epidemic

the house ball community hbc consists of sexual gender and ethnic minority sgem youth who form familylike houses and compete in balls many rely on communitybased organizations cbos as venues for socializing and accessing healthrelated resources in recent years urban gentrification has challenged the economic survival of cbos that serve the hbc and community members themselves from 2016 to 2017 we collected 45 indepth interviews with houses and gay families in the san francisco bay area and conducted regular participant observation at community events including balls along with forcing cbos to close or move rising rents have increased housing instability among hbc members themselves with some moving to distal locations participants felt nostalgia for cbos that provided hivrelated services and hosted balls in previous years feeling the loss of space keenly to maintain community and generate employment the hbc offers vogue classes at private dance studios this allows participants to recruit new house members welcoming a broader array of individuals into the hbc than those who have historically participated however accessing culturally appropriate sexual health services remains difficult health advocates should consider that cbos are necessary for sgem youth to build community and access hivrelated and sexual health services

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introduction clear accurate and transparent risk communication during health emergencies is critical to providing policy makers and the public with direction to reduce transmission through the implementation of public health strategies 1 however in times of uncertainty misinformation can quickly spread sparking public fear distrust and stigmatization of population subsets 2 the world health organization reported that the covid19 pandemic was the first in history that relied heavily on social media to rapidly communicate information to the public about evolving evidence public health precautions and directives 3 yet this abundance of information resulted in an overwhelming amount of data known as the covid19 infodemic and led to the sharp rise of covid19 misinformation and disinformation 34 although misinformation and disinformation both involve the spread of false information disinformation is false information that is purposefully disseminated to cause harm or serve a specific person group organization or country agenda 34 misinformation and disinformation can be harmful and may prevent individuals from appropriately partaking in public health measures disinformation further aims to cause distrust of groups governments or institutions 5 thus the publics perceptions of the quality and trustworthiness of information regardless of its actual validity is an important factor to explore susceptibility to health misinformation is complex driven by psychological processes levels of trust in science and ideology 6 understanding public perceptions of health communication and patterns of information seeking provides important insights to developing and disseminating risk communication strategies during future health emergencies the purpose of this study was to explore among those living in ontario canada preferred sources of covid19 health information perceptions of encountering misinformation levels of trust in information sources and suggestions on optimizing public health messaging methods study design the conduct and reporting of our survey study adhered to the checklist for reporting results of internet esurveys 7 we recruited a convenience sample of residents from ontario canada survey development our survey was composed of 2 sections the first section explored perceptions of stigma during the covid19 pandemic these results are reported elsewhere 8 the second section explored preferred sources of acquiring covid19 information during the first and second waves of the covid19 pandemic in canada perceptions of encountering misinformation during the pandemic trust in information sources and suggestions on how to optimize public health messaging questions included 5point likert scale multiple choice and openended responses and demographic questions branching logic was used to further explore responses members of the study teams research network piloted the survey to improve overall user experience and ensure face validity prior to dissemination the survey was delivered in english language recruitment we aimed to generate a sample that was evenly distributed between men and women although we were inclusive of all gender categories we also aimed to include a broad representation of age we conducted an open survey using several recruitment avenues and used a market organization canadian viewpoint 9 to support recruitment of ontario residents who reflected diversity in race or ethnicity canadian viewpoint distributed the survey invitation to their email listservs potential participants were those who previously agreed to receiving email communications from them study recruitment ads were also posted to our websites and to twitter linkedin kijiji and reddit ethics approval this study was approved by the toronto academic health science network research ethics board participants who clicked the survey were directed to a landing page which provided an overview of the study purpose and consent information participation was voluntary people who did not wish to participate were directed to close the web page or exit the browser responses were anonymous and survey questions were not mandatory participants were not compensated for participation but were provided an option to enter into a draw for the chance to win a visa gift card data collection surveys were hosted through qualtrics on our kt program website and were also distributed via a webbased link by canadian viewpoint data were collected between june 10 2020 and december 31 2020 data analysis duplicate responses questionnaires with less than 5 completion or those completed by nonontario residents were excluded from analysis quantitative data were summarized using descriptive statistics qualitative data were analyzed by using content analysis 1011 responses to the questions regarding perceptions of information and trust were analyzed using ordinal regression to explore trends by gender and age the 5point likert response questions regarding agreement were grouped into 3 categories and age categories were combined into 3 groups to facilitate analysis responses from genderdiverse persons who made up less than 1 of the sample were excluded from the regression analysis due to insufficient sample size responses for which the gender or age questions were not answered were excluded from the regression regression analyses were conducted using r statistical software the r packages foreign ggplot2 mass hmisc and reshape2 and rstudio software 12 and were overseen by a biostatistician results participant demographics a total of 1823 individuals participated in the survey of them 990 identified as women 703 identified as men 9 identified as gender fluid transgender gender variant or nonbinary and 14 preferred not to respond of 1823 participants 982 were between 18 and 40 years of age 518 were 4160 years of age and 215 were 61 years and older of the sample 907 were college or university educated 259 had some college or university education and 336 had a postgraduate degree over half of the participants worked fulltime the majority of the participants were canadian citizens participants most commonly resided in central ontario and the toronto region use of information sources participants obtained covid19 information from local television news social media national or international television news friends and family health authority websites radio news local newspapers national or international newspapers health care professionals blogs or opinion websites talk radio and other sources such as youtube scientific journals employers and podcasts table 2 5 a few differences in use of sources were noted across population subgroups men had greater odds of using local newspapers international and national television news and talk radio as covid19 information sources and lesser odds of using health minister updates health authority websites social media and friends or family as covid19 information sources compared to women individuals aged 41 years and older were more likely to use radio and local television news as information sources and less likely to use social media blogs and websites and friends or family as sources compared to those aged 1840 years trust in information sources of the participants 70 and 68 reported high or very high levels of trust in health authority websites and health care providers respectively more than half of the participants reported high levels of trust in health minsters or public health ontario international and national television news and local television news sources seen as less trustworthy by the participants included friends and family talk radio social media and blogs and opinion websites men were more likely to trust friends or family and blogs or opinion websites compared to women participants aged 41 years and older were more likely to report increased levels of trust in almost all assessed sources of information compared to those aged 1840 years with the exception of social media as well as blogs and opinion websites challenges of information seeking a total of 58 of the participants reported sometimes often or almost always experiencing difficulty in determining the accuracy of covid19 information and sorting through conflicting information 45 of the participants reported difficulty in identifying the covid19related information they needed and 46 had difficulty making sense of the covid19 information they identified those aged 41 years and older were less likely to report challenges with identifying or making sense of the covid19 information compared to those aged 1840 years a odds ratio estimates with 95 cis of the response of agreestrongly agree with statements in the left column for different levels of the demographic variables perceptions of misinformation of the study sample 55 believed that they encountered misinformation sometimes a lot or quite a lot men were more likely to report encountering misinformation than women participants aged 41 years and older were less likely to report encountering misinformation than those aged 1840 years social media and community influencers were the sources most commonly perceived by participants as the biggest drivers of misinformation followed by news media outlets international health authorities federal health authorities and provincial health authorities academia was least commonly perceived to be a source of information as compared to other sources listed in the survey table 2 xsl • fo renderx to perceive all of these sources to be drivers of misinformation with the exception of social media participants 41 years and older were less likely to see all explored sources as drivers of misinformation as compared to those 1840 years old suggestions on optimizing public health communications participants believed policy makers should engage in the following actions to optimize public health communications during health emergencies share facts and information educate the public to distinguish accurate from inaccurate information correct misperceptions challenge myths and stereotypes create a list of accurate or inaccurate data sources and use social influencers to correct misinformation discussion principal findings the covid19 pandemic presented a gap between the publics desire for immediate information and the availability of evidencebased guidance 13 we surveyed ontario residents during the first and second waves of the covid19 pandemic in canada to assess patterns of obtaining covid19 health information trust in various information sources and perceived exposure to misinformation we hypothesized that participants would turn to sources they found trustworthy to obtain covid19 health information however this was not observed over 50 of respondents reported encountering covid19related misinformation social media news channels and family or friends were perceived as significant drivers of misinformation and participants reported low levels of trust in these sources despite this 51 reported using social media to obtain covid19related information 61 and 49 used local or national and international news sources respectively and 46 obtained covid19 information from friends and family conversely sources perceived to be highly trustworthy such as health care providers or health authorities were less commonly sought out to obtain information though these sources likely leveraged news and social media platforms for dissemination our findings are consistent with similar studies conducted during this period of the pandemic this includes research showing that although individuals level of trust typically correlates with the factual quality of that source people consume news sources that they do not inherently trust 14 our disaggregated results by age and gender provide further insights on trust and use of information sources participants aged 1840 years were less likely to trust assessed information sources compared to those aged ≥41 years the 1840 age group was also more likely to report challenges with identifying trustworthy information sources compared to participants older than 41 years this suggests individuals older than 41 years were more likely to trust in information sources and thereby had an easier time obtaining and sorting through information though we did not assess whether these perceptions correlated with data validity those aged 41 years or older were also less likely to report encountering misinformation which may be attributed to their increased level of trust in information sources with respect to gender men were more likely than women to report news organizations family or friends health authorities and academia to be sources of misinformation they were also more likely to turn to newspapers television news and talk radio for covid19 information compared to women there are some data to suggest that the consumption of digital media compared to traditional media is associated 615 with increased belief in misinformation in our sample men were more likely than women to trust digital sources of media such as opinion websites or blogs though we did not explore which sites or sources participants in our sample used a limitation to our study is that we did not assess the quality of information obtained and whether the participants perceptions of misinformation correlated with data validity 6 systematic review data are inconclusive regarding the correlations between age gender and susceptibility to believing misinformation 6 it is likely that susceptibility to misinformation cannot be attributed directly to a single characteristic and is rather correlated with complex processes 6 still perceptions of misinformation are important our study suggests that public health information in ontario should be tailored to population subgroups recognizing gender and age differences in perceptions of information quality and patterns of information seeking further health officials and policy makers should not discount the importance of disseminating public health information via news sources perceived as less trustworthy given that data consumption was not inherently correlated with levels of trust other actions suggested by participants included educating the public about misinformation challenging myths flagging inaccurate data sources using social media influencers to correct misinformation and sharing facts and information in a timely and accessible way limitations our survey was limited to residents in ontario and may not be representative of experiences of individuals residing in other canadian provinces and territories although we aimed to include a diverse sample of ontario residents our sample included more women than men and genderdiverse persons were underrepresented in our sample and analysis participants were collapsed into age groups to facilitate analyses yet disaggregation of our broad age categories may provide further insights on preferred information sources and trust additionally 50 of our participants had college or university degrees and we did not disaggregate our data based on levels of education it is possible that these demographics as well as other characteristics such as literacy fluency in english language or political alignments confounded our findings as presented our study did not assess other important factors including which news or television radio and social media channels participants were using and whether sources seen as trusted used these channels to disseminate health information we also did not evaluate the quality of information that participants obtained and trusted thus it is possible that individuals who did not experience challenges obtaining information were in fact trusting and sharing misinformation finally our survey was disseminated during the first and second covid19 waves in canada it is likely that perceptions and opinions on misinformation evolved throughout the course of the pandemic conclusions this study describes ontarians patterns of obtaining covid19 health information and their levels of trust in various information sources more than half of the participants reported encountering misinformation when seeking information about covid19 and many reported at least one challenge with information seeking participants also consumed information sources that they perceived to be less trustworthy we noted differences in trust and information seeking patterns by gender and by age our results suggest that health communications during public health emergencies should be tailored to account for differences in perceptions by population subgroup and should leverage a number of sources including those perceived as more and less trustworthy data availability the data sets generated and analyzed during this study are available from the corresponding author on reasonable request conflicts of interest none declared multimedia appendix 1 misinformation and demographic survey questions docx file 25 kbmultimedia appendix 1 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 formative 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 abbreviations kt knowledge translation or odds ratio

background clear accurate and transparent risk communication is critical to providing policy makers and the public with directions to effectively implement public health strategies during a health emergency objective we aimed to explore the publics preferred sources of obtaining covid19 information perceptions on the prevalence and drivers of misinformation during the pandemic and suggestions to optimize health communications during future public health emergencieswe administered a webbased survey that included likert scale multiple choice and openended response questions to residents of ontario canada we aimed to recruit a sample that reflected population diversity with respect to age and gender data were collected between june 10 2020 and december 31 2020 and were analyzed using descriptive statistics openended data were analyzed using content analysis subgroup analyses to explore perceptions by age and gender were conducted using ordinal regression results a total of 1823 individuals participated in the survey n990 54 women n703 39 men n982 54 aged 1840 years n518 28 aged 4160 years and n215 12 aged ≥61 years participants most commonly obtained covid19 information from local television news n1118 61 followed by social media n938 51 national or international television news n888 49 and friends and family n835 46 approximately 55 n1010 of the participants believed they had encountered covid19related misinformation 70 n1284 of the participants reported high levels of trust in health authority websites and health care providers 66 n1211 reported high levels of trust in health ministers or public health organizations sources perceived to be less trustworthy included friends and family talk radio social media as well as blogs and opinion websites men were more likely to report encountering misinformation and to trust friends or family odds ratio or 149 95 ci 124179 and blogs or opinion websites or 124 95 ci 103150 compared to women compared to those aged 1840 years participants aged ≥41years were more likely to trust all assessed information sources with the exception of webbased media sources and less likely to report encountering misinformation of those surveyed 58 n1053 had challenges identifying or appraising covid19 information conclusions over half of our participants perceived that they had encountered covid19 misinformation and 58 had challenges identifying or appraising covid19 information gender and age differences in perceptions of misinformation and trust in information sources were observed future research to confirm the validity of these perceptions and to explore informationseeking patterns by population subgroups may provide useful insights on how to optimize health communication during public health emergencies

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introduction religion is a powerful social force in subsaharan africa today with the arrival of christianity since the late nineteenth century african countries have been the site of religious syncretism and fusions of christianity and african traditional practices and beliefs while it was the goal of early christian missionaries to banish the superstitions of the local populations local christianity ultimately incorporated many of these practices transforming into distinctive forms of organization and worship commonly referred to as africaninitiated churches in africa today these syncretic religious practices have given rise to pluralistic medical fields with newly emerging constellations of healing modalities that meld western biomedical and traditional forms of diagnosis and treatment medical pluralism refers to the concurrent usage of multiple treatment modalities and is common in places where biomedical and alternative treatments coexist such as in subsaharan africa in recent decades this encounter between traditional and biomedical healing practices has attracted significant interest from researchers south africa in particular is a country that has elicited attention due to its pluralist system of health provision with developed biomedical systems and relatively strong state support for traditional healers referred to as traditional healing practitioners thps in south africa work as faith healers in the christian traditionreferred to as prophets or as healers in the african traditions as diviners or herbalistsreferred to as sangomas or inyangas sangoma is commonly used to designate a traditional healer in the african tradition as many thps utilize both herbs and divination and will therefore be the term used in this text with regards to illness thps generally treat conditions brought about by causes such as spirits ancestors sorcery and bewitchment in addition to curing illness thps also assist clients in making decisions finding lost or stolen objects resolving problems attracting or retaining lovers getting a job or for protection previous studies have estimated that between 70 and 80 of south africans consult thps for the treatment of illness additionally the vast majority of south africans who consult thps are of black african ethnicity while many studies have assessed health seeking behaviors of the south african population within this pluralistic religious and medical environment few have examined pluralism with regards to the beliefs practices and behaviors of thps themselves this study seeks to examine pluralistic religious and medical practices among thps so as to understand how spiritual worldviews among traditional healers have been revitalized to meet contemporary challenges of health and wellbeing in south africa 3 journal of religion and health 63907923 methods study setting and design this study enrolled 18 thps practicing in townships surrounding johannesburg south africa between january and may 2022 in particular the thps interviewed lived and worked in either soweto katlehong or vosloorus townships a qualitative study design was utilized with semistructured interviews to elucidate thp understandings of illness and healing within pluralistic religious and medical contexts an interview guide was developed with guidance from two thps associated with the health economics and epidemiology research office at the university of the witwatersrand this guide was pilot tested on two thps in january 2022 however these responses are not included in this analysis recruitment and sampling during the recruitment process participants were informed that this study was associated with a local university in johannesburg participants were recruited using a snowball sampling technique in which thps were referred via word of mouth participating healers were asked if they could provide contact information for other healers working in johannesburg as the sector is largely informal this sampling strategy allowed researchers to maximize representation of healers from throughout the townships surrounding johannesburg a sample size of 18 was guided by the concept of data saturation in which interviews no longer reveal new content and participants often repeat information previous interviewees reported transcripts of interviews were analyzed on an ongoing basis throughout the study process to ensure that emerging themes could be understood and explored further data collection eligibility criteria included being 18 years of age or older able to provide informed consent and consenting to recording of the interview and recognized as an official thp after completing thwasa interviews lasted between 35 and 60 min and were conducted by the study pi and study research assistants who are also practicing thps or in training at the home or workplace of the healer research assistants were fluent in english isizulu and isixhosa and could ensure real time translations in the event the participant did not speak fluent english data analysis and ethical considerations interviews were consequently transcribed and translated into english two authors reviewed all english transcripts for content relevant to religious and medical pluralism in thp practices this analysis utilized a directed content analysis method that combines deductive and inductive aspects of codebook development themes were developed and refined resulting in the generation of a final set of codes both researchers subsequently utilized nvivo 120 to code the transcripts intercoder reliability was used to ensure common understandings of concepts and codes this study received approval from the human research ethics committee at the university of the witwatersrand and the research committee of johannesburg health district participants provided written informed consent and were compensated 100 rand for their time this amount was determined together with the university of the witwatersrand and he 2 ro all covid19 protocols were followed during the collection of study data results eighteen thps were interviewed for this study including 9 males and 9 females healers ranged between 21 and 74 years old with an average age of 39 years old thps also had between 2 and 48 years of experience as a healer with an average of 16 years see table 1 for participant demographic characteristics thps as sangomas and prophets fifteen of the 18 thps we interviewed were both sangomas and prophets reflecting a syncretic relationship between traditional african beliefs and christianity for the difference between sangomas and prophets refer to table 2 of the 15 sangomas that also worked as prophets 9 were with the apostolic church 3 with the zion christian church 1 with shembe and 2 with other independent churches thps who were both sangomas and prophets described having to ensure a balance between the two roles often referred to as gifts we another thp referred to switching between the two roles as being like acting for example last weekend i had a ceremony where i was appointed as archbishop of a church and then this week i have a ceremony with traditional healers its another world so when i work in the church i just put my mind on that thing its like acting like a character on a stage this week episode 2 he or she is a pastor episode 3 etc its just like that you adjust to that environment in that present moment there was no designated order in which a thp becomes a sangoma or a prophet as 6 became sangomas first 6 became prophets first and 3 were initiated into both at the same time usually the thp would become initiated into one of the two healing traditions first based on their family or community as one recounts my grandmother was a church person i played drums at the church and then all of a sudden i would see things i had visions i said to the pastor when you were talking about this and this i was seeing this and this the congregation also was amazed thats how it came about i graduated in the prophecy others described initiating into a second healing tradition after repeated sickness that wasnt cured by the first initiation or having specific dreams or visions associated with either sangoma or prophetic healing sickness and dreams as calling to become a healer initiation as a thp is almost always preceded by a sickness that represents an ancestral calling to become a healer sixteen of the 18 healers interviewed reported experiencing their calling via illness most healers explained that the illness related to their ancestral calling was one that doctors cannot treat once it was established that doctors could not treat the illness the individual would go to a sangoma who would confirm that it was a calling the family didnt understand we went to the doctors and nothing was helping then we went to see a traditional healer and discovered it was a calling i couldnt walk i was weak the doctors said there was nothing they could see on their end and thats when the healer said i have the calling as mental illness is often more difficult for medical professionals to diagnose and treat many healers experienced mental illnesses which they interpreted as their ancestral callings they come as a mentally disturbed person people say oh this person is mad but you have to check whats wrong why they are like this some want to kill themselves some want to be alone all the time some leave their marriages everything goes back to how the calling comes through somebodys body you have to be very careful to see why someone is mad in relation to their ancestors besides mental illness other thps reported sicknesses such as seizures fainting spells back pain headaches chronic fatigue and vision problems as their callings the sickness caused by the ancestral calling is not considered the same as a normal illness rather it is a manifestation of the ancestors compelling the individual to follow in the footsteps of one of their relatives who was a thp in the past i didnt know i had a calling originally to be a traditionally healer or sangoma but i was sick they thought i was mentally disturbed i was doing funny things strange things then my grandmother took me to a traditional healer in eastern cape province in 1994 i was 11 years old this traditional healer said i had a calling i didnt know there was anyone in my family who was a traditional healer except for my aunt she was a traditional healer so i took this from my aunt she passed away in 1986 1 3 journal of religion and health 63907923 all thps reported that upon starting traditional healing initiation school the illness immediately disappeared as one describes because of the back pain i went to several healers spiritual traditional and faith i was told that i have a calling that i must heed and do traditional healing initiation the pain stopped when i started receiving treatment which was aimed at becoming a traditional healer thwasa is thus seen as the only cure for supernatural forms of illness that indicate the individual has a calling in addition to sickness thps usually also have dreams or visions which indicate an ancestral calling there is a distinction between dreams which indicate a calling to become a sangoma and a calling to become a prophet however as one describes in prophecy you dream about water candles singing in church yourself flying that represents you being a prophet but being a sangoma you dream about ancestral animals like lions snakes being on the water other common dreams reported which indicate a calling include being top of a mountain or in a river placing your hands on people to heal them being under water seeing people in sangoma dress or hearing drums and holding a bible in addition to dreams some thps reported visions in which they could foresee the future as one described if there was going to be a death in the family i would dream about it and tell them and it would happen the day my father passed on i had a dream his spirit was coming out of his body i woke up and told my mom my dad is no more and thirty minutes later they called us to alert us that he was no more while nearly all thps have a sickness which indicates their calling many also have dreams however few reported prophetic visions in which they could predict future events thps tradition and churches thps who practice as both sangomas and prophets are members of nonpentecostal aic churches sometimes these churches are referred to locally as omoya or spirit in isizuluwhich can be differentiated from pentecostal or born again churches for the differences between aic churches refer to table 3 unlike pentecostal churches these churches generally welcome sangomas conversely pentecostal churches largely do not allow sangomas as they often view them as evil as one described if our church was bazalwane we wouldnt be able to pray to the ancestors and burn impepho traditional incense i wouldnt be able to go there if it was bazalwane they dont like sangomas two of the thps interviewed said they had to leave their pentecostal churches when they decided to become sangomas as they were no longer welcome another described having to move out of his mothers houseas her side of the family was pentecostalwhen he realized he had a calling and decided to become a sangoma he consequently relocated to his fathers house whose side of the family was more involved with traditional religious practices he recounts i went home to my mother and told her i had a calling and she said they didnt want to interfere she said we dont have that here sangomas since her family is bazalwane pentecostal she said if you want those things go to your dads house in light of this rejection by pentecostal christians many sangomas described feeling resentment toward born again churches and saw them as turning away from their roots these people run away from african culture they think being born again or bazalwane pentecostal they can push these things away they try to brush these things off but these things are alive and are living with us they are our main purpose of being on earth connecting with our ancestors and they dont want that nonpentecostal aic churches on the other hand not only welcome sangomas but often blend traditional african practices with christian practices one described how at his church they also burn traditional incense and pray to their ancestors during church services similarly as healers thps describe using both the christian god and traditional practices together when performing rituals as one described at the end of the day we are all gods creation jesus god so god comes first whatever we do we throw the bones a sangoma divination practice we pray with no guidance from god we are nothing traditional beliefs and western medicine similar to these forms of religious pluralism melding christianity and traditional beliefs many thps also often practiced medical pluralism mixing western treatments with traditional practices one thp was both a sangoma a prophet and a practicing nurse and described how she often encourages patients from the hospital to come visit her for traditional healing services after hours this reflects a commonly held belief among thps that some illnesses are supernatural and for traditional healers to treat and other illnesses are natural and for doctors to treat by encouraging patients to go through both treatments they are ensuring a cure regardless of the illness etiology even if a patient is diagnosed with a commonly known illness such as hiv or tuberculosis at the hospital thps argue that these could actually be supernatural illnesses disguised as western ones thus requiring traditional intervention im the muthi herbs curses can cause you to have cancer it can cause you to have hiv the spell thats cast on you is so heavy any bad thing can happen to you all the negative energy and misfortunes so if you go to western medicine to get treatment and its not working you will come back to me and i can tell you if someone cast a spell on you the doctors medication will not work but we fight with that curse several thps argued that they had the power to cure illnesses such as hiv as it was at times of supernatural origin in the case of these supernatural illnesses some thps argue that a doctors treatments could not only be ineffective but could also be harmful so doctors are western and sangomas are traditional right there are sicknesses that a doctor cannot see for example if you are being troubled by an ancestor like if you have a calling and need to thwasa you will be getting sick and having headaches or lots of flu or asthma sometimes its ancestors and not really asthma but the western doctor will think its asthma but its really amadlozi ancestors … if they doctors think its asthma theyll give you an asthma pump and it will just make you worse in spite of these differences almost all thps interviewed viewed collaboration with western medicine positively while they saw many similarities between the two professions they also understood that doctors go through many years of rigorous training and that thps complete significantly less years of training the only difference is doctors are qualified and sangomas only need to go for initiation we dont go to university for 6 years we just go to initiation thwasa for 6 months or 10 months and were done in addition to thwasa however many thps had completed short medical training courses at local hospitals on topics ranging from hivaids covid19 cancer first aid fundamental nursing stis tb hygiene nutrition family planning and basic counseling these courses were largely organized by local thp associations of which many healers are members many healers reported desiring more training in biomedical approaches almost all healers also encouraged patients to get tested for hiv at a clinic or hospital prior to starting treatment with them due to the high community infection rates in south africa this reflected an almost universal willingness to ensure that their patients are engaging with doctors simultaneously to receiving their treatment as traditional healers discussion thps as sangomas and prophets the thps interviewed in this study represent a common trend in contemporary southern africa in which many sangomas practice faith healing as prophets as a form of african syncretic christianity p 5 this movement started with the rise of early twentieth century africaninitiated churches which broke away from more westernoriented churches brought by european missionaries and share a common theory of health and disease with traditional african beliefs as a result a large segment of south african religious practices today are an amalgamation of traditional cosmology and christianity others have described them as syncretic cults… mixing halfbaked christian teachings with indigenous religious practices to create a new hybrid form of syncretic spirituality in this sense the sangomaprophets we interviewed are seen as persons with clairvoyant healing powers operating within african church cosmology this reflects broader trends within african societies in which virtually no religious practices and beliefs are entirely pure or free from african traditional ideas that preexisted the arrival of christianity rather this syncretism is part of a broader cultural fusion that represents a vibrant market for religious ideas in which few are effectively monoreligious and almost everyone is continually shopping within a religiously pluralistic environment 3 journal of religion and health 63907923 sickness and dreams represent a calling the sangomaprophets we interviewed were almost all called to their profession via illness this calling means that the individuals ancestors are compelling him or her to become a healer in order to use supernatural powers to explain misfortune and illness and offer guidance on how to appease ancestors whether as sangomas or prophets thps often use their powers to treat witchcraftsorcery related problems highlighting the influence of traditional beliefs on african syncretic christianity as well for sangomas in particular the calling in the form of an illness derives from the worldview of precolonial african belief systems in which the ancestral calling is handed down from generation to generation by completing the thwasa training one is answering the ancestral call and continuing the familial tradition of healing work as prophets also often receive a calling via illness we can see the influence traditional african beliefs have had on the evolution of local christianity as described by the thps interviewed above the calling is most often related to mental illness with psychotic disorders the most prominent manifestation and mood disorders and anxiety disorders to a lesser extent mental illnesses are more difficult for medical professionals to diagnose and treat as symptoms are determined by selfreport rather than blood tests xrays or other biomarkers for this reason individuals experiencing symptoms of mental illness such as social withdrawal strange behavior or unexplained aggression are often told they have a calling and should undergo thwasa lastly many thps also described their calling as coming in the form of dreams from a cultural perspective dreams are regarded as messages from the ancestors and represent an essential connection between conscious and unconscious life similar to dreams visions and unseen voices can also be interpreted as ancestors or other spirits seeking to communicate with the living dreams such as those including scenes from the bible or ancestral animals indicate a calling specific to the prophecy or rites of sangomas pentecostal and nonpentecostal aic churches while it is difficult to measure there are estimated to be hundreds of thousands of prophets in south africa many of these prophets are part of born again or pentecostal churches which represent the fastest growing sector of south african christianity the largest of these pentecostal churches is the zion christian church designated by a yellow star that members wear this differentiates it from other zion or zcc churches which are not born again highlighting complex denominational divisions in countries such as south africa in other words many churches share similar names or titles but have different approaches to incorporating sangomas and other traditional african beliefs such as ancestor worship there were no pentecostal prophets interviewed for the purposes of this study as bazalwane church members do not generally associate themselves with sangomas who they revile as primitive dirty and spiritually dangerous in fact much of the work of pentecostal prophets is directed toward counteracting the work of witches sorcerers and other figures associated with traditional african belief systems this is a form of evangelism that some experts on african pentecostalism have termed confrontationist in that they view local african beliefs through the prism of christian demonology bazalwane beliefs are still arguably syncretic mixes of christianity and traditional beliefs however as in their attempt to combat witchcraft they were instead drawn into the witchcraft world in other words in demonizing traditional beliefs they are acknowledging them as active forces within their own religious worldview similarly with regards to ancestor veneration bazalwane believe people who venerate their ancestors… do so because they are kept in darkness by the devil and do not realize the vastly superior power available to them should they become saved by jesus while the prophets we interviewed for this study also perform similar roles in combating witchcraft they do not view traditional african beliefs in a negative light rather they incorporate traditional african rituals and customs into their work as christian prophets and see them as another tool in the spiritual toolbox in this sense the prophets we interviewed simultaneously pray to the christian god along with their ancestors when seeking spiritual guidance some researchers argue that with the rise of pentecostal and born again churches in subsaharan africa thps are increasingly positioning themselves to appeal to the bazalwane antitraditional rhetoric medical pluralism and collaboration similar to religious pluralism with the south african spiritual landscape medical pluralism is also common among both the general population and thps although western biomedicine has become increasingly accepted in recent decades belief in supernatural explanations of illness and misfortune remain widespread this distinction is particularly strong with regards to the foundational distinction between natural illnesses and supernatural manmade or african illnesses while natural illnesses are susceptible to treatment by western medicine supernatural illnesses are thought to only respond to the intervention of healers deploying spiritual powers in this sense even thps hold multiple explanatory models when it comes to illness as they refer patients they determine are afflicted with natural illness to doctors for treatment thus as we saw with the thp who also worked as a professional nurse the possibility of simultaneously subscribing to and participating in disparate healthcare systems is commonly accepted 3 journal of religion and health 63907923 in another study examining medical pluralism among psychiatric nurses in south africa researchers found that the nurses subscribed to pluralistic systems which drew on both african and western cultural worlds without an absolute allegiance to either this reflects the view that different practitioners can fulfill different needs an additional distinction may be the role thps play in african societies in which they not only work to assuage the symptoms of the illness but also provide an explanation for the illness some experts argue that this may justify the continued popularity of thps even in places where biomedical treatment is relatively easy to access due to the strong tendencies toward medical pluralism already in place among thps in this region collaboration between doctors and thps is overwhelmingly supported by the latter as evidenced by the results of this study a significant literature already exists exploring this subject in south africa with many researchers in support of such arrangements this reflects the notion that traditional healers are extensively patronized have a large clientele maintain significant respect within local communities and therefore should be viewed as bottle openers rather than bottlenecks for collaboration and treatment recent research has found that collaborations have been successful between biomedical healthcare workers and traditional healers throughout subsaharan africa nevertheless it is important to point out that there are also many researchers who warn against potential pitfalls of collaboration between biomedical and traditional health practitioners the lack of a uniform code of ethics or training among thps to protect patients reports of exorbitant fees charged to patients physical or sexual abuse at the hands of thps reports of acute poisoning caused by traditional herbal remedies delays in receiving evidencebased treatments and lack of trust between traditional healers and biomedical workers are just some of the issues that experts warn could plague potential collaboration in spite of these challenges there remains widespread interest in exploring medically pluralistic models of treatment in contemporary south africa this can potentially be achieved through the opening of dialogues and conducting workshops with both thps and biomedical healthcare workers in presence as well as suggestions of both parties working together to discuss points of synergy where their work could dovetail within the different levels of care this could also include biomedical healthcare workers building enough rapport with their own patients to be able to ask them in a more openended manner if they are actively seeking out or are already taking alternative modes of treatment and then accommodating this into treatment planning limitations as this study is qualitative and only interviewed 18 thps it is not meant to be generalizable to the general population of healers in johannesburg or southern africa rather this study provides specific and detailed information about a unique population of interest for example this study did not include bazalwane prophets who also work as spiritual healers in this context and is therefore not generalizable to them while there are many similarities with other studies that have examined the beliefs and practices of healers in johannesburg and southern africa more research is needed to fully assess the constantly evolving relationship between religious and medical pluralism among these populations in order to understand how they impact trends in spirituality and health seeking behaviors in the region conclusion contemporary south africa is a site of increasingly complex religious and medical pluralism giving rise to newly emerging constellations of beliefs systems and therapeutic possibilities the thps interviewed for this study adapt elements of western and african beliefs and healing practices in eclectic ways to span multiple religious and medical fields selfpositioning across a range of traditions and forms of knowledge recent research highlights that collaborative and decentralized healthcare services would be highly acceptable among pluralistic communities while few studies have tested collaborative healthcare interventions between thps and biomedical practitioners this study shows that there are multiple avenues for cooperation with this new generation of thps in south africa author contributions all authors contributed to the study conception and design material preparation data collection and analysis were performed by mg lc and am the first draft of the manuscript was written by mg and all authors commented on previous versions of the manuscript all authors read and approved the final manuscript informed consent informed consent was obtained from all individual participants included in the study publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations authors and affiliations michael

religion and spirituality are powerful social forces in contemporary south africa traditional health practitioners thps are commonly consulted for both spiritual and medical ailments as a first line of care many studies have assessed african traditional health seeking behaviors but few have examined beliefs practices and behaviors of thps themselves this study sought to explore spiritual worldviews among south african thps semistructured indepth interviews were conducted with 18 thps in johannesburg south africa between january and may 2022 interviews were transcribed and translated into english data were managed using nvivo 12 software and thematically analyzed the majority of thps interviewed indicated that initiation as a thp was almost always preceded by a sickness accompanied by dreamsvisions that represented an ancestral calling to become a healer most thps also trained as both sangomaswho healed according to traditional beliefsand prophetswho healed according to christian beliefs this reflects a syncretic relationship between traditional african beliefs and christianity however not all churches are accepting of traditional beliefs and subsequently these thps are members only at nonpentecostal aic churches who blend both african and christian practices similar to these forms of religious pluralism melding christianity and traditional beliefs many thps also often practice medical pluralism mixing western treatments with traditional practicesmedicines thps are able to adapt elements of western and african beliefs into healing practices that span multiple religious and medical fields thus collaborative and decentralized healthcare services may be highly acceptable among such a pluralistic community

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introduction social entrepreneurship is widely acknowledged as an effective tool to address the increasing discrepancy between the very top and the very bottom of societies it works by blending financial and social value creation fosters innovation and financial independence of stakeholders and further positively influences individuals groups and societies due to its benefits various programmes have been launched to foster social entrepreneurship the majority of these programmes promotes the individual intention to become a social entrepreneur as this intention is considered the single most important predictor of founding a social enterprise there is large consensus that seintention is strongly driven by personrelated antecedents such as values motives or personality traits yet three central limitations blur this consensus first the number of personbased antecedents for seintention is enormous and thus difficult to overlook in fact the large quantity of antecedents impedes navigation through the field and further bares the risk of an inability to build cumulative knowledge second most of the studies investigating antecedents of seintention focus on a single theoretical model it goes without saying that se is an interdisciplinary phenomenon and thus various theoretical models have to be considered conjointly to understand its antecedents finally there isat least to our knowledgeno agenda that specifically guides future empirical research on antecedents of seintention a circumstance that clearly impedes progress in the field in essence seresearch seems to lack an integrative framework of personbased antecedents of seintention which is empirically supported and allows deriving a distinct research agenda for future studies in the field the significance of this study is threefold first as research matures in social entrepreneurship greater attention to theory building regarding its antecedents becomes a priority theory building enhances the field and is best done when drawing on systemised and structured knowledge currently a systemised and structured overview of personbased antecedents regarding seintention is missing preventing advancements in theory building this study presents a theoretically grounded systematization of personbased antecedents of seintention and thus helps to enable theory building in the field more detailed it systemises the most prominent personbased antecedents alongside the distalproximalmotivation framework of kanfer and assigns them to the level of personality cognition or entrepreneurial exposition second this study offers an empirical validation of the systematization framework according to which the antecedents are structured thus it goes beyond sheer theoretical reasoning and suggests that the personbased antecedents of seintention are indeed grouped on different levels more detailed a largescale sample of south african students shows that antecedents from different levels complement each other when predicting a persons intention to launch a social enterprise finally this study enhances theory building by identifying three particularly promising streams for future seintention research which are derived on the basis of this studys empirical insights in fact we derive specific research questions which are thought to inspire future theory and research on se theoretical background social entrepreneurship as a new form of entrepreneurship social entrepreneurship is considered a new form of entrepreneurship which deliberately incorporates a social mission into a business model the social mission can be diverse and includes but is not limited to alleviating poverty or integrating marginalized groups into the labor market as boththe social mission and the incomeoriented business modelare combined social enterprises are also referred to as hybrid enterprises importantly while acting on a social mission is possible for any business including forprofit and nonprofit enterprises social enterprises focus on selffinancing their social actions and on remaining independent from political or private donations as a result social enterprises are likely to be perceived as apolitical and more sustainable than for instance ngos this is a major advantage as political neutrality helps to avoid governmental interference and higher sustainability supports the enterprises independence even in times of crises like the covid19 pandemic when donations are commonly cut down in essence se can be conceptualized as a new hybrid form of entrepreneurship which combines the fulfillment of a social mission with the aspiration to generate monetary profit and to selffinance the social actions therefore se is largely seen as a hybrid form of entrepreneurship bridging the gap between forprofitonly enterprises and traditional ngos the increasing interest in social enterprises builds on their great potential to contribute to a more just and equal society social entrepreneurial intention behavioral intentions are the single most important predictors of any planned behavior and explain about 28 of its variance importantly this also holds true for the entrepreneurship context where a clear link between entrepreneurial intention and action was found while entrepreneurial intention is an important prerequisite of entrepreneurial activity social entrepreneurship intention determines social entrepreneurship activity in this regard social entrepreneurial intention refers to a persons determination to plan a new social business and to consciously set it up at some point in the future whether individuals intend to become a social entrepreneurs strongly relies on their personbased characteristics such as personality traits cognitive skills or individual values two strategies have been applied to pin down personbased antecedents of seintention first antecedents are derived from theoretical models transferred from other disciplines to the field of se an example thereof is the theory of planned behavior which is used in but not limited to the context of entrepreneurship second antecedents are drawn from theoretical models specifically developed for se an example thereof is the model of social entrepreneurial intention formation by mair and noboa which was specifically developed for the context of social entrepreneurship subsequently we summarize the most prominent personbased antecedents of seintention alongside the theoretical models they originate from and finally structure them according to a new integrative multilevel framework personbased antecedents of seintention and the theories they originate from seintention antecedents proposed by the theory of planned behavior the tpb is one of the most widespread theories to predict entrepreneurial intention and behavior according to the theorys assumption any planned behavior relies on the intention to perform it in the context of se intention formation is thought to be influenced by attitudes toward se subjective norms regarding se and perceived behavioral control according to ajzen a negative attitude toward se describes the negative evaluation of becoming a social entrepreneur and will decrease the probability of becoming one whereas a positive evaluation will increase this probability subjective norms reflect normative beliefs that signify the influence of others on personal decisions in personal life for instance if friends approve seactivities then the probability of performing these activities will increase finally perceived behavioral control refers to a persons selfefficacy to successfully perform entrepreneurial behavior and to its perceived controllability thus perceived behavioral control is high if individuals consider themselves capable of starting and managing a social enterprise and if they see themselves capable of controlling relevant aspects recent empirical findings demonstrate that the antecedents postulated by the tpb are valid in the secontext and influence a persons intention to found a social enterprise even across different cultures and economic circumstances important for this study the tpb suggests a socalled thinkingdoing link and thus stresses a cognitive approach to entrepreneurship accordingly in order to do something individuals have to think of their actions beforehand naturally this approach highlights the individual thinking and decisionmaking processes which is why all antecedents derived from the tpb are considered as cognitive antecedents of seintention seintention antecedents proposed by the model of social entrepreneurial intention formation a second approach frequently applied in se is the model of social entrepreneurial intention formation by mair and noboa this model suggests that empathy moral judgement selfefficacy and social support are direct antecedents of seintention which in turn triggers actions relevant to found a social enterprise while empathy refers to the ability to cognitively understand and affectively share the emotional situation of others moral judgement denotes the motivation to help others to create a common good both empathy and moral judgement enhance the attractiveness of careers in se and in turn increase the intention to pursue such careers additionally selfefficacy describes the conviction of being able to found a social enterprise while social support refers to the expected help of others when striving for a career in se conjointly selfefficacy and social support increase a persons conviction to successfully perform as a social entrepreneur in line with the models assumption all four antecedents directly predict the intention to found a social enterprise similar to the tpb mair and noboas model highlights the cognitive elements of seintention important for this study while the tpb explains the intention formation processes in a wide variety of settings but is not limited to the social entrepreneurial one mair and noboas model is exclusively developed for social entrepreneurship therefore it includes only those antecedents which are thought to be of relevance for nascent social entrepreneurs due to the cognitive nature of the antecedents proposed by mair and noboa we also see them as cognitive antecedents yet we account for their conceptual proximity to seintention which is why we consider them as sespecific or socalled secondlevel cognitive antecedents seintention antecedents proposed by the basic human values theory the basic human values theory of schwartz is the third theoretical approach frequently used to describe antecedents of seintention accordingly differences in peoples values are responsible for their varying professional goals and varying intention to pursue a se career schwartz distinguishes figure the integrated structural model of personal values ten values which are arranged in a circular model according to their similarity more similar values are located more closely to each other and are grouped into one of the following higherorder values selftranscendence openness to change conservation and selfenhancement the higherorder value selftranscendence refers to benevolence and universalism and emphasizes the importance and willingness to help others as social entrepreneurs aim at creating value to fight social challenges selftranscendence values are meant to foster seintention openness to change refers to selfdirection and stimulation as open persons enjoy free thinking are innovative and seek new experiences because this kind of selfdirection and stimulation is prototypical for entrepreneurial tasks openness to change is also meant to enhance seintention conservation describes a persons aspiration to maintain the status quo preserve traditions and live a secure life this value opposes entrepreneurial tasks which commonly include risktaking breaking with tradition and exploiting novel opportunities consequently individuals who express high conservation values presumably express reduced seintention a similar logic applies to schwartzs last higherorder value selfenhancement refers to an individuals aspiration to reach goals which strongly match personal interests as the focus on selfinterest and personal achievement opposes the social entrepreneurs mission to create social value a high level of selfenhancement should impede the intention to pursue a career as social entrepreneur in line with this reasoning there is growing evidence that all four integrated values are valid antecedents of an individuals seintention importantly but in contrast to the previous models schwartzs model does not refer to cognitive antecedents of seintention as values rather reflect the personality than the cognition of social entrepreneurs we refer to them as personalitydriven antecedents personalitydriven antecedents are commonly regarded as more distal exerting their influence on seintention via the more proximal cognitive antecedents a proposition that was recently confirmed in the context of se next to the three models summarized above there are several singleconstructs which are regularly discussed as important antecedents of seintention these include the personality traits proactivity risktaking and altruism as well as the experiencebased antecedents seknowledge and seexperience these singleconstruct antecedents are subsequently outlined and their relation to the previously listed antecedents is discussed singleconstruct antecedents of seintention proactive personality bateman and crant define proactive personality as a relatively stable tendency to affect environmental change people who are proactive consider themselves as change agents who actively shape their environment instead of passively waiting for change to happen proactivity is considered an important antecedent of seintention as it was repeatedly linked to persons intention to become a traditional entrepreneur entrepreneurial outcomes and social entrepreneurship intention as proactivity is a relatively stable personality trait and thus similar to schwartzs values it will also be considered a personalitydriven antecedent risktaking risktaking is a key element in entrepreneurship and metaanalytic findings show that those who are more willing to take risks report stronger entrepreneurial intention compared to traditional entrepreneurship risktaking should be even more important in se as social entrepreneurs bare the risk of failing twicefinancially and in their social mission while traditional entrepreneurs deal with financial risks alone social entrepreneurs also have to deal with high moral standards which bare an enormous risk to backfire even when only slightly bent for the benefit of financial goals consequently se is closely tied to risktaking for why individuals with higher willingness to take risks should also be more drawn to careers in se and should thus express higher seintention given that risktaking is largely considered as a personality trait we take the view that risktaking is on the same conceptual level as proactivity and schwartzs personalitydriven values thus it is an antecedent on the personality level altruism altruism is the tendency to generously and kindly help others without or with lowscale external incentives altruistic reasoning was spotted as a strong motivational driver for se and is further regarded as one of the most important traits of social entrepreneurs similar to risktaking proactivity and schwartzs values altruism is considered a relatively stable and rather general personality trait consequently it also represents the personality level of antecedents seknowledge and seexperience knowledge about and experience with certain careers prevent from unrealistic career expectations and facilitate career decisions this holds also true for the field of se and turns the business experience as well as experience with social problems into relevant antecedents of seintention consequently knowledge about and experience with se will be considered as important drivers for seintention in this study however compared to the previously mentioned cognitive and personalityrelated antecedents seknowledge and experience are highly specific for se and provide the most detailed information on a future career as a social entrepreneur therefore we take the view that knowledge and experience are very proximal antecedents of seintention with a larger effect on seintention than the previously presented antecedents on the personality and cognitive level a multilevel framework for systemising antecedents of seintention as shown entrepreneurship research provides a rich diversity of antecedents for seintention although this diversity is fruitful for the development of se theory it also impedes navigation through the field which bares the risk of an inability to create cumulative knowledge for theory building while this risk was generally spotted in entrepreneurial researchindependent of whether the focus was set on social or general entrepreneurshipeffort to address it was primarily put into general entrepreneurship zhao et al andalferaih for notable examples in contrast and according to recent research the effort for systemising antecedents of social entrepreneurship falls comparably short the main reason why antecedents of seintention still lack systematization might lie in the fundamental disparities between general and social entrepreneurship which directly affect the motivational drivers thereof for an overview keeping in mind that social and general entrepreneurship differ and that their personbased intentional drivers differ makes a sheer adaption of findings from general to social entrepreneurship inappropriate findings by wach et al strengthen this argument and show substantial differences in personbased antecedents of the intention to launch a general vs social enterprise these differences are particularly clear when it comes to personal attitudes or perceived behavioral control and appear to be globally present as they were found in different cultures consequently we build on this research demonstrating that the personbased antecedents for general vs social entrepreneurial intention differ and argue that it is thus necessary to offer a systematization framework particularly derived for antecedents of seintention in fact a structured framework allows for more detailed insights on whether antecedents are unique or redundant complement each other or trigger each other in a processual manner to structure the drivers of seintention we apply the distalproximalmotivation framework of kanfer this particular framework was used because it validly groups motivational antecedents is meaningful in the setting of se and helps following a recent call for more systematization of antecedents in se in line with kanfer we suggest that seintention is influenced by antecedences which can be organized according to their conceptual proximity to entrepreneurial actions proximal antecedents are narrowly defined and sespecific they shape a persons wish to pursue a career in se and help to set the stage for actions in se in contrast distal antecedents are more broadly defined and rather unspecific which is why they are important for a wide variety of settings including but not limited to se distal antecedents exert their impact often rather indirectly through more proximal ones which is why their direct link is commonly weaker important for this study both more proximal and distal antecedents predict a persons intentional level separately however considering proximal and distal antecedents conjointly should result in the most accurate prediction of a persons seintention figure 2 depicts the antecedents of seintention grouped according to the distalproximalmotivation framework the most distal level integrates all of schwartzs personal values as well as the personality traits proactivity risktaking and altruism we will refer to it as the personality level according to bergner the personality of an individual reflects the enduring set of traits and styles that he or she exhibits consequently the common core of antecedents on the personality level is that they are relatively stable across time and situations and are usually not bound to a certain career context they are rather distal and shape a persons career intention in diverse settings including but not limited to se for example a person scoring high on the value selftranscendence they are perceived to be more proximal than the tpbcomponents attitudes subjective norms and perceived behavioral control which are applicable to a wide range of di erent behaviors will probably favor a job with social and caring tasks however this could result in the intention to become a social entrepreneur but also in the wish to work as a caregiver social worker or teacher thus the antecedents on the personality level drive career intentions in a rather broad and general way and compared to antecedents on the cognitive level which are presented next they do not involve a mental or intellectual reflection of career options and are less prone to change as a result of ones own thinking process for instance when acquiring more information about alternative career tracks for an overview in the entrepreneurship context in brief antecedents on the personality level are understood as enduring innate socioemotional characteristics of a person the next level of our integrated multilevel framework refers to antecedents of seintention on the cognitive level and comprise the components of the tpb and the model proposed by mair and noboa antecedents of this level denote a persons cognitive effort to evaluate the attractiveness of a career as social entrepreneur as this evaluation involves critically questioning the specific tasks of social entrepreneurs and challenging ones own capabilities to successfully complete them there is a certain proximity to the seintention formation process in fact initial empirical findings provided by kruse et al suggest that cognitive antecedents of seintention are more proximal than antecedents on the personality level important for this study we see a difference between the antecedents derived from the tpb and the model by mair and noboa which is why we distinguish a first and second cognitive level the antecedents of the tpb are applicable to a wide range of planned behaviors including but not limited to entrepreneurship and are thus more distal to seactions therefore they are considered as antecedents on the more distal first cognitive level in contrast the model of mair and noboa comprises solely sespecific antecedents with a high proximity to seactions therefore they are considered as antecedents on the more proximal second cognitive level the final set of antecedents for seintention refers to the amount of seknowledge and seexperience it is termed the exposition level the antecedents on this level are all directly linked to the targeted intention and include the active gain of serelevant knowledge and experience importantly this knowledge and experience goes beyond the sheer cognitive assessment of an secareer which is reflected on the cognitive level consequently the exposition level is the most proximal one based on kanfers distalproximalmotivation framework we propose that more proximal antecedents are not only more strongly tied to seintention but also enhance the prediction of more distal ones translating this assumption to an empirical level means that more proximal antecedents should add incremental validity over more distal ones when predicting the intention to become a social entrepreneur thus the following hypotheses are stated h 1 antecedents on the personality level significantly predict seintention h 2 antecedents on the cognitive level 1 incrementally predict seintention beyond the antecedents of the personality level h 3 antecedents on the cognitive level 2 incrementally predict seintention beyond the antecedents of the personality and cognitive level 1 h 4 antecedents on the exposition level incrementally predict seintention beyond the antecedents of the personality cognitive 1 and cognitive 2 level methods data acquisition and sample in total 499 participants with a mean age of 22 years provided data in this study overall the participants were between 17 and 35 years old 74 reported having a blackafrican background whereas 10 had an indian 10 a whiteeuropean 5 a colored and 1 a chinese ethnical background the majority of the participants were undergraduates participation was voluntary anonymous and not incentivised the data was collected using a paperpencil questionnaire which was distributed in undergraduate courses of a university in johannesburg notably the south african sample is a clear benefit for research on se first it allows examining the seintention in a country with one of the highest seactivity rates second it represents a nonwestern entrepreneurial mindset and thus increases the generalizability of findings on seintention which mainly build on western samples measures seintention as the criterion of interest seintention is defined as the aspiration to found a social enterprise in ones professional career it was measured using the social entrepreneurial intention scale of kruse et al where participants rate six items on a 7pointlikert scale ranging from 1 to 7 the following item is a sample i have the intention to found an enterprise that combines a social mission and an elaborated income strategy in this study the scales internal consistency was 90 personbased antecedents of se intention antecedents on the personality level antecedents on the personality level include the schwartz values selfenhancement selftranscendence openness and conservation and the singleconstruct antecedents proactivity risktaking and altruism the schwartz values selfenhancement selftranscendence openness and conservation were measured using the portrait value questionnaire that subsumes 19 statements which represent other peoples goals in life participants have to rate the extent to which these goals fit their own ones by using a 6point likert scale ranging from 1 to 6 four items represent the selfenhancement subscale which denotes the aspiration to achieve challenging goals and gain power in ones life the subscale selftranscendence was measured by five items and refers to the aspiration to help other people and to be benevolent the subscale openness to change refers to the aspiration to think freely and to be innovative and was measured with four items finally the fiveitem subscale conservation denotes the aspiration to keep the status quo preserve law and order and live a secure life proactive personality refers to the disposition to act as a change agent and affect ones environment it was measured using the proactive personality scale by bateman and crant which consists of five items participants rate their level of agreement on a 7pointlikert scale ranging from 1 to 7 the following is a sample item i can spot a good opportunity long before others can risktaking was measured with the subscales financial and ethical risktaking of the domainspecific risktaking scale participants indicated the probability to perform certain actions on a 7pointlikert scale ranging from 1 to 7 financial risktaking defines the willingness to invest money in a risky manner and was assessed with three items ethical risktaking describes the willingness to perform actions widely considered as immoral and was measured with six items altruism denotes the disposition to help others despite no or just minimal external incentives it was measured using the altruism scale by rushton et al which asks study participants to indicate the frequency of six behavioral items answers were provided on a 5pointfrequency scale ranging from 1 to 5 the following is a sample i have donated goods or clothes to a charity antecedents on the first cognitive level antecedents on the first cognitive level include all components of the tpb attitudes attitudes toward social entrepreneurship subjective norms and perceived behavioral control were assessed using the entrepreneurial intention questionnaire by liñán and chen in its adapted version for social entrepreneurship participants had to rate their agreement to various statements using a 7pointlikert scale from 1 to 7 attitudes toward social entrepreneurship reflect the attitudes toward social entrepreneurship and are measured with five items such as being a social entrepreneur implies more advantages than disadvantages to me subjective norms refer to the social pressure of trusted ones when it comes to the personal goal of becoming a social entrepreneur it was measured with four items similar to this example item if i decided to create a social enterprise my close family would approve of that decision finally perceived behavioral control describes the extent to which a person believes to perform as and control the process of becoming a social entrepreneur it was assessed with six items similar to the following to start a social enterprise and keep it working would be easy for me antecedents on the second cognitive level antecedents on the second cognitive level include all components of mair and noboas model of social entrepreneurial intention formation empathy moral judgement selfefficacy and social support were measured using the social entrepreneurial antecedents scale by hockerts participants provided their agreement regarding various statements using a 5pointlikert scale varying from 1 to 5 empathy describes the ability to cognitively understand others and emotionally share their feelings it was assessed by six items similar to the following when thinking about socially disadvantaged people i try to put myself in their shoes moral judgement refers to the motivation to help others achieving a common goal and was measured with four items selfefficacy denotes the conviction that one is able to found and successfully run a social enterprise it was measured with four items similar to the following i am convinced that i personally can make a contribution to address societal challenges if i put my mind to it finally social support describes the degree to which a person thinks that others support hisher aspiration to act as a social entrepreneur it was assessed with four items antecedents on the exposition level antecedents on the exposition level include knowledge and experience in the context of social entrepreneurship seknowledge describes the extent to which a person is familiar with the concept of social entrepreneurship as a career option it was assessed with three items particularly developed for this study which are rated on a 7pointlikert scale ranging from 1 to 7 the following is a sample item i had been familiar with the term social entrepreneur before participating in this study seexperience refers to the degree to which a person has already gained practical insights in the field of se it was measured with five items particularly developed for this study which had to be rated on the same likertscale an example item is i have already gained practical experience in the field of social entrepreneurship control variables sociodemographic variables impact the intention to found a social enterprise for instance women express higher seintention compared to men also age and education level have been shown to affect the seintention formation process consequently we included sex age and educational level as controls furthermore due to the ethnic diversity in south africa the participants ethnicity was also included as a control variable analysis strategy to test our hypotheses we conducted hierarchical regressions on the participants intention to become a social entrepreneur using the software ibm spss 25 the control variables were entered in the first model subsequently we arranged the personbased antecedents according to our multilevel framework of figure 2 and added the antecedents on the personality level the antecedents of the first cognitive level the antecedents of the second cognitive level and finally the antecedents of the exposition level results preliminary analyses before testing the hypotheses requirements for the hierarchical regressions and common method bias were checked with respect to the statistical requirements we visually inspected the histograms of all variables which confirmed the normality of the data and supported the use of a hierarchical regression analysis common method bias was investigated using a single factor test studying all items conjointly in a factor analysis and limiting the number of extracted factors to just one resulted in 1645 of explained variance as this level of explained variance is well below the suggested threshold of 50 there was no need to account for the common method bias in our analyses finally we checked whether multicollinearity was an issue in our sample the variance inflation factors ranged from 119 for risktaking to 218 for selfenhancement and were all below the threshold of vif 400 thus it was assumed that multicollinearity does not systematically bias the subsequent analyses descriptive analysis and bivariate correlations the descriptive results and bivariate correlations of all study variables are displayed in table 1 the intention to become a social entrepreneur most strongly relates to selfefficacy attitude toward se selftranscendence and moral judgement importantly seintention relates to the respective antecedents only in a positive manner concerning the intercorrelations of the antecedents small to mediumsized values were found hierarchical regression analysis table 2 shows the results of the hierarchical regression analyses to examine the hypotheses the incremental value between the separate regression steps is considered in the first step of the hierarchical regression the control variables were entered in a second step the most distal antecedentsthose on the personality levelwere added we found a significant change in r 2 after including the antecedents of the personality level when predicting a persons seintention thus h 1 is confirmed in a next step the antecedents of the first cognitive level were added which led to another significant increase in the amount of explained variance therefore h 2 is also confirmed and the prediction of a persons seintention is improved by adding antecedents of the first cognitive level to those of the personality level subsequently including the more proximal antecedents of the second cognitive level resulted in a further increase of explained variance and offered support for h 3 finally adding the antecedents of the most proximal level in model 5 the exposition level did not result in an increase of explained variance thus the prediction of a persons seintention cannot be further improved by adding antecedents of the exposition level to those of the previous levels therefore h 4 was not supported when all antecedents were considered conjointly 26 of the variance in a persons seintention was explained discussion this study provides three main results first it demonstrates that the manifold personbased antecedents of seintention can be structured using a multilevel framework which differentiates them according to their conceptual proximity to entrepreneurial intentions applying this framework offers a way to systemise and integrate the rather fragmented research body of antecedents of seintention second this study initially validates the multilevel framework by empirically supporting its underlying assumptions in a country known for its lively se community third this studys findings clearly suggest an agenda for future research when it comes to antecedents of seintention which is subsequently outlined assessment of a multilevel framework for antecedents of seintention our findings reveal that kanfers distalproximalmotivation logic is an eligible basis to structure the most frequently discussed personbased antecedents of seintention in fact all frequently studied antecedents could be integrated importantly and anew our findings suggest that the personbased antecedents represent four quite diverse categories which differ regarding their proximity to seintention moreover our findings offer an initial explanation for why some antecedents are more strongly linked to seintention than others as it seems to be the relative proximity to seintention that affects the empirical link between the antecedents and seintention to validate the multilevel structure of our newly proposed framework we used hierarchical regressions and analyzed a large south african sample our hypotheses 13 suggested that simultaneously considering antecedents of different proximity levels provides better prediction of seintention and that antecedents of the personality first and second cognitive level each bear information about a persons intention to become a social entrepreneur which is not provided by antecedents of the other proximity levels including the antecedents of the personality level first cognitive level and second cognitive level repeatedly resulted in an increase of explained variance in seintention and confirmed hypotheses 13 regarding our empirical findings hypothesis 4 was not supported and antecedents on the exposition level did not enhance the prediction of seintention one reason therefore might be found in research on general entrepreneurship where previous entrepreneurial exposure is also regarded as an important facilitator for entrepreneurial intention however the effect of work experience in a small or newly founded firm on entrepreneurial intention is mediated by positive attitudes toward entrepreneurial careers and perceived behavioral control similar pattern for seintention though knowledge of and experience with se are the most proximal antecedents linked to seintention their contribution to predicting seintention might be encapsulated in mediating variables on cognitive level 1 in addition se is still a relatively new phenomenon and more specific measures are needed to assess both seknowledge and seexperience before final conclusions on their relative importance can be derived especially cultural effects are expected fields for further research in seintentiona research agenda in light of our newly proposed multilevel framework for antecedents of seintention we take the view that it may serve as a solid scientific underpinning for future research in the field the following research streams seem particularly promising a identification and investigation of seintention formation mechanisms in line with our framework we found that adding cognitive antecedents to personalitydriven ones leads to a more accurate prediction of seintention the distinct mechanisms underlying this finding have only rarely been investigated however first evidence suggests that both the personalitydriven and cognitive antecedents separately and directly affect seintention and even more interestingly personalitydriven antecedents affect seintention via cognitive ones given that our multilevel framework identifies more than just personalitydriven and cognitive levels it becomes obvious that the relation between diverse antecedents is still ill understood nevertheless in line with our results it can be assumed that there are overlaps as well as interdependencies among the various antecedents on the same level and across different levels consequently we consider a thorough investigation of the following questions as essential to further understand the complex interplay between seintention antecedents 1 how do the various antecedents on the same conceptual level relate to each other what does their internal structure look like is the cognitive antecedent attitudes toward se an independent predictor of seintention or is it rather a mediator which triggers other cognitive antecedents on the same level 2 do distal antecedents on the personality level indirectly affect seintention via more proximal antecedents on the first and second cognitive level furthermore we consider our framework an open framework that allows to add a wide variety of constructs on each level for instance the big five personality traits thus we explicitly encourage scholars to contribute to the empirically validated extension of our multilevel framework ultimately this will help to get a thorough understanding of the seintention formation process b cultural embeddedness of seintention antecedents the vast majority of samples investigating seintention stems from so called weirdcountries which are western educated industrial rich and democratic this holds true even though the biggest need for and activity in se is found in developing countries based on the circumstance that cultural differences between weird and developing countries exist and that they affect seintention we encourage scholars to pay more attention to a countrys culture when studying seintention consequently the following question should be addressed 3 can our proposed multilevel framework with its innate assumptions be applied in different cultures ie is it crossculturally solid even though our investigation is a first step toward a more culturally diverse investigation of the antecedents for seintention as it uses an african sample more work is needed to gain a better understanding of the cultural dependence across antecedents and their impact to gain such understanding we suggest conducting studies with samples from multiple countries and cultures c contextualizing individuallevel processes in seintention formation in addition to our personbased perspective on seintention antecedents institutional theory suggests that also contextual circumstances like economy and society influence decision making processes regarding economy amit and muller distinguish between so called push entrepreneursentrepreneurs rather forced into their career due to a lack of alternativesand pull entrepreneursentrepreneurs attracted by entrepreneurship due to its benefits considering the innate motivational differences comparing these two types of entrepreneurial action the following question emerges 4 are different antecedents of seintention differently important in various economic situations for instance are antecedents on the personality level more relevant for internally motivated pull entrepreneurs while antecedents on the cognitive level are more important for externally driven push entrepreneurs regarding society it is commonly acknowledged that the context individuals grows up in impacts the attractiveness of entrepreneurial careers considering recent findings by brunel et al and kruse who examined the effect of role models on entrepreneurial intention a particularly complex interplay between personality cognitive and social antecedents of seintention was found however the effect of social influences like a parental entrepreneurship background has hardly been studied so far thus the following question should be addressed 5 to which extent does the social context influence the personbased antecedents of seintention proposed in our framework in addition to culture economic drivers and social background the intention to found a social enterprise is impacted by gender and biological sex therefore research within our multilevel framework of seintention antecedents should address the following question 6 does gender or sex impact the interaction between antecedents of different levels for instance through gender selfconcepts limitations as with any study there are limitations to consider first applying a convenience sampling technique our results are neither representative for south africa nor for other developing countries furthermore despite controlling for ethnicity in our analyses we did not explicitly account for the wide variety of different ethnicities in south africa and their individual cultural characteristics thus future studies should consider individual measures of culture such as the scale proposed by yoo et al that assesses hofstedes cultural dimensions on an individual level second despite the vif not exceeding the threshold of 400 indicating that no notable multicollinearity problems emerged in our analysis recent findings by vatcheva et al suggest that even mediumsize interpredictor correlations about 30 can cause multicollinearityrelated biases undetected by the vif thus we limited our analyses to the proposed levels only and did not take the single variable effects into account third future studies might want to extend the research scope to sebehaviors and thus offer a more comprehensive investigation on the question what affects the actual creation of a social enterprise in that regard longitudinal studies are certainly needed to close the intentionbehaviorgap and to directly link antecedents of seintention to observable sebehavior conclusion this paper proposes a new multilevel framework to structure personbased antecedents of the intention to become a social entrepreneur based on the relative proximity to seintention we identified four levels on which antecedents can be anchored one personality level two cognitive levels and one exposition level while the personality level refers to socioemotional traits relevant for a wider variety of jobs including but not limited to entrepreneurial contexts the cognitive level entails a persons effort to evaluate the entrepreneurial process and the exposition level includes sespecific knowledge and experience empirical examination of the multilevel framework using a large south african sample provides initial support for its basic assumptions and shows that the antecedents from different levels largely complement each other importantly we consider our framework an open framework that enables an empirically validated extension by adding a variety of constructs at each level which ultimately should enable a thorough understanding of the seintention formation process finally our findings suggest three central streams of future research which seem particularly fruitful to disentangle the twisted net of seintention antecedents the identification and investigation of seintention formation mechanisms the cultural embeddedness of antecedents and the contextualization of individuallevel processes in seintention formation data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the current study involved human participants and was reviewed and approved at technical university of dresden germany the participants provided their written informed consent to participate in this study participation was voluntary author contributions sb pk and cp contributed to the conceptual idea data analyses and write up md contributed to the data management all authors contributed to the article and approved the submitted version publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

social entrepreneurship se increasingly contributes to diversity in entrepreneurship the di erent approaches to se suggest a variety of antecedents which drive individuals intention to become social entrepreneurs while this variety of antecedents is insightful it also creates a need for systemisation and prioritization we address this need by introducing an integrative multilevel framework for personbased antecedents of seintention based on this multilevel framework the antecedents are grouped on three theoretical levels which refer to an individuals personality cognition and entrepreneurial exposition when testing our framework with south african university students we find support for the multilevel framework and its notion that antecedents from the diverse levels complement each other therefore this study provides a structure for personbased antecedents of seintention and additionally points to future research which may extend the proposed framework

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depression is a common mental health problem among older adults a report from the national institute of mental health estimated that the prevalence of major depression among communitydwelling older adults aged 65 or older ranges from 1 to 5 the percentage of older adults who experience depressive symptoms is much higher with an expected range from 72 to 36 negative consequences of chronic depressive symptoms include increased risks for the onset of major depression physical disabilities early mortality as well as escalated health care costs the nonlinear growth of depressive symptoms as found in some studies indicates a need to examine factors that might influence how depressive symptoms fluctuate over time among older adults knowledge of factors that protect older adults from increases in depressive symptoms may lead to prevention or early treatment of depression thus the aim of this study was to examine whether religiosity predicts the trajectory of depressive symptoms among a sample of communitydwelling older adults living in a southern state in the us religiosity may help counteract depressive moods through psychosocial mechanisms including enhanced social support increased activity engagement and improved coping smith mccullough and polls metaanalysis found a small yet consistent association between religiosity and fewer depressive symptoms on the basis of 147 independent studies furthermore wink dillon and larsen identified an indirect salutary effect of religiosity buffering against depression associated with poor health in a sample born in the 1920s in the san francisco bay area one limitation of wink et als study is a failure to use an objective measure of physical health and to control for functional status which may confound their conclusions overall evidence suggests that religious involvement in general decreases the risks for and leads to faster remission of depressive symptoms however a few studies suggest some aspects of religiosity may have detrimental effects on mental health when referring to the relationships between depressive symptoms and specific domains of religiosity evidence is rather complicated for the purpose of this study we define religiosity as shared sets of beliefs and practices that have been developed in community with people who have similar understandings of god or the transcendent we operationalize religiosity as a multidimensional concept that encompasses organizational religiosity nonorganizational religiosity and intrinsic religiosity in the following section we review evidence regarding the relationships between different domains of religiosity and depressive symptoms religiosity and depression the first dimension or refers to the engagement of individuals in organizational religious activities such as church attendance church attendance is often related to physical health and functional status which in itself predicts depression when controlling for physical functioning status koenig et al found that frequent churchgoers are less likely to be depressed than nonchurchgoers among a sample of communitydwelling american older adults in north carolina similarly braam and associates identified an inverse relationship between church attendance and depressive symptoms among a sample of older adults in netherlands thus the benefits of involvement in or include opportunities for individuals to meet with other church members and participate in church activities that could be religious or social in nature furthermore attendance may promote a sense of purpose in life that is critical to the selfesteem and wellbeing of individuals the overall crosssectional evidence suggests an inverse relationship between religious service attendance and depressive symptoms but there is a need for longitudinal evidence to support this finding in one of the few available longitudinal studies law and sbarra followed a sample of australian older adults over an eightyear period and found that nonchurchgoers had higher levels of depression at baseline and an increased rate of developing depressed mood over time than churchgoers yet law and sbarras findings may be limited because only two time points separated by an eight year interval were assessed and only church attendance was examined thus the possible relationships between other dimensions of religiosity and the trajectories of depression were not explored however based on the minimal evidence to date we tentatively hypothesized that religious service attendance would be related to fewer depressive symptoms at baseline and would have a buffering effect on the increases in depressive symptoms over time the second dimension nor refers to private religious behaviors such as prayer meditation or bible study inconsistent evidence has been found regarding the influence of this religious domain on depression on the one hand mccullough and larsons review found a minimal and inconsistent association between private religious activities and depression one the other hand king and colleagues longitudinal study of older patients found an inverse relationship between nor and depression at baseline and a nonlinear relationship over time participants who reported high or low engagement in nor at baseline were more likely to be depressed one year later than those who reported moderate amounts of nor engagement because of the mixed and limited previous research we did not make explicit hypotheses regarding the associations between nor and changes in depressive symptoms the third dimension ir reflects the perceived importance of religion to the individual ir captures the ultimate significance of religion in individuals decision making koenig george and peterson found that intrinsic religiosity predicted shorter time to remission of depression in a sample of 87 medically ill older patients while the effects of or and nor were not significant older persons with high intrinsic religiosity may derive selfesteem and sense of wellbeing from their religious faith which comprises an important component of their identity they may have a sense of larger social networks and become better equipped to cope with adversities one of the few longitudinal studies on the effects of ir confirmed that individuals who had a strong religious faith were less likely to be depressed over a oneyear period based on previous findings we hypothesized that higher levels of intrinsic religiosity would be related to fewer depressive symptoms at baseline and have a buffering effect on the changes in depressive symptoms over time purpose of study a review of the literature indicated the need to examine the trajectories of depressive symptoms among communitydwelling older adults in the us first neither crosssectional nor longitudinal studies that have assessed depressive symptoms have elucidated the trajectories of depressive symptoms in older adults second most studies in the us have been based on samples of medically ill older patients who may have more physical or mental illness than their community counterparts grounded in the thinking of preventive care this study recruited participants from community settings where the majority of older participants are not clinically depressed understanding the changes in depressive symptoms and associated risk factors in the community sample would help health care personnel manage depressive symptoms and prevent major depression third the multiple domains of religiosity have not been examined systematically in relation to changes in depressive symptoms to prevent depression or provide early treatment it is important to know about the changes in depressive symptoms among community samples responding to these gaps we examined the trajectories of depressive symptoms over time and the influence of three dimensions of religiosity on those trajectories while controlling for the effects of other known risk factors of depressive symptoms these known risk factors included gender nonmarried status poor physical health cognitive deficits functional limitations and lower social support methods this study was based on a secondary data analysis of the university of alabama at birmingham study of aging the uab study of aging is a populationbased prospective study of communitydwelling adults the sample consisted of 1000 adults aged 65 years and older from a list of medicare beneficiaries in five alabama counties the sample was stratified by county race and sex and included balanced numbers of black men and women and white men and women all baseline interviews and the fouryear followup interviews were conducted in the participants homes followup interviews at years 1 2 and 3 were conducted by telephone the current study examined baseline data and four waves of followup data collected annually from 1999 to 2003 we found that the fouryear attrition rate was similar to previous longitudinal studies depressive symptom scores of one participant were missing at baseline 85 were missing at wave 1 161 missing at wave 2 264 missing at wave 3 and 376 missing at wave 4 by the fouryear followup period 217 participants died and 49 were unable to give answers to the survey questions on their own leaving 734 eligible participants of these 624 agreed to followup inhome assessments at year 4 we compared participants for whom we had depressive symptom scores at baseline and all four followups with those who did not compared to participants who completed all five interviews those who did not were more likely to be older male and nonmarried to have lower education lower mmse scores more adl and iadl difficulties and poorer health to report more sick days and less income adequacy and to engage less in religious service attendance and prayer similar to findings in a previous study those who reported more depressive symptoms at baseline were less likely to complete all interviews in light of this the assumption of data missing completely at random is implausible estimation of the trajectories could be biased if only participants who completed assessments at all time points were included thus we decided to use all available data to estimate the trajectories of depressive symptoms measures depressive symptomsthe short form of the geriatric depression scale was used to assess depressive symptoms the gds counts the number of symptoms of depression reported by the participant scores can range from 0 to 15 a score of six or higher suggests possible depression and the need for a more comprehensive assessment and accurate diagnosis about 69 of participants reported 6 or more symptoms at baseline in this study this proportion is comparable to what is found in rokee and klenows and diem et als studies both studies reported that about 5 in their community samples of older adults had a gds score worthy of clinical attention the cronbachs alphas over the five time points were 73 70 67 65 and 70 religiosityto measure religiosity we used a slightly modified version of the duke university religion index this is a 5item measure of three major dimensions of religiosity organizational religiosity nonorganizational religiosity and intrinsic religiosity or was measured by a single item scored from 1 never to 6 more than once a week on attendance at religious services or other religious meetings nor was measured by the frequency of private religious activities such as prayer meditation or bible study on a scale from 1 never to 6 more than once a week ir was measured by the summed scores of three items participants indicated how true each of the following statements was for them using a 5point scale in my life i experience the presence of the divine my religious beliefs are really what lie behind my whole approach to life and i try hard to carry my religion over into all other dealings in life scores on the intrinsic religiosity variable could range from 3 to 15 cronbachs alpha for the intrinsic religiosity subscale was 83 health variablesthe measures of physical health included selfrated health number of sick days in bed physical limitations and cognitive status selfrated health was measured by a single item ranging from 0 poor to 4 excellent another indicator of physical health was the number of sick days in bed in the past 12 months functional capacity was measured by difficulties with activities of daily living such as dressing and eating and the instrumental activities of daily living such as cooking and doing laundry the range of the adl difficulties was from 0 to 7 and the number of iadl difficulties ranged from 0 to 6 cognitive status was assessed using the mini mental state examination resource variablesperceived social support was measured using the social support subscale of the arthritis impact measure it included four questions that asked participants to indicate the perceived availability of sensitivity to interest in and understanding of friends and family in providing assistance on a fivepoint likert scale the total score ranges from 5 to 20 with a higher score indicating more perceived social support the cronbach alpha was 79 at baseline on this sample income adequacy was measured by a likert scale ranging from 1 not enough to make ends meet to 4 allows you to do more or less what you want sociodemographicsin addition to health and resource variables control variables included sociodemographic characteristics age gender ethnicity marital status and education analysis strategies the hlm procedure was used to estimate the trajectory of gds scores over a fouryear period hlm has the capacity to analyze information about the rate and the pattern of change in targeted variables over multiple time points taking into account interand intraindividual variability in change and crosslevel interactions of time with predictors we ran analyses using the hlm software we used a twolevel hierarchical linear model to predict individual change in depressive symptoms the level 1 model specified the shape of individual change parameters over time the level 2 model tested the effects of measures of baseline religiosity on individual change parameters when controlling for the effects of sociodemographic characteristics health and resources available to an individual at baseline these models assumed that individuals have different growth parameters the two models are represented by the following equations level 2 model y ij is the depression scale score of subject j at time i β 0j is the intercept of depression score at baseline for subject j β 1j is the linear rate of change at baseline and β 2j represents the acceleration of the linear rate of change the level 2 model predicted the individual change parameters the γ terms represent intercepts and the expected effects of the covariates on the individual change parameters to determine the appropriate level 1 model we examined the graphs of depressive symptoms over time to ascertain whether a quadratic function might be appropriate to verify the decision on the basis of the visual information we also examined the statistical significance of the individual change parameters in the fixedand randomeffects unconstrained models the continuous predictors were modeled in the grand mean deviation form to reduce multicollinearity concerns results table 2 presents the means and standard deviations of gds scores over a fouryear period the mean of gds scores was 236 at baseline decreased to 128 at two years from baseline and then increased to 211 at four years from baseline to determine the appropriate model for the trajectories of depressive symptoms we ran two unconstrained models that examined the linear and quadric effects of time table 3 shows the fixed effects random effects and deviance scores for gds scores the quadratic model was a better fit than the linear model on the basis of the comparison of their deviance scores χ 2 546 p 001 there were significant fixed effects for the intercept linear effect and curvilinear effect in the quadric model indicating that participants appeared to have a decrease in the number of depressive symptoms over the first two years and an increase in the last two years random effects indicate if there is evidence of significant individual variations in growth trajectories if these trajectory parameters are significant inclusion of predictors of the trajectory parameters could be justified to explain individual variations the results of the random effects show there were significant variations in the intercept and slope table 4 shows the hlm results of the effects of level2 factors on the trajectories of gds scores among the three religiosity measures only religious service attendance was associated with fewer depressive symptoms at baseline in addition two sociodemographic factors and all health and resource variables were related to depressive symptoms in expected directions being white and having higher education were associated with more depressive symptoms more adl and iadl limitations and more sick days were also associated with more depressive symptoms while better selfrated health better cognitive status more social support and higher level of income adequacy were related to fewer depressive symptoms in examining quadratic effects among the three religiosity domains only ir was predictive of a quadratic effect the relationship between ir and the number of depressive symptoms over time was better illustrated in a graph that plots the changes in gds scores by three different ir levels participants with the highest levels of intrinsic religiosity at baseline experienced a steady decline in the number of depressive symptoms over the fouryear period while those with lower levels of intrinsic religiosity experienced a shortterm decline followed by an increase in the number of depressive symptoms the quadratic effects of two sociodemographic factors one health indicator and two resource variables were significant whites and those with higher educational levels tended to experience a substantial decrease initially followed by a more rapid increase in depressive symptoms than blacks and those with lower educational levels similarly participants with better health more social support and higher levels of income adequacy had a minimal decrease initially followed by a slower increase in depressive symptoms than those with poorer health less social support and lower income adequacy discussion the first aim of our study was to describe the trajectories of depressive symptoms over time we tested both linear and quadratic effects between time and changes in depressive symptoms a rough description of changes in depressive symptoms can be achieved by simply comparing values at starting and ending points a method often used in existing longitudinal studies our findings were comparable to other previously published longitudinal studies when we compared the gds scores of those who completed all five waves the average gds scores increased from 198 to 211 on a scale from 0 to 15 over the fouryear period that is fairly consistent with the findings concerning austrian older adults who increased 251 on a cesd scale from 0 to 60 over a fiveyear period it would be premature to conclude that older adults have a steady increase in their depressive symptoms over time given that those who were more depressed at baseline were more likely to drop out of the study it is also important to note that these are small fluctuations in people who have normal mood moreover the significance of quadratic effects indicated a potentially complicated pattern of depression trajectories in our study we found the trajectories appeared to be nonlinear the depressive symptoms followed a downward trend first and then an upward trend a similar pattern was identified in a longitudinal study of depressive symptoms in swedish oldest old adults haynie et al suggested the decline in depressive symptoms in the midpoint could be due to the positive feelings associated with participants anticipations of meeting with the interviewer given little evidence in this regard future studies need to extend findings of this study by examining concomitant life events at each assessment point our first hypothesis about the effects of religious service attendance was partially supported the association between religious service attendance and baseline depressive symptoms was substantiated in our analyses this finding corresponds to koenig et als conclusion based on a review of crosssectional studies of the relationship of organized religious activity with depression service attendance may reflect a persons functional status in that those who have mobility difficulties might be limited in their church attendance which may lead to depressive feelings yet the fact that church attendance was still significantly related to depressive symptoms with adl and iadl difficulties controlled suggests possibility of other explanations frequent service attendees tend to be less isolated or unhappy because they were more socially integrated into a group and into their communities than those who do not frequent service attendees may also have more opportunities to access educational or health information available in some religious communities consistent with schnittkers finding we found religious service attendance did not predict the change rate of depressive symptoms in other words the initial difference in depressive symptoms among participants with different levels of religious service attendance remained constant over the years thus facilitating religious service attendance among older adults with few depressive symptoms could maintain a low risk for the onset of depression over time however for persons already experiencing substantial depressive symptoms encouraging religious service attendance could be one among a number of potential interventions that might be beneficial our second hypothesis was partially confirmed there was no relationship between ir and baseline depressive symptoms but participants with the highest levels of ir at baseline experienced a steady decline in the number of depressive symptoms over the fouryear period while those with lower levels of ir experienced a shortterm decline followed by an increase in the number of depressive symptoms this finding indicated that the importance of religiosity to an individuals life might not influence ones current mood but over time it influenced the rate of change in depressive symptoms this finding is similar to a previously mentioned study by koenig et al which found medically ill patients with higher ir tended to have a 70 faster recovery from depression as mccullough and larson pointed out people who are religious because they believe that being religious is meaningful in and of itself are predisposed to slower increases in depressive symptoms another explanation could be that people with higher ir are more capable of handling stressful life situations because they are motivated and empowered by their religious faith we speculate that in situations of declining physical health people with higher ir may be able to better manage their disease symptoms because of their hope and confidence derived from strong religion identity or faithfacilitated networks the importance of intrinsic religiosity identified in this study reinforces some practical implications for helping professionals it is recommended that clients spiritual history be assessed to ensure treatment of the whole person a panel of the american college of physicians suggested the use of four questions to assess spiritual history and two of these questions are related to intrinsic religiosity is faith important to you in this illness and has faith been important to you at other times in your life there is also emerging evidence supporting the efficacy of spiritually modified cognitive therapy and faithbased interventions in treating depression inspired by such evidence we recommend health professionals assess intrinsic religiosity support religious beliefs and coping when such needs are perceived among older clients and design and implement possible interventions to boost the salutary effect of intrinsic religiosity there was no relationship between nor and depressive symptoms found in this study considering that sicker individuals might be more likely to engage in private religious practices and that private religious activities are linked with coping mechanisms for pain associated with chronic illness such as arthritis we suspect that stressful events such as chronic conditions may obscure the relationship between prayer and depressive symptoms as expected higher levels of selfrated health social support and income adequacy were related to fewer depressive symptoms at baseline and slowed down the acceleration of depressive symptoms over time this implies that future interventions should continue to work on improving elders health enhancing their access to social support and ensuring financial security the findings of this study need to be interpreted with certain limitations in mind first of all our analysis was limited to the variables in the data set for example we did not have a measure of religious coping which could counteract depressive symptoms directly or act through ir to affect changes in depressive symptoms future studies may include other important covariates of depressive symptoms such as traumatic events perceived discrimination and resilience second we found that those who had more functional limitations engaged less in church attendance and prayer and scored higher on gds were more likely to drop out of this study such attrition could affect the range of change in gds observed in this study third the existence of heterogeneities in individual trajectories of depressive symptoms may limit the generalizability of our findings for example penninx et al examined changes in depression among 2000 dutch older adults over a threeyear period and identified four groups the chronicly depressed the nondepressed the emerging depressed and the remitted depressed future studies need to examine the trajectories for each of these subgroups lastly it should be noted that participants in this study were predominantly christian further research is needed to understand how different dimensions of religiosity affect depressive symptoms among people of other faiths conclusion the present study represents one of the first attempts to examine the influence of multiple dimensions of religiosity on the trajectories of depressive symptoms among community dwelling older adults we found that different domains of religiosity exerted different influences on depression measured by the gds in this sample of older adults overall religious service attendance and intrinsic religiosity were inversely correlated with depressive symptoms religious service attendance was associated with a smaller number of depressive symptoms at baseline while intrinsic religiosity predicted a slower acceleration rate of depressive symptoms over time given that the evidence is preliminary we recommend more longitudinal studies to be conducted to more fully examine the relation of religiosity and depressive symptoms if these findings are confirmed in future research then interventions for depressive symptoms including a careful assessment of a persons religiosity should be tested in addition to the religious measures used in this study clinical assessment tool should be included for example fitchett et al found that some people experience religious struggle following a diagnosis of severe illness and that religious struggle is associated with depressive symptoms thus using the screening tool for religiousspiritual struggle is recommended as the first step in clinical assessment of a persons religiosity before the possible integration of religious elements into psychotherapeutic treatments changes in gds over a fouryear period note gds the geriatric depression scale

backgroundthis study examined the effects of religiosity on the trajectories of depressive symptoms in a sample of communitydwelling older adults over a fouryear period in a southern state in the us methoddata from the university of alabama at birmingham study uab of aging were analyzed using a hierarchical linear modeling hlm method this study involved 1000 participants aged 65 and older m age 75 at baseline sd 597 and data were collected annually from 1999 through 2003 the geriatric depression scale measured depressive symptoms the duke university religion index measured religious service attendance prayer and intrinsic religiosity and control variables included sociodemographics health and social and economic factors resultsthe hlm analysis indicated a curvilinear trajectory of depressive symptoms over time at baseline participants who attended religious services more frequently tended to report fewer depressive symptoms participants with the highest levels of intrinsic religiosity at baseline experienced a steady decline in the number of depressive symptoms over the fouryear period

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underlying graph see eg de la cruz cabrera et al de la cruz cabrera et al estrada estrada and higham newman for many examples a fundamental topological property of a graph which will be briefly recalled in the section notation and some properties of graphs and networks is multipartivity the nodes in an mpartite graph can be split into m disjoint subsets v i i 1 2 ℓ called partite sets with connections occurring only between the subsets but not within the subsets when ℓ 2 the graph is said to be bipartite a refinement of bipartivity for undirected graphs referred to as the chained structure of the graph was introduced in concas et al the chained structure characterizes undirected multipartite graphs an mchained graph has only edges between nodes that belong to subsequent partite sets v i and v i1 i 1 2 ℓ 1 this paper extends the notion of chained graphs from undirected graphs to directed graphs the chained structure reveals the depth of a graph ie how many steps it may take to go from a specified node to any other node by following edges along their direction in concas et al we used chained graphs to identify central nodes by introducing the position centrality measure for nodes of an undirected graphs this notion is a generalization of closeness centrality central nodes are identified by their location in the chained structure for an overview of other centrality measures see borgatti estrada and higham estrada and rodriguezvelazquez this paper generalizes position centrality to directed graphs specifically for directed graphs that have directed spanning trees we define inposition and outposition centralities of a node by examining two different types of directed spanning trees associated with the graph see gabow and myers for a discussion on directed spanning trees these centrality concepts shed light on the ease of communication within a network in the two sections devoted to numerical examples we compare them to other existing centrality measures in general it is impossible to state which centrality measure is the best as the concept of centrality takes different meanings in different applications what we show is that position centrality by varying the value of the parameter on which it depends is able to spot specific aspects of a network that are not detected by traditional measures and that depend upon the underlying chained structure the identification of the chained structure of a directed graph also can be useful for detecting the presence of anticommunities ie node subsets that are loosely connected internally but have many external connections with the rest of the graph several methods have been developed to identify anticommunities in undirected graphs see concas et al estrada and knight fasino and tudisco the relation between clustering and community detection in directed graphs has been discussed in laenen and sun in concas et al we illustrated how the chained structure may be used for introducing a density measure for computing an anticommunity score for undirected graphs we extend this measure to directed graphs in the present paper to the best of our knowledge while the identification of anticommunities has been studied in the literature the identification of nearanticommunities has not been discussed yet this paper is organized as follows the section notation and some properties of graphs and networks introduces notation and discusses general properties of graphs that will be used later directed chained graphs are defined in the section directed ℓchained graphs and their adjacency matrices they can be studied with the aid of directed spanning trees this is discussed in the section directed chained graphs and directed spanning trees the chained structure naturally leads to the concept of position centrality defined in position centrality and some applications section nodes with the largest position centrality are referred to as central nodes some data sets deriving from realworld applications including a social network are analyzed in the section some examples the section a case study about position centrality sheds light on the properties of center nodes by considering a case study concerning a bus transportation network finally the section conclusion contains concluding remarks notation and some properties of graphs and networks a network can be represented by a graph g v e where v v i n i1 is a set of nodes or vertices and e e i m i1 a set of edges which connect the nodes two nodes v i and v j for i j are said to be adjacent if there is an edge from node v i to node v j in this context an undirected edge between the nodes v i and v j points both from v i to v j and from v j to v i the node v i is said to be connected to the node v j if there is a path from v i to v j that is if there is a sequence of edges e r s k s1 such that e r 1 originates from v i e r k points to v j and if e r s points to v ℓ then e r s1 starts from the same node for s 1 2 k 1 a cycle is a path that starts and ends at the same node v i an undirected graph is connected if each pair of distinct nodes is connected by a path a directed graph is said to be strongly connected if for each vertex pair the node v i is connected to the node v j and the node v j is connected to v i a directed graph is said to be semiconnected if for each vertex pair either the vertex v i is connected to the vertex v j or v j is connected to v i a directed graph is weakly connected if there is a path between each vertex pair in the underlying undirected graph that is in the undirected graph obtained by replacing all directed edges by undirected ones we refer to estrada and newman for discussions on graphs and their properties an unweighted graph g with n vertices can be represented by an adjacency matrix a a ij n ij1 with a ij 1 if there is an edge from vertex v i to vertex v j otherwise a ij 0 since an undirected edge can be thought of as being made up of two directed edges the adjacency matrix of an undirected graph is symmetric the adjacency matrix of a directed graph is nonsymmetric multipartivity and in particular bipartivity are fundamental topological characteristics of graphs that model interactions between different types of objects bipartite graphs contain vertices that can be partitioned into two disjoint vertex subsets v 1 and v 2 such that there are no connections between vertices in the same subset assume that the n vertices of a bipartite graph g are separated so that the first n 1 vertices make up the vertex set v 1 and the remaining n 2 nn 1 vertices make up the vertex set v 2 then the adjacency matrix a of g is of the form where c 1 ∈ r n 1 ×n 2 c 2 ∈ r n 2 ×n 1 and o denotes a zeromatrix of suitable order if the graph g is undirected then c 2 c t 1 where the superscript t denotes transposition a o c 1 c 2 o in undirected ℓchained graphs the nodes are divided into ℓ disjoint subsets so that there are edges only between nodes belonging to adjacent node sets that is all edges from a node in v i point to a node in v i1 or in v i1 for some i this kind of parti tioning is discussed in concas et al directed ℓchained graphs and their adjacency matrices the directed chained graphs introduced in this section generalize the notion of undirected chained graphs defined in concas et al definition 1 a directed graph g v e is said to be directed ℓchained with ini tial vertex v i if the set of vertices can be subdivided into ℓ disjoint nonempty subsets v 1 v 2 v ℓ see 2 2 such that v i ∈ v 1 and all edges from vertices in the set v j point to vertices in the set v j1 for j 1 2 ℓ 1 where the chain length ℓ is the largest num ber of vertex subsets v j with this property the vertex subset v j1 is said to be adjacent to the vertex set v j the chain length ℓ of a directed ℓchained graph may depend on the choice of the initial vertex v i after a suitable permutation of the nodes the adjacency matrix a of a directed ℓchained graph g v e becomes upper block bidiagonal with zero diagonal blocks where the submatrix a i ∈ r n i ×n i1 describes the connections from vertices in v i to verti ces in v i1 for i 1 2 ℓ 1 example 31 consider the graph of fig 1 this is a 3chained graph with the chained node sets v 1 v 1 v 2 v 2 v 3 and v 3 v 4 the initial node can be chosen to be either v 1 or v 2 the adjacency matrix is v v 1 ∪ v 2 ∪ • • • ∪ v ℓ a         o a 1 o a 2 o a 3 o a ℓ1 o         1 2 3 4 fig 1 a directed 3chained graph g with initial vertex v 1 where we can choose the submatrices assume that a graph is known to be directed ℓchained for some ℓ ≥ 1 but that the value of ℓ is not known moreover let a permuted version of the matrix be known thus the available adjacency matrix is of the form where p is a permutation matrix that modifies the vertex ordering given the adjacency matrix a we are interested in determining the vertex subsets v 1 v 2 v ℓ in defini tion 1 as well as the number of sets ℓ ≥ 1 a method for determining if a directed graph is ℓchained and partitioning the nodes into subsets is described by algorithm 1 given an adjacency matrix a of a directed graph the first node subset v 1 is obtained by con sidering the column indices j such that a ij 0 for each row index i see line 1 of the algorithm then the other vertex subsets are determined by identifying the blocks in a that describe connections with nodes in the preceding node subset if it is not possible to determine the first vertex set or if during the process it results that some node is connected to a vertex in a preceding subset then the graph is not ℓchained this process gives a constructive proof of the following result proposition 1 let g v e be a directed graph then it is possible to detect if it pos sesses an ℓchained structure and determine the number of subsets ℓ as well as the vertex set partitioning v v 1 ∪ v 2 ∪ • • • ∪ v ℓ a    0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 0    a 1 1 1 ∈ r 2×1 a 2 1 ∈ r 1×1 a pap t the definition of directed ℓchained graphs is quite restrictive to be able to discuss properties of a larger set of directed graphs we relax the requirements of definition 1 to allow edges between vertices in the vertex subset v i to vertices in vertex subset v j for some j ≤ i with j not much smaller than i definition 2 the directed graph g v e is said to be directed ℓ k i chained with initial vertex v i if it has the chained structure described in definition 1 with the exten sion that edges from vertices in the set v j are allowed to point to vertices in the sets v max jk i 1 v j v j1 for j 1 2 ℓ 1 and some k i ≥ 0 the integer k i which we refer to as the lower bandwidth is the largest integer with this property we note that definition 1 corresponds to the situation when k i 1 for all i in definition 2 definition 3 the minimal lower bandwidth k of a directed chained graph is defined as where the minimum is over all initial vertices v i in the vertex set v ⊂ v that gives max imal chain length ℓ when k is the minimal lower bandwidth the graph is said to be directed ℓ k chained the ℓ k chained structure is quite general we conjecture that any weakly con nected graph with n nodes is ℓ k chained for some n ≥ ℓ k ≥ 1 a small value of k indicates that information in the graph flows in a preferred direction with small back propagation this structure can be investigated by means of spanning trees as described in the section directed chained graphs and directed spanning trees example 32 consider the directed graph g shown in fig 2 it is a directed 5 2 chained graph with initial vertex v 1 if one removes the edge from vertex v 4 to v 2 the graph becomes a directed 5 1 chained graph with initial vertex v 1 if one continues by removing the edge from v 3 to v 2 then a directed 5chained graph with the same initial vertex is obtained the adjacency matrix analogous to eq for a directed ℓ k chained graph g v e can be represented by a lower block hessenberg matrix k min v i ∈v k i 1 2 3 4 5 fig 2 a directed 5 2 chained graph g with initial vertex v 1 when the nodes are suitably ordered here the block a ij represents edges that point from the vertex subset v i to the vertex subset v j all superdiagonal blocks a ii1 are nonvan ishing because if all entries of the block a ii1 were zero then there would be no edges from the vertex subset v i to vertices in the subset v i1 but this would contradict the fact that the graph g is directed ℓ k chained if the minimal lower bandwidth defined by eq is k 0 then there is at least one edge from a node to another node in the same vertex subset the adjacency matrix corresponding to such a graph is upper block bidiagonal when the nodes are suitably ordered similarly a lower bandwidth k 1 indicates that when the nodes are suitably enumerated the adjacency matrix can be represented by a block tridiagonal matrix more generally a small lower bandwidth indicates that there only are edges between vertex subsets v j with close indices the following result shows that for strongly connected directed ℓ k chained graphs directed cycles will be observed if k ≥ 1 for semiconnected or weakly connected directed graphs cycles are not guaranteed to exist proposition 2 let g v e be a strongly connected directed ℓ k chained graph with vertex partition v v 1 ∪ • • • ∪ v ℓ assume there are no edges between vertices belonging to the same vertex set and that k ≥ 1 let e ji ∈ e represent a directed edge from vertex v j to v i where v i ∈ v i and v j ∈ v is for 1 ≤ s ≤ k then there exists at least one directed cycle that starts at v i contains the edge e ji and ends at v i the possible minimum length of the directed cycle is s 1 proof since the graph g is strongly connected and there are no edges between any nodes in the same vertex subset the shortest possible directed path from vertex v i to v j has length s as shown below where v i t ∈ v it for t 1 2 s 1 combining this path with the edge e ji determines a directed cycle of length s 1 identification of the ℓ k chained structure of a directed graph sheds con siderable light on properties of the graph including the presence of anticommunities anticommunities are vertex subsets w i i 1 2 q of v such that there are many fewer edges from nodes in w i to nodes in w i than from nodes in w i to nodes in w j a               a 11 a 12 a 21 a 22 a 23 a k11 a k22 a ℓ1ℓ1 a ℓ1ℓ a ℓℓk • • • a ℓℓ1 a ℓℓ               v i → v i 1 → • • • → v i s1 → v j for j i for instance the node subsets v j of an ℓchained graph are anticommunities recent discussions on anticommunity detection for undirected graphs can be found in concas et al estrada and knight fasino and tudisco there are several methods and measures that allow one to identify communities or clusters such as the intracluster density which for undirected graphs is defined as the ratio of the number of internal edges and the number of all possible internal edges see fortunato an analogous density measure for computing the anticommunity score for undirected graphs was introduced in concas et al here we extend this measure to directed ℓ k chained graphs definition 4 the anticommunity score ρ ∈ 0 1 for a node subset v i of the node set v of a directed ℓ k chained graph is the ratio of the number of directed edges between the vertices in v i and the total possible number of directed edges between them an anti community with score ρ is said to be a ρanticommunity we remark that the anticommunity score aims at identifying an approximate anticommunity as a node set for which ρ takes a small value a large value of ρ does not nec essarily identify a community because it does not consider the connections between the nodes in v i and those not contained in v i example 33 for directed ℓchained graphs with node subset partitioning the subsets v i for i 1 2 ℓ are 0anticommunities because there are no internal edges for a directed ℓ k chained graph described in definition 2 the subset v i has a positive anticommunity score ρ i when it has internal edges if ρ i is small then the subset v i may be considered as an approximate anticommunity directed chained graphs and directed spanning trees the chained structure of a spanning tree t for an undirected graph g is used in concas et al to determine a chained structure for a graph g if such a structure exists and to approximate a graph without a chained structure by a graph with such a structure in this section we consider directed graphs that have directed spanning trees we remark that not all directed graphs have a directed spanning tree the directed spanning trees are employed to partition the node set v into subsets v i that determine directed ℓ chained graphs cf this approach to partition the node set v is applied to parti tioning node sets of directed graphs that have a directed spanning tree but do not possess a chained structure and provides an approach to approximate a directed graph g without chained structure by a directed graph with chained structure we first briefly review results for undirected graphs let g v e be an undirected graph a spanning tree for g is a subgraph t v e ′ that is a tree and contains all the vertices of g see eg concas et al deo newman a spanning tree t is not uniquely determined by g and in particular depends on the chosen initial ver tex of the tree the socalled root when the graph g is directed two different types of spanning directed trees the out tree and the intree can be defined see deo we will employ both these directed trees definition 5 an outtree rooted at node v i for a directed graph g v e is a sub graph t i out v e ′ of g that is a tree with the same vertices as g and such that for every vertex v j for j i there is only one directed path starting at v i and ending at v j in the tree definition 6 an intree rooted at v i for a directed graph g v e is a subgraph t i in v e ′ of g that is a tree with the same vertices as g and such that for every vertex v j for j i there is only one directed path from v j to v i in the tree in an outtree information may flow from the root to each vertex in the graph while in an intree information may flow from any vertex to the root in the first case the root is a good source of information for the nodes of the graph in the second case the root is a good receiver outtrees and intrees exist for every vertex of a directed graph only if the graph is strongly connected any vertex in a semiconnected graph belongs to an outtree or an intree this follows from proposition 3 below we remark that this property is not guaranteed to hold for a weakly connected graph proposition 3 let g v e be a semiconnected directed graph then the graph g has at least one outtree and one intree proof let v i v j ∈ v be arbitrary distinct vertices then either v i is connected to v j or v j is connected to v i assume there is a directed path p from v i to v j if all the vertices of g except for v i and v j are on the path p then p is an outtree rooted at v i and an intree rooted at v j let u be a vertex of g that is not on the path p assume that there is neither a directed path from u to v i nor a directed path from v j to u otherwise we extend p by including u as a root then e contains directed paths from v i to u and from u to v j therefore an out tree rooted at v i and an intree rooted at v j are obtained proposition 4 let g be a directed graph if the vertex v i of g is the root of both an out tree t i out and an intree t i in of g then the graph g is strongly connected proof let v i satisfy the assumption of the proposition then for any vertex v j j i there is a directed path from v i to v j and viceversa hence for every pair of vertices k j i there is a directed path from v k to v j passing through v i and vice versa it follows that the directed graph g is strongly connected each directed spanning tree has a directed ℓchained structure for outtrees the root of the tree is the only vertex in the first set v 1 of the chained structure and the par tition of the vertex set v is determined by the relation between the vertices of the tree thus the vertex set v 2 contains the children of the root and in general the vertex set v i contains the children of the vertices in v i1 i 2 3 ℓ for an intree the root belongs to the last vertex set v ℓ and the partition of the vertex set is determined by fol lowing the direction of the edges backwards until one reaches the set v 1 which contains the leaves farthest away from the root remark 41 let g v e with v v 1 ∪ v 2 ∪ • • • ∪ v ℓ be an ℓchained graph a directed outtree for g does not exist for example if the first set v 1 contains more than one node similarly a directed intree does not exist when the last set v ℓ contains more than one node the process of generating directed spanning trees for a directed graph is illustrated in the following example example 41 consider the directed graph g shown in fig 3 it is semiconnected the outtree t 1 out and the intree t 3 in rooted at v 1 and v 3 respectively are displayed in fig 4 these are the only outtrees and intrees for the graph g their directed chained struc ture is illustrated in fig 5 the chained structure of a directed spanning tree t of g can be used to detect or approximate the directed chained structure of g the chained structure of g might not be unique as it depends on the starting vertex and the directed spanning tree t definition 7 let t v e ′ be an outtree for the graph g a directed ℓ chained vertex set decomposition for t is said to be a directed ℓchained vertex set decomposition for g we will refer to leaves of t as leaves of g v 4 v 4 v 6 thus ℓ 4 see fig 5 the graph may have other directed ℓchained parti tions that are not determined by using spanning trees for example starting with vertices v 1 v 4 we obtain the partition v 1 v 1 v 4 v 2 v 2 v 5 and v 3 v 3 v 6 and ℓ 3 now consider the intree t 3 in in fig 4 in this case v 1 v 1 v 2 v 2 v 3 v 3 v 5 v 1 v 1 v 4 v 6 v 2 v 2 v 5 v 3 v 3 and ℓ 3 we have already mentioned that some semiconnected graphs may not allow an ℓ chained partitioning for an arbitrarily chosen initial vertex for example vertex v 2 in example 41 neither can be the root of an outtree nor of an intree that spans the graph let d e e ′ be the set of the edges in g that are not in t and let c denote the graph obtained by adding the edges in d to the spanning tree t the graph c coin cides with g and inherits the chained structure of t definition 8 a directed graph g is said to be compatible with a spanning tree t if all the edges in d are compatible with the chained structure of t that is if for each edge 3 fig 5 the directed chained structure of the spanning trees t 1 out and t 3 in in fig 4 e j ∈ d there is an index 2 ≤ i ≤ ℓ 1 such that e j connects a vertex in v i to a vertex in v i1 if g is compatible with t then the graph g c is directed ℓchained if instead there is at least one edge connecting a vertex in v i to a vertex in v ik for i k 1 k 2 ℓ and k ≥ 0 is the maximal number with this property then the graph g c is directed ℓ k chained the graphs c and c obtained by adding the missing edges to the spanning trees of fig 5 are displayed in fig 6 the former graph is 4 1 chained and the latter one is 3 1 chained position centrality and some applications the notion of position centrality for vertices of an undirected network was introduced in concas et al it is a generalization of closeness centrality this section generalizes position centrality to directed graphs by defining the inposition and outposition centralities of a node the incloseness centrality of a node measures how close this node is to those it is receiving information from while the outcloseness centrality of a node shows how close the node is to the nodes it is sending information to let denote the number of vertices in the set v i definition 9 let us assume that an outtree t out v e ′ rooted at the node v for the directed graph g exist moreover let v 1 v 2 v ℓ be the directed ℓchained structure starting at vertex v determined by the tree for a fixed p ∈ r the outposition centrality of v is defined as we refer to a vertex v c with the smallest outposition centrality as a poutcenter vertex p out p ℓ1 k1 k p definition 10 let us assume that an intree t in v e ′ rooted at the node v for the directed graph g exist moreover let v 1 v 2 v ℓ be the directed ℓchained structure ending at vertex v determined by the tree for a fixed p ∈ r the inposition centrality of v is defined as we refer to a vertex v c with the smallest inposition centrality as a pincenter vertex the inoutposition centralities depend on the spanning tree chosen they can be defined for every node only if the directed graph is strongly connected the outcenter vertex can be described as an information transfer station such that it can easily send information to all the other vertices in the graph a similar interpretation holds for the incenter vertex which acts as an information sink the following example illustrates how the inoutposition centralities of a vertex can be computed by using the chained structures starting from the vertex example 51 consider the strongly connected directed graph g in fig 7 to com pute the outposition centrality of vertex v 3 we identify an outtree rooted at v 3 letting v 1 v 3 v 2 v 4 v 5 and v 3 v 1 v 2 the 1outposition centrality of vertex v 3 is while p out 12 424 and p out 5 96 we turn to the inposition centrality of vertex v 2 consider the intree rooted at v 2 with vertex set partitioning v 1 v 3 v 4 v 2 v 1 v 5 and v 3 v 2 we have since the graph g is strongly connected we can compute the inoutposition centralities for all the other vertices similarly when p 1 2 and p 1 the vertex v 3 has the smallest outposition centrality this indicates that v 3 is the outcenter vertex the incenter verti ces are v 2 and v 5 for p 1 2 and p 1 when p 5 the outcenter vertices are v 1 and v 5 while the incenter vertex is v 1 p in p ℓ1 k1 k p p out 1 1 • 2 2 • 2 6 p in 1 1 • 2 2 • 2 6 p in 12 424 p in 5 96 1 2 3 4 5 fig 7 a strongly connected directed graph g in a semiconnected directed graph the vertices can be divided into three subsets o which contains vertices connected to every other vertex in the network i whose ele ments are vertices to which every vertex can send information and m which contains intermediate vertices there may be a nonempty intersection between the sets o and i outposition centrality is defined only for vertices in o while inposition centrality can be computed for vertices in i since every vertex belongs to at least one spanning tree semiconnected graphs are directed ℓchained or directed ℓ k chained vertices for weakly connected directed graphs also can be divided into the above three subsets o i and m however the sets o and i may both be empty since outintrees are not guaranteed to exist hence weakly connected directed graph may not possess a chained structure some examples this section describes a few examples concerned with directed graphs for each graph we analyze the presence of anticommunities by identifying its directed chained structure the outincenter vertices are identified by computing the smallest outinposition centralities knowledge of the chained structure is beneficial in the following contexts • information dissemination in a social network we are interested in determining directed ℓchained or directed ℓ k chained structures with initial vertex such that information from this node can reach all other individuals in the least amount of time where we assume that the time is proportional to the path length similarly we may be interested in determining which individual can collect information from all other vertices in the least amount of time moreover in a directed ℓ k chained graph the presence of an edge e ji from vertex v j ∈ v j to ver tex v i ∈ v i for i j indicates the possibility of feedback of the information from v j to v i the minimal lower bandwidth k shows the minimal length of the path from v j to v i • prevention of the spread of an infectious disease let the edges of a directed chained graph represent the spread of an infectious disease among subjects that are represented by nodes an edge e ji from vertex v j ∈ v j to vertex v i ∈ v i for i j repre sents a secondary infection of v i from v j it is reasonable to prevent the spread of disease by detecting and possibly eliminating the outcenter vertex in the context of covid19 it is important that outcenter vertices be vaccinated similarly it can be important to protect an incenter vertex from infection from other nodes vaccination may be one way to achieve this to graphically illustrate the chained structures revealed by the model discussed above we first consider the following two small directed graphs • ibm32 collected from the ibm 1971 conference advertisement after removing selfloops the graph has 94 edges it is available at sparse tamu edu hb ibm32 • n2c6b10 short for jgdhomologyn2c6b10 simplicial complexes from homology by volkmar welker there are 329 edges after removing the selfloop the graph is available at cise ufl edu resea rch sparse matri ces list by dimen sion html these networks are not social networks but nevertheless will be seen to have structure that can be studied with the concepts introduced in the present paper the network n2c6b10 is represented by a weighted graph we consider the corresponding unweighted graph obtained by setting all weights to 1 figure 8 displays the outtree t 20 out and the intree t 20 in for the ibm32 network both trees are rooted at vertex v 20 of the graph and have maximal chained struc ture length ℓ 7 the set c which contains the additional edges that are not in t 20 out is shown on the lefthand side of fig 9 it has ℓ k chained structure with mini mal lower bandwidth k 4 that is edges in c from vertices in the subset v i are allowed to point to vertices in the subsets v i4 v i v i1 for i 5 ℓ the right hand side of fig 9 displays the graph c with minimal lower bandwidth k 4 we conclude that the graph ibm32 is directed 7 4 chained with initial vertex v 20 consider the chained structure determined by the intree t 20 in there are four 0anticommunities and 3 anticommunities with scores ρ 3 010 ρ 4 011 and ρ 5 006 moreover since both the outtree and intree are rooted at vertex v 20 it follows from theorem 4 that the graph is strongly connected starting from each vertex an outtree and an intree are constructed and their associated chained structures are determined figure 10 displays the chain length ℓ and the lower bandwidth k of the ℓ k chained structure associated with the outtree and the intree rooted at each vertex of the graph ibm32 the property of exact length in the legend represents the maximal chain length and the property not exact length indicates that the chain length is not maximal the symbol • in the figure displays the chain length of each structure as a function of the initial vertex v j j 1 2 32 when the chain length is maximal we use the symbol the symbols and × display the lower bandwidth k j of the chained structure with ini tial node v j for j 1 2 32 see definition 2 the lower bandwidths of the chained structure with the maximal chain length are displayed by symbols for the other chained structures the symbol is × among the lower bandwidths associated with the maximal chain length the smallest k j is the minimal lower bandwidth hence fig 10 shows the maximal chain length to be ℓ 7 and the minimal lower bandwidth k 4 it can be seen that the maximal chain length and the minimal lower bandwidth are not achieved for each starting or ending vertex the lefthand side of fig 11 displays the 1outposition centrality ie the outposition centrality for p 1 of each vertex of graph ibm32 the 1inposition centrality for each vertex is shown on the righthand side of fig 11 the outcenter vertices of the graph are v 2 and v 3 and the incenter vertex is v 10 figure 12 displays the outtree t 28 out with maximal chain length and its corresponding graph c for the graph n2c6b10 we note that this graph is directed 4 0 chained with initial vertex v 28 since the outtree t 28 out is the only spanning tree of n2c6b10 the initial vertex is the outcenter vertex and the graph is semiconnected the graph n2c6b10 has three 0anticommunities and the node subset v 2 is an anticommunity with ρ 2 004 we now determine the directed chainedlike structure and center vertices for the mediumsized directed graph gre1107 with 1107 vertices and 5664 edges this graph arises from simulation studies in computer systems and is available at math nist gov matri xmark et data harwe llboeing greno ble gre 1107 html we refer to the graph as gre after removing selfloops this graph has 4557 edges the outtree t 808 out and intree t 644 in with maximal chained structure length are displayed on the left and the right of fig 13 respectively the graph c is 53 4 chained and the graph c has a 53 5 chained structure the chain length and lower bandwidth of ℓ k chained structures starting and ending at each vertex of the graph gre are shown in fig 14 only one directed outtree t 808 out and one directed intree t 644 in are found to have maximal chain length their corresponding ℓ k chained structures have minimal lower bandwidth k 4 and k 5 respectively this is not visible in the figure because of the density of the symbols hence the graph gre is a directed 53 4 chained graph with initial vertex v 808 it has five 0anticommunities and 48anti communities with the minimal score ρ 001 and maximal score ρ 05 the graph gre is strongly connected since each vertex has both outtrees and intrees the 1outposition centrality and 1inposition centrality of each vertex of the graph gre are shown in fig 15 the outcenter vertex is v 400 with 1outposition cen trality p out 1 10129 and the incenter vertex is v 7 with 1inposition centrality p in 1 9030 for the previous test networks of small to medium dimension it was possible to determine both a spanning outtree and an intree now we investigate the presence of such spanning trees in larger networks some of which are extracted from the stanford large network dataset collection the networks are the following • twitter available from wiki gephi org index php datas ets reproduces the connections of some part of the twitter social network • wikivote the nodes in the network represent wikipedia users and a directed edge from node i to node j represents that user i voted on user j in an administrator election • gnutella is the p2pgnutella04 network from leskovec and krevl • foldoc is an online searchable dictionary foldoc org an edge from term i to term j exists in the network if in the foldoc dictionary the term j is used to describe the meaning of term i the network is available at vlado fmf unilj si pub netwo rks data • math is available from leskovec and krevl and represents the interactions on the stack exchange web site math overflow matho verow net in particular a direct edge is present between node i and node j if user i commented on user js answer table 1 displays for each network if a spanning outintree exists and the values of ℓ and k in the corresponding ℓ k chained structure three of the above networks admit either a spanning outtree or an intree two of them do not so we eliminated the outin dangling nodes that is vertices that do not have incoming edges or outgoing edges respectively this preprocessing is reflected in a different number of nodes in columns 3 and 5 than in column 2 the absence of dangling nodes is a necessary condition for the existence of an outin spanning tree but not sufficient as the results in table 1 confirm the results show that there are realworld networks resulting from important applicative settings that have a directed spanning tree and that inherit from it a chained structure we now analyze in more detail the network twitter to illustrate the different center nodes determined by varying the value of p in definitions 9 and 10 we analyzed this graph for the p values reported in the first column of table 2 it turns out that no vertex admits an intree while most of the nodes have an outtree the table shows that different outcenter vertices are identified when p varies even if there is some stability for p between 0 and 1 both the depth ℓ and the minimal lower band width k of the corresponding ℓ k chained structure can be seen to grow with p in the same table we also report the outcenter nodes identified by other wellknown centrality measures the outdegree betweenness centrality pagerank and hubs score from hits have been table 2 confirms the wellknown fact that centrality measures often disagree making it hard to judge which result is the best the table also points out that trees rooted at the vertices with largest position centralities tend to identify chained structures with a smaller depth ℓ and bandwidth k than trees rooted at nodes considered impor tant with respect to other measures table 2 illustrates that when using position centrality we are able to identify chained structure with the smallest ℓ and k values figure 16 displays the spanning trees rooted at the first two outcenter nodes of table 2 it is evident that the tree corresponding to the larger value of p shown on the right produces a chained structure for which the cardinality of the v j sets with small j is larger at the beginning of the sequence than for the tree on the left the cardinality of the sets in the tree on the left are more balanced however it is difficult to understand the effect of this parameter on the choice of the center nodes without knowledge of the identity and history of the people defining the vertices the transportation network analyzed in the next section aims to clarify the meaning of poutcenter nodes as well as to compare position centrality to other centrality measures to gain some insight into how the centrality measures considered in this section are related we computed the kendall rank correlation coefficient between the inout position centrality with p 1 and degree closeness betwenness hubauthority and pagerank centralities the comparison has been performed on the ibm32 n2c6b10 gre twitter and busca networks the last network will be discussed in the next section the results are displayed in fig 17 the networks n2c6b10 and twitter do not appear in the graph on the left because they have no incenter nodes there is only one outcenter node in n2c6b10 so for this data set the comparison is meaningless as it is clear in the graph on the right as it is expected the kendall coefficients of position centrality and closeness centrality for both incoming and outcoming connections are 1 meaning that the agreement of the two ranks is perfect position centrality is seen to be strongly correlated to degree and pagerank for some of the data sets but the two graphs demonstrate that the considered centrality indexes represent different features of the networks a case study about position centrality to investigate the effect of the parameter p on the choice of the center vertices determined by the outposition centrality p out p and the inposition centrality p in p of a ver tex v we studied a transportation network for which it is possible to judge by common sense the results of the analysis like all transportation networks it is closely related to the social behaviour of the individuals living in the area of interest we considered the bus network that serves the metropolitan area around the town of cagliari in sardinia italy the area is about 65 km 2 hosts 42 • 10 5 people and includes the town of cagliari as well as four smaller municipalities very close to cagliari contiguous in some parts monserrato selargius quartucciu and quartu santelena see fig 18 the bus network was constructed using data available on the web we refer to this network as busca there are 970 bus stops they define nodes the distance between the bus stops is not available we therefore measure distance as the number of bus stops between the starting and ending nodes on the shortest path the bus routes define edges the resulting network is unweighted some bus routes depend on the direction of travel eg because some streets are oneway the bus network therefore is directed a bus network like most geographical networks is strongly influenced by the landscape and urbanization the cagliari commercial center is located on the southwest border of the network in front of the harbor a large pond the molentargius saline regional nature park is located in the center of the urban area it separates the four municipalities from cagliari and prevents straight travel between them we computed the poutcenter and the pincenter vertices of the bus network for different values of p the results are reported in table 3 where the bus stops are identified by their name the table also reports the center nodes according to the degree betweenness pagerank hits and hub authority centrality since betweenness and pagerank do not distinguish outcenters from incenters only one center node is reported for them for each inoutcenter vertex the depth ℓ is reported here the distance is measured in terms of the number of edges on the shortest path between the root and the leaf we also report the minimal lower bandwidth k of the ℓ k chained graph structure the center nodes corresponding to p 05 and p 1 are in the commercial center of cagliari the part of town where the largest number of shops and restaurants are located and where a large number of bus routes converge the outtree rooted at the outcenter corresponding to the san benedetto bus stop is displayed in the right pane of fig 19 the density of nodes in the upper part of the tree shows that many of the first chained sets v i ie sets with small index i contain a large number on nodes this indicates that it is possible to reach a large number of destinations within a small number of bus stops ie in a small time when p is significantly smaller than one the outand incentralities defined in definitions 9 and 10 give a smaller weight to sets v i with large cardinality than when p is larger than one the effect is that the spanning tree rooted at the corresponding outcenter node is more balanced see the picture on the left of fig 19 this corresponds to a less rapid decay in the number of elements of the sets v i and also to a smaller depth of the tree the center node legnano is located in the pirri district of cagliari while zuddas and riu mortu are in monserrato a neighboring municipality both these zones join cagliari with the small towns in the west part of the area so they are barycentric for the network it is possible to reach the farthest parts of the network from them after a relatively small number of bus stops fig 19 network busca on the left the outtree spanning the network rooted at the node corresponding to the zuddas bus stop the outcenter vertex for p 10 1 01 on the right the outtree rooted at the san benedetto bus stop outcenter node for p 05 1 for a value of p somewhat larger than 1 say p 5 the center nodes are found in densely populated parts of cagliari when the value of p becomes very large the center nodes are suburban bus stops that are served by strategic routes that connects them rather easily to the rest of the network the depth of the spanning trees that is the maximal length of the routes starting from the tree root increases monotonously with p it is remarkable that the minimal lower bandwidth is rather large this is a consequence of that there are some bus routes going back towards the center node with only a single bus stop before reaching the center the other centrality measures reported in the lower part of table 3 with the exception of the betweenness centrality produce center vertices located in the cagliari harbor area the touristic center in any case these measures produce results complying with the traditional idea of centrality while varying the parameter p in the position centrality gives the possibility to consider different aspects of this transportation network the betweenness central vertex is difficult to interpret as it is located in the central part of the quartu santelena town which does not appear to identify the real center of the network conclusion it is important to be able to identify interesting structural properties of directed graphs because they shed light on how the vertices are connected this paper introduces the notion of directed chained graphs and illustrates how it helps us to understand the structure of directed graphs also the related notions of incentral and outcentral nodes are defined and illustrated the latter notions are quite intuitive and examples illustrate that they are helpful for identifying important nodes that differ from nodes that are identified by several popular available centrality measures author contributions ac cf lr gr and yz contributed equally to this work in particular ac cf lr gr and yz collaborated in designing the research and the methodology performing the analyses and implementing the algorithms all authors edited the paper and read and approved the final manuscript funding work by lr was supported in part by nsf grant dms1720259 ac cf and gr were supported by the regione autonoma della sardegna research project algorithms and models for imaging science rassr57257 and the indamgncs research project tecniche numeriche per lanalisi delle reti complesse e lo studio dei problemi inversi cf gratefully acknowledges regione autonoma della sardegna for the financial support provided under the operational programme por sardegna fse competing interests the authors declare that they have no competing interests

a complex system that is composed of separate items that are interconnected in some way can be modeled by a network networks are represented by graphs which are made up of nodes and edges the latter connect the nodes networks arise in many areas of science and engineering such as biology communication transportation and social media see eg estrada 2012 newman 2010 for discussions of these and many other applications the edges in a network may have weights which are real values and generally positive and may measure the strength of the interaction between linked nodes the connections may have a direction a graph is referred to as undirected if all edges are undirected ie they are twoway streets a graph with at least one directed edge which can be thought of as a oneway street is said to be directed we are concerned with directed unweighted graphs without selfloops thus all edges have the same weight which we set to one and there are no edges from a node back to itself a considerable number of mathematical and computational methods for studying networks have been developed among the aims of network analysis is the identification of the most important nodes or edges of a graph by using the notion of centrality which first arose in the context of social science or to determine the structure of the

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introduction in the past few decades there has been a debate about the role of the welfare state and the use of informal care or family care is revalued 28 the role citizens themselves have in society is subject to change they are summoned to be more independent from the welfare state and need to feel the responsibility to care for themselves and loved ones 33 in great britain this development is known as big society where the reformation of society and the transformation of the state to facilitate relationships between citizens are key elements 8 in the netherlands similar voices are heard emphasizing the participation of citizens rather than depending on the government and having a wait and see attitude they have to help others in need 46 trappenburg 46 describes how this requires different attitudes and actions from citizens and advocates for a change from passive to active solidarity furthermore she explains the moral call help someone in need isnt heard by everybody this means that the burden of caring for someone in need is not always distributed in a fair way we recognize the difficulties in this transition where informal care becomes of more importance and want to add that persons may experience certain tensions between the willingness to care for a family member or neighbor and the time constraints that are inherent to living in a modern society where being productive through labor is seen as important and where not everyone has the possibility to reduce their working hours 184550 how do persons shape their involvement with and commitment to others if there are conflicting expectations and moral dilemmas that accompany them how do they want to relate to family friends or peers how is that reflected in forms of sacrifice and selfinterest of solidarity and calculation of generosity and obligatory giving of intimacy and aloofness these different feelings are well illustrated in the italianfrench film mia madre by nanni moretti where we see the struggles of a son and daughter in taking care of their ill mother 31 the daughter who pursues a career in film making experiences severe problems in dealing with her personal problems and professional career whereas the son takes leave from his job to care for his mother both struggle in this process and have different reasons for their actions giving priority to ones own ambitions or to caring for loved ones seems to be surrounded by ambivalence different moral values may come into conflict with each other persons can also experience feelings of responsibility to support a loved one based on love and generosity or on a sense of obligation towards others or because one cannot bear the suffering of another the social and therapeutic value of social networks and social support can hardly be overestimated the mental health of people can be enhanced and preserved when social support is present 354849 persons with a mental illness also benefit from a committed network because with their help worsening of the situation can be prevented the network has protective features 254344 social support has a positive influence on coping with stress selfcontrol a sense of optimism and hope 4447 having a social network that offers support or care in short has a profitable effect on the mental health of people but how selfevident is giving support or care to a familymember or friend with a mental illness on the one hand solidarity generosity and intimacy seem to be important values but simultaneously pursuing a career earning money and living your own life is seen as meaningful nowadays persons in western societies have to deal with these moral ambivalences because there are conflicting visions on what is considered good how persons shape their involvement and commitment in the life of relatives in need has been studied extensively from a care ethics perspective by lindemann according to lindemann 26 families can be seen as networks where love and trust are important the affection in the family leads to a certain kind of vulnerability and induces responsibilities to care for and commit to each other 26 however lindemann 26 also mentions that affection in the family can be combined with aspects like selfishness indifference or carelessness the moral ambivalences persons may experience when experiencing these different feelings when they care for someone remain mostly unclear the purpose of this article is to illustrate moral ambivalences in a neoliberal context using both theory and the reality of a case and to explore what theoretical concepts such as communities of fate communities of choice or personal communities may add in understanding how people shape their involvement and commitment when a family member or friend experiences recurrent psychiatric crises we have carried out this study in the field of mental health care a field where persons with severe and ongoing psychiatric problems and their families and friends often have complex relationships where uncertainty and ambivalences to be involved in informal care occur 40 these moral ambivalences also crop up in other areas of medical decision making the length of the stay in hospitals and nursing homes is often related to the support of family members 52 in all situations where compensation of selfcare deficits is required these dilemmas arise the question we want to answer in this article is how do persons shape their involvement with and commitment to a family member who has severe and ongoing mental health problems and how are they dealing with the moral ambivalences they experience in this situation and what is the contribution of theoretical concepts from the field of sociology including communities of choice communities of fate and personal communities in understanding these ambivalences first we will discuss a case example that illustrates the moral ambivalences that family members and friends may encounter then we will point out theoretical concepts and will begin to explore what these concepts add in understanding how persons shape their involvement and commitment when a family member experiences recurrent psychiatric crises case example a case that illustrates the moral ambivalences family members may encounter comes from the research project family group conferencing in psychiatry 1 in this project we investigated whether it is possible to reduce coercive measures in psychiatry by organizing a family group conference the psychiatric patients in this research project were at risk of being involuntary admitted in a psychiatric hospital or sometimes still are admitted due to risky or dangerous behavior in relation to their own safety or that of others research on the application of fgcs in public mental health care shows that fgcs hold potential in preventing coercive measures in psychiatry 12 this corresponds with the findings on the application of fgcs in youth care where forced residential and foster care are prevented using fgcs 3851 fgcs also reduce the risk of recidivism in juvenile crime 5920 and are applied in elderly care as a means to reinforce relational autonomy and resilience 30 fgcs originated in new zealand and can be regarded as a decisionmaking model where the formal world of the government and organizations comes together with the informal world of individuals families and friends 14 the conference is a meeting organized by the patient and fgccoordinator where plans are made along with family friends and sometimes professionals to deal with the situation an fgc gives the patient and social network the opportunity to deal with a situation in a way that matches their own culture and lifestyle 121930 the potential of fgcs in avoiding coercive treatments in psychiatry lies in the widening of the circle of support restoring of relationships and the evolvement of a knitted community that is available 247 1011 plans can be made wherein social networks have a signaling function and can prevent escalation of an situation into a coercive treatment in collaboration with a client the idea is that bringing these groups together offers possibilities for new solutions that improve the situation 7 furthermore fgcs appeal on the ownership and autonomy of the persons involved this is contradictory to coercive measurements which most clients experience as a loss of ownership and infringing their fundamental rights 132224 in the research project 60 cases where patients volunteered to participate in an fgc have been evaluated the patients were included in three different mental health care organizations in the netherlands the methodology can be described as a responsive evaluation the purpose of the evaluation is to describe experiences during the process of the fgc the character of the project is exploratory process and outcomes of the fgcs have been studied by interviewing the participants afterwards the case we selected has elements that are recognizable for persons in similar situations holds learning potential and will be used to illustrate moral ambivalences persons experience in caring for a loved one this is in line with abma and stake 3 who describe that case studies are especially fit to pinpoint the particularities and complexity of situations furthermore they specify that if we are able to capture the essence and uniqueness of the case in all its particularity it will reveal something that is universal 3 p 1159 by discussing the case identifying patterns and combining it with theory we hope to achieve a better understanding of the complexity that comes along with caring for a relative in need in a meritocratic and neoliberal political context we discuss a case in which a professional referred a mother of two daughters in their twenties for an fgc the mother has had a long history in psychiatry characterized by strong mood swings caused by a bipolar disorder and behavior making it sometimes difficult for family and professionals to approach her mother her daughters and other family members have a history of incidents where the safety of all was at stake the social network of the mother had shrunk to only a few family members when the risk of being involuntary admitted to a psychiatric hospital was high and an fgc was being considered at the same time she was staying in different places and avoided necessary forms of care the professionals who were involved wanted to prevent an involuntary admission and suggested the possibility of an fgc mother didnt want to participate in an fgc her family however did and with them the dialogue for organizing an fgc continued in the preparation of the fgc it became clear that the whole situation was a heavy burden for the family the daughters have been through a lot with their mother and experienced psychological and emotional problems in their own lives despite everything the eldest daughter felt a strong responsibility towards caring for her mother according to an aunt it was better if she would take less responsibility due to the experienced burden this aunt had also been through a lot with her sister and would rather walk away from the sorrow and misery she had been insulted and harassed by her sister yet she also indicated of course this is not what my sister wants herself one of the sisters approached the aunt with the question whether she wanted to participate in the fgc actually she wanted to reject the request given the past she had lost the faith in a positive outcome and doubted that the fgc would succeed according to the aunt other attempts had failed too often it required a lot from the aunt to participate in the fgc also because she did not live in the same region and she had her own job and family furthermore it cost energy and time it is imaginable that the aunt would experience feelings of doubt and guilt if she decided not to attend the conference the daughters of her sister had already been through so much with their mother that they couldnt do without her support despite the possible doubts and feelings of guilt that the aunt might experience she had the choice not to interfere with the situation this applied to everyone involved in the situation all could choose to end the relationships and continue with their own lives the mother in this case might avoid contact with her family because of everything she put them through the daughters probably realized that if they decided to walk away from their mother she had little reason to control her mood swings and seek for professional help the aunt in turn would probably realize that her involvement in the situation could make a difference the moral ambivalences in this case are far from unique in cases of severe and ongoing mental health problems we see besides commitment all sorts of reservations doubts aloofness and hesitation neoliberal identity the willingness to practice a certain degree of commitment in the life of important others in need and the moral ambivalences experienced in this process are set against the backdrop of a neoliberal discourse in which humans understand themselves as largely selfish individuals making choices autonomously sandel 39 addresses the problem of the illusory promises of liberalism that liberal subjects have autonomy and control over their lives in such a context it seems like success is directly related to the persons own efforts they have control over their own destiny and determine what happens in their lives harvey 16 describes the rise of neoliberalism in recent decades and mentions that individuals are personally responsible for their own success and failure markets and market oriented thinking expanded and market values reached into aspects of life that are traditionally driven by more nonmarket norms 39 success means that people can live up to the demands of society and when they fail they owe this to themselves it isnt hard to imagine that others may pose a threat in the quest of the individual to lead a successful life this may create competition between individuals in society competition between individuals and also between organizations is an important virtue in neoliberalism 16 competition is believed to be the route to excellence and quality this fits the notion of negative liberty discussed by berlin 6 negative liberty means that other persons should not interfere with your choices or hinder you from attaining a goal berlin 6 however mentions that persons are interdependent and that no one can ever act in such a way that he will never hinder the lives of others he also states that some will need help support or education before they can understand the concept of freedom and make use of it and asks the question what is freedom to those who cannot make use of it without adequate conditions for the use of freedom what is the value of freedom 6 p 124 moreover persons can be hindered by themselves to attain their goals and their freedom they can experience internal barriers to achieve freedom the help or support of others is necessary to achieve freedom and autonomy fukuyama 15 discusses the hobbesian fallacy the idea that humans are primary individualistic beings and that they only enter society on the base of a rational calculation that social cooperation is the best option for them to achieve their own life goals and projects building on primate studies of chimpanzees he illustrates how our apelike ancestors behaved in a social way and that chimpanzees and humans have similar forms of social behavior this makes it reasonable to assume that humans have always behaved in a social way and never were isolated individuals 15 nevertheless selfinterest plays a role in relations indeed it is important to recognize and accept the tension between selfishness selfinterest and social and altruistic behavior if this succeeds the inconsistencies that people experience can be embraced and confined as mentioned before in current western society the competitive side of people is stimulated it remains hidden that we stand on the shoulders of our predecessors and cannot perform without the support of others the myth of autonomy as selfdetermination continues in this dominant meritocratic ideal success and failure are seen as the responsibility of individuals themselves 21 success is linked to personal excellence and failure to personal shortcoming 21 against this background it appears to be acceptable when people choose for themselves to a greater or lesser extent everyone wants to be successful in this market orientated thinking altruism solidarity or generosity are resources that come under pressure when used they are seen as scarce resources that need to be used carefully market tradition neglects the option however that our capacity to act altruistic or generously is increased with practice 39 sandel sees altruism and generosity as muscles that develop and grow stronger with exercise 39 p 130 the foregoing is also relevant in understanding the moral ambivalences of the aunt she is free to make the choice not to join her family and others could see this as an understandable choice if she decides to join in the situation this means that she has to invest time energy attention and commitment and this is also required for her own family and job ultimately the aunt decides to engage in the situation and is present at the conference she says maybe its a good thing to come togetherwith my nieces and the involved professional she wants to be there for the daughters of her sister and she wants to make life more enjoyable for them the decision of the aunt raises the question how it is possible that in contexts where neoliberal values dominate persons still show involvement in each others life and seem to care about relatives in need the moral neoliberal in her book the moral neoliberal muehlebach 32 discusses that despite the neoliberal context we live in persons do actually behave morally and feel responsible for others although the established neoliberal order creates rational utilitarian and instrumental acting persons these persons do have an affective identity characterized by compassion and empathy according to muehlebach the market and the moral life have always coexisted besides the abundance of material wealth there is also an abundance of socalled virtues people are fanatically seeking success and wealth but also have a moral sense which makes them sympathize with others and care for them following muehlebach compassion for others and the coldness of wealth and success are not opposed to each other 32 p 20 muehlebachs 32 study of italian volunteers in milan gives an image of a moral style of contemporary neoliberalism she shows that volunteering is especially important in a relational way and is based on the affection of persons for each other the government is withdrawing itself from the moral responsibility to care for citizens and shifts this responsibility to citizens themselves the idea of citizenship lived with the heart 32 p 11 arises and this becomes the moral soil on which a community of solidarity can be reformed the emergence of volunteering in italy originates from a discourse in which a new kind of ethical commitment is seen between different groups in society this commitment is based on a moral obligation rather than based on social rights and is not controlled or facilitated by the state 32 in addition there is a need for meaning commitment and love for persons in vulnerable situations a volunteer in the study of muehlebach describes this as helping others while helping oneself 32 p 161 reciprocity between generations is not central but a spirit of free gifting is 32 melucci 29 also points out that people can act in a selfless and altruistic way and this can be seen as altruistic action altruistic behavior can be seen as a symbolic challenge it is at odds with the rationality of calculating behavior and the efficiency of technology because it is based on the commitment of people their generosity and the desire for communication without a hidden program 29 to give and offer without expecting a favor in return is an essential point rather than thinking in costs and benefits 2 altruistic action is established on a voluntary basis and has no direct gain or benefit for those who act this way people do get something in return the opportunity to have an active and meaningful role in the life of important others and experience feelings of connection and belonging to a group major resources for altruistic action are gratitude and the ability to provide support or assistance 2 the work of muehlebach and melucci makes it conceivable that expressions of solidarity and commitment do not need to be scarce and that there are resources outside the nuclear family as sandel mentions altruism solidarity and generosity have to be exercised more strenuously to renew our public life 39 p 130 fgcs can play a role here by utilizing the available resources and facilitating forms of solidarity communities even in neoliberal and meritocratic contexts supporting others or feeling compassionate for them is seen as an important value it is however not hard to imagine that interfering in the life of someone with severe and ongoing mental health problems while dealing with the obligations of ones own life is challenging a number of theoretical concepts are meaningful in understanding the shaping of involvement and commitment and the moral ambivalences that persons experience doing so first we will discuss these concepts and later on we will illustrate with the for mentioned case how useful these concepts actually are the first theoretical concept to be discussed is that of communities of fate stinchcombe 41 points out that communities of fate can be seen as communities where the success and wellbeing of the individual is linked to that of the larger whole 41 more explicit according to hirst 17 they can be seen as existential communities in which a person is born and then grows up in communities of fate involve the sharing of a situation process or particular fate despite the sharing of a fate process or situation it is still possible for people to withdraw themselves from the care for others to what extent can we speak of a shared fate persons have to submit to hirst 17 mentions a shift from communities of fate to communities of choice which corresponds to the development of a neoliberal identity the collective identities of people are increasingly influenced by their individual life projects people build their lives according to their own preferences and want to be part of selfchosen often temporary communities 27 this means that the family as traditional community is losing relevance people want to be part of networks wherein others have the same preferences or interests or where they can meet contacts who would yield a career advantage communities of choice emphasize the choice for a community whereas communities of fate imply a shared fate or destiny persons do not choose each other they are connected through the situation fate or process they share relations in chosen communities can be for example friends acquaintances or fellow members of an association or party whereas communities of fate can be seen as family sharing a fate and a blood tie the distinction between choice and fate is however arbitrary the family we have is given to us but we can choose to keep distance likewise we can also choose to be involved with family despite the shared fate when living in a small town friends can be seen as part of a community of fate because there are few options to choose your social contacts pahl and spencer 35 question the shift from communities of fate to communities of choice to demonstrate this shift demographic studies are used which show an increasing number of divorces greater social mobility an increase in the number of highly educated people an increase in the number of women in the labor market and the growth of nonheterosexual households 35 this implies an increase in the importance of communities of choice there are however other statistics showing that family ties are still relevant and there are few signs that friends are completely replacing family 3437 it is more plausible to assume that traditional communities gradually disappear and new forms occur simultaneously 3542 the vertical and more mandatory relationships that accompany traditional communities gradually merge with horizontal chosen and more free forms of communities where mandatory relationships play a smaller role 23 involvement with society and the communities where citizens are part of seem to have a different shape relationships with family or friends are not always clearly distinguishable persons have more flexibility and freedom organizing their personal relationships 434 for example in choosing how they want to live together and how they want to raise their children even though the fore mentioned freedom is limited by social and economic location a less standardized normative image of relations and a tendency for diversity is developing 4 taking account of the composition of relationships with family and friends pahl and spencer 3536 developed the concept of personal communities with this they mean that persons have different relationships that vary in the degree of commitment and the extent to which they are given or chosen the chosen relationships that pahl and spencer describe correspond to the previously described communities of choice the given relationships resemble the communities of fate using the concept of personal communities pahl and spencer 3536 study the social world of persons at the micro level and want to gain insight into the different relationships and communities where they are part of pahl and spencer 35 recognize that different stakeholders such as family and friends can play similar and contrasting roles they also notice that a sharp distinction between given and chosen relationships is difficult to make and mention a range of given and chosen relationships representing different forms and styles of suffusion 35 p 203 despite the neoliberal culture we live in people are willing to behave in altruistic or solidary ways within a fgc choices are made intersubjective were values like altruism or generosity are negotiated upon with others in a community using the concept of personal communities brings insights who might be involved in a problematic situation the concept makes social contacts outside the given ones more distinguishable a reservoir of social recourses opens up this opens up opportunities to use fgcs as a means to alleviate the burden of the community of fate and to expand the given relationships with chosen relationships returning to the case that the aunt in this case decides to interfere in the situation and doesnt abandon her nieces because of what theyve been through together can be described as a form of shared fate in line with pahl and spencer 3536 the relationships in the case can be seen as given they are based on the sharing of a situation sharing the difficult process as a mother sister daughter or aunt creates a bond that no one leaves behind easily the involvement of the aunt seems to be primarily based on wanting to ease the burden experienced by the daughters of her sister because they have been through a hard time she apparently expects nothing in return considering muehlebach 32 and also melucci 29 this can be seen as altruistic because reciprocity seems less important and the aunt can play a meaningful role in the lives of her nieces the expectation of reciprocity applies to a lesser extent because the mother and her daughters dont have much to offer in return because of the struggles they experience in their own lives during the process of the conference the family decides to start a procedure for a compulsory admission for their mothersister because they cant endure the situation any longer in the following weeks however she stays at a psychiatric ward voluntary the outcome of the conference revealed for the daughters and sister that they can actually support each other and also has created a better cooperation with the involved professional yet the situation remains fragile durable support was not created there is only a small group of persons involved who seem to experience that they are bound together by a particular fate the case illustrates how challenging it can be to shape informal care and offer durable support where the involvement first seems to be based on a shared fate later on the choice for professional help with the appeal on an involuntary admission is made this illustrates that while on the one hand the relationships are experienced as given they also have an aspect that is experienced as a choice by reaching out to professional help just as mentioned by pahl and spencer 3536 a sharp or dichotomous distinction between given and chosen relationships seems difficult to make looking back on the preparation of the conference there could have been more focus on the restoring of relationships and widening the circle of those involved the small family network doesnt feel capable to resolve the problems and keep supporting their mother or sister considering that little reciprocity is to be expected specific for the mother in this situation it would probably be necessary to restore relationships because her social network has shrunk to only a few family members building on the insights of muehlebach 32 it would be fruitful to expand this small and fragile network with persons who are not connected by a shared fate what would emerge when the small family group was expanded with neighbors acquaintances or maybe volunteers or peers an fgc could play an active role in restoring andor strengthening the existing network widening the circle and building a bridge between professionals and the social network by widening the circle opportunities to include new points of view considering the problematic situation arise in other words the given relationships could be strengthened and ultimately widened with chosen relationships conclusion and discussion in current western societies persons experience moral ambivalences how to balance their own life style choices with caring for family members or friends who are in need in a society with numerous options there can be various ways to be involved in the life of others how this is experienced or realized may differ the concepts of communities of fate and communities of choice are used to explore how persons shape their involvement and commitment in the life of loved ones and the moral ambivalence it brings about the boundaries between the two communities are not dichotomous to what extent do persons actually have a choice in relationships with friends or neighbors location and social personal and material resources are of importance in experiencing the possibility of having choices and making them furthermore there is also the possibility to evade obligations crucial is however the way in which persons experience their relationships do they see them as given or chosen does the sharing of a particular fate play a role or are the relationships based on a thoughtout choice the value of both concepts lies in identifying that persons can experience given and chosen relationships and that friends and family can play the same role theres more to it than just a connection through blood ties the concept of personal communities is useful in understanding the different relationships that persons have and in understanding their motives to be involved we can however challenge the use of the word personal it implies that relationships are centered around one person and that this one person can decide who is part of that particular community it is more plausible to assume that everyone in the community must contribute to maintain the relationship or community fuelling reciprocity in the process lindemann 26 mentioned that carelessness or selfishness can also occur in families using a case we identified moral ambivalences persons may experience and showed that making choices about caring for a relative is complex and full of tensions the three women in the case for example may indeed choose not to commit to the situation but they decided otherwise because they experience a shared fate and have motives not to abandon or hurt their mother or nieces the aunt shows how complex it can be to deal with different moral expectations on the one hand she has the choice not to interfere with the situation and pursue selfinterest but on the other hand she has feelings of generosity and a certain feeling of obligation towards her nieces to support them the latter appears to be of more importance for the aunt than pursuing her selfinterest and invest time in her own life only through discussing the case we identified feelings of selfinterest solidarity and calculation generosity and obligatory giving intimacy and aloofness they seem to form a complex whole and exemplify the feelings and ambivalences that persons can encounter when caring for a relative in need the concept of personal communities makes insightful who are involved in a problematic situation as described in the case when a reservoir of social resources becomes visible opportunities to widen the circle and strengthen relationships with the help of a fgc arise further research into the use of concepts like personal communities and describing the different social networks involved and the motives and ambivalences they experience is necessary to comprehend what occurs in informal care against a meritocratic and neoliberal background awareness for the moral ambivalences of persons who have both solidary aspirations and the desire to pursue their own life goals provides opportunities for family friends and professionals to consider how they want to shape their involvement and commitment a positive tension between given and chosen relationships reveals itself both are of value on the one hand we have our given relations with whom we share a fate but the choice to engage in meaningful relationships with others is also present despite the neoliberal and meritocratic culture people are relational beings and they need each other to form and give expression to relational autonomy muehlebach 32 argues that relations with others are not always based on reciprocity but can also be based on an a form of charitas this means caring out of love or charity the social network in the example of the case is small and worn out the protective features of the network could be expanded through restoring relationships and widening the circle with volunteers or peers doing so this relational autonomy can be formed again moreover it may lead to a more balanced distribution of care and support and gives a hopeful perspective for those involved the majority of psychiatric patients however experience social isolation or have difficulties to fuel the process of reciprocity especially in those situations it seems necessary to widen the circle and alleviate the burden for the few persons that are involved and to strengthen those relationships fgcs can be useful when persons need support or facilitation in restoring relationships or widening the circle by facilitating this process sandel 39 argues altruism needs to be evoked and practised this requires changes in long term care structures and policies in the mental health arena this also invokes a change from professionals in mental health care policy makers and communities themselves further research into conditions for informal care and the role of communities and professionals herein is needed am i my brothers keeper individualisation and detraditionalization are transforming the way people respond to this call the work of muehlebach and the case example show however that there is hope for expanding social networks into a wider network of care despite the time pressure of todays life projects in a neoliberal context and holds a promise to widen the circle for those in need of support conflict of interest the authors declare that they have no conflict of interest open access this article is distributed under the terms of the creative commons attribution 40 international license which permits unrestricted use distribution and reproduction in any medium provided you give appropriate credit to the original author and the source provide a link to the creative commons license and indicate if changes were made

within the current dutch policy context the role of informal care is revalued formal care activities are reduced and family and friends are expected to fill this gap yet there is little research on the moral ambivalences that informal care for loved ones who have severe and ongoing mental health problems entails especially against the backdrop of neoliberal policies giving priority to ones own life project or caring for a loved one with severe problems is not reconciled easily using a case study we illustrate the moral ambivalences that persons may experience when they try to shape their involvement and commitment when a relative is in need the case comes from a research project which explores whether it is possible to reduce coercive measures in psychiatry by organizing a family group conference the purpose of the article is to explore what theoretical concepts such as communities of fate communities of choice and personal communities add in understanding how persons shape their involvement and commitment when a family member experiences recurrent psychiatric crises

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retrospective analysis of establishing independent media in ukraine russia and poland the russian researcher o strukova determines 1976 as a year when the latest stage of alternative periodical press of the russian federation or so called samizdat began from lowcirculation opposition leaflets and bulletins that started circulating among the narrow circles of likeminded people from new sociopolitical movements in particular publicpolitical magazine glasnost religiousandphilosophical journals vybor and zemlіa historicalandpatriotic journal neprіadva historicalandpolitical journal obshchina informatsionnyi bіulleten informatsionnogo agentstva svobodnogo mezhprofessionalnogo obedineniya trudіashchikhsіa human rights newspaper ekspresskhronika etc however v kipiani a ukrainian historian and journalist believes that 1965 is the important date both for the russian and ukrainian samizdat 16 issues of a typewritten magazine volya i batkivshchyna published in ukraine in 1965 can be considered a harbinger of periodical samizdat in the conditions of clandestine activities it was enormous periodicity because the majority of samizdats had a much shorter life even at better times three two five ten issues it was printed on «rolling paper» and as a result very few copies have been preserved in the same year 1965 in middle asia a periodical called informatsia appeared among the crimean tatars as for that time it was the first periodical with a huge area of circulation later in 1968 a journal khronika tekushchikh sobytiy appeared in moscow and it was the main samizdat edition in the soviet and russian history its makers write in their memoirs that they were inspired and driven by the experience of informatsia in 1970 the first of new ukrainian samizdat publishers vchornovil did not hide his authorship in the journal ukrainskyi visnyk this edition was not the first by periodicity but in v kipianis opinion is no 1 edition by publicity the same as moscows khronika tekushchikh sobytii for the russian human rights movement in january 1972 a group of publishers of ukrainskyi visnyk were destroyed just as almost the entire dissident movement several hundred people were arrested expelled from jobs or higher educational institutions etc and the following waves of repressions covered already several thousand all over ukraine as a result there were no nonstate periodicals in ukraine until 1986 in 1986 one of the first soviet rockmagazines of the perestroika period was published kharkivs rockkurier its editor was omartynenko under the pseudonym of nhalia in the end of the 1980s other forms of samizdat that were absent in the 1970s appeared in particular nationalandcultural samizdat in the summer of 1988 in crimea the first independent periodic newspaper vatan crimean tatars samizdat was released it was published in the crimean tatarian and russian languages and included numerous materials on the history of crimea before deportation the editor was professor r muzaffarov who transformed the newspaper into the journal vatan in v kipianis opinion a history of crimean tatars periodicals in the territory of crimea in the latest period begins from this edition in november 1988 a ukrainian newspaper dvizhenie arises it is also considered to be the first periodical leaflet in the territory of the ussr it is published in russian in the city of sumy as an independent body to support perestroika an edition of takie dela appeared in the 1980s it reminds a commercial leaflet it included both particular information and a commercial advertisement block with classified ads like pillows of fur rub 23 pants knitted bags rub 810 recording onto mk90 cassette rub 67 and the information people needed to solve routine and commercial problems the demand for this information was huge moreover the edition published jokes sometimes even personal ads which was a new and unusual practice for the soviet period december 2 1988 can be called the beginning of the ukrainian printed advertising when the first issue of the advertisingandinformation newspaper posrednik the first commercial advertising edition in ukraine was published simultaneously it was the first advertising edition in the former ussr the newspaper was founded by kyiv journalist v novozhylov posrednik launched publication of numerous principally new advertisingandinformation editions and business newspapers in ukraine in 1989 v chornovil established the first independent news agency ukrainian independent publishing information association which started to publish beside ukrainskyi visnyk a thin bulletin of uvekspres ie ukrainskyi visnyk express issue appearance and circulation all over the ussr of informal editions by peoples fronts and movements for reforms of the baltic republics at the end of 1988 and the beginning of 1989 significantly influenced the establishment and development of informal press of the soviet republics ukraine in particular in the fall of 1988 the russianspeaking editions by the lithuanian movement for reforms of saiudis soglasie and vozrozhdenie arose in december of the same year a newspaper of latvias peoples front atmoda was published in a week after the newspaper publication in latvian atmoda was published in russian which became perhaps the most popular newspaper of that time in the territory of the whole ussr it encouraged the appearance and explosive development of informal press of ukraine the establishment and intensive development of noncommunist nongovernmental and youth associations in ukraine at the end of the 1980s and later political parties specified the appearance of numerous printed samizdat media not registered officially they were the typewritten articles pictures and headlines affixed by the application method journal copies were produced semilegally on rotaprint linotype or xerox photocopying machines in provincial soviet printing offices or outside of ukraine these journals were later sold off hands in march 1989 the first issue of the journal by the ukrainian helsinki union called holos vidrodzhennia was published in kyiv in april of the same year in riga the atmoda typography printed the print run of the first issue of information bulletin of lvivs tovarystvo levas postup it was exactly in 1989 when the first ukrainian private independent tv channel tonis started work it was founded by vivanenko who had received a license for worldnet satellite channel the channel began operating in the central office in mykolaiv and in 1992 moved to kyiv where it was renamed slovianskyi kanal for satellite broadcasting for 12 regions of ukraine the ukrainian researcher bskuratovskiy believes that tonis was one the first commercial tv companies launched in the territory of the ussr as of the time of its appearance tvorche obiednannia novykh informatsiynykh system created by the initiative group of enthusiasts of cable television from mykolaiv and registered in december 1989 included such monsters as the state committee for cinematography soviet fund of culture the union of war and labor veterans ministry of defense and many other organizations and was planned to be an allunion tv company the same year 1989 a famous ukrainian journalist and a dissident s naboka became a cofounder and director general of the ukrainian independent information agency respublica the first one officially registered in ukraine that is why we believe that the newest history of ukrainian journalism and development of national information space of ukraine started in 1989 after the ussr law on press and other mass media was adopted in 1990 the regulatory problems of functioning were resolved and the process of legalization of the ukrainian press started political opposition in ukraine used this unique opportunity at once especially in western regions of the country where it obtained majority in the elections to local authorities in may 1990 the lviv oblast council considered the issue on usurpation of district town and districttown press by party committees of lviv oblast at its session a process of the division of newspapers started based on the right to make such decisions numerous district councils agreed to create alternative mass media real fight began around each largecirculation newspaper as soon as a plant or high school party committee lost control of them they were immediately transformed into the bodies of rukh for example in the town of stryi where there was one russianspeaking newspaper stroitel kommunizma two started to be published they were absolutely opposite by political orientations and value priorities communist partys holos stryishchyny and ukrainianlanguage holos svobody soon a process of division and publication of new newspapers at the oblast level started in lviv simultaneously with vilna ukraina an oppositeminded za vilnu ukrainu began to be published and in ivanofrankivsk halychyna was published as oblast councils newspaper alongside with prykarpatska pravda in rightbank ukraine all these processes were not so intensive and dramatic but they were of the same vector influence of the partys committees was becoming weaker as local councils were taking control over mass media miners strikes the first wave of which fell onto summer 1989 accelerated the events the transformed media market of poland was also an example for ukrainian mass media to follow it motivated for new editions and tv companies to arise as well as encouraged implementation of private ownership for mass media until 1989 all printed periodicals of poland both local and national were included into the publishing cooperative presaknyzhkarukh which also included publishing houses and typographies news agencies the concern was totally controlled by the polish united workers party two laws were the most important for establishment of free media in poland the first one was on cancellation of censorship and the second one was on the foundation of the liquidation commission to liquidate the cooperative the liquidation commission founded in april 1990 governed all the activities related to the liquidation of the cooperative and privatization of approximately 200 editions included in it was announced through tenders as a result the majority of political groups received their printed editions the main printed newspaper of the communist party pl trybuna ludu was renamed as trybuna and remained under the partys control the newspaper express wieczorny was under the party pl porozumienie centrum by the kaczynski brothers beside the sale of editions the law allowed acceptance of the edition into ownership by the collective of journalists if more than 50 of its employees could make a financial contribution in general approximately 70 newspapers were transferred to the collectives of journalists among which was in particular a weekly magazine polityka and głos wielkopolski it in compliance with these documents printed periodicals founded by the central committee of the communist party of ukraine oblast committees town committees and district committees of the communist party of ukraine were reregistered all republican oblasts towns districts plants and collective farms newspapers were reregistered without exceptions in total they included more than 500 titles their new founders were mostly the local councils of peoples deputies jointly with labor collectives of the editorial offices and other founders thus according to international researchers the transformation of media systems in central and eastern europe began from the changes occurring during perestroika and glasnost in the soviet union during 19861987 and soon covered the countries of centraleastern europe in 30 years it became obvious that the postsoviet countries chose different ways to transform their media systems in other words the differences are not marginal on the great stage of history any more as the british researcher leslie holmes believed the clearest separation line is now between the countries that became the eu members and the ones which are not even oriented at the membership it should be mentioned that at the time when media regulating of the postsoviet countries focuses on the regulation of traditional information legal relations particularly activity of the mass media state and commercial secrets advertisement information resources and services information legislation of the european union countries which the baltic countries joined is based on european criteria of securing information rights freedoms and information security of a person and a citizen from maidan to maidan the development of the information space of independent ukraine on october 2 1990 the ukrainian youth unions of ukrainian students association in kyiv and students brotherhood of lviv initiated and organized the first civil disobedience action which came into the newest history of ukraine as students revolution on granite on october revolution square in kyiv studentsactivists from several cities of ukraine went on hunger strike with political demands to the verkhovna rada of ukrainian ssr on october 17 the verkhovna rada approved the resolution concerning the demands of the striking students after which hunger strike was over at the same time revolution on granite became a powerful push for the development of informal press in central and eastern regions of ukraine the editorinchief of the shliakh peremohy newspaper v roh states that his assignment was to wake up as early as possible and then collect periodicals to transfer them later to sumy they were always in short supply… since the declaration of ukraines independence public consciousness has been gradually turning from an undeniable orientation towards russian publications to a prevailing orientation to ukrainian newspapers and magazines if in 1992 416 of ukrainian citizens subscribed to russian editions 226 national newspapers and 358 local ones in the second quarter in 1993 the amount of subscribers to the russian editions decreased to 98 correspondingly taking into account that an ordinary ukrainian family subscribed at that time on average to one usually district or oblast newspaper one can talk about a significant increase in the information influence of local mass media on the public consciousness in ukraine 1995 became the start for numerous ukrainian tv studios tv companies and production centers that made tv programs not intending to have an individual tv channel first lack of program products to fill in the channel completely was among the main reasons moreover there were no free channels thus ukrainian television including commercial channels started to be gradually divided into broadcasting and production during 19971998 ukrainian media started to launch their own internet websites in 1999 first online editions appeared in ukraine uatoday and elektronni visti elvisticom since 2000 the number of websites of traditional mass media has been rapidly growing in ukraine for example such tv channels as mahnoliia tv stb newspapers kievskii telegraf korespondent and telekrytyka magazines as well as new internet editions in particular ukrainska pravda proua uaportal forum and many others in general this period is significantly notable for a continuous increase in the number of web resources simultaneously at the beginning of 2000 in the verkhovna rada of ukraine a propresidential parliamentary majority was formed which comprised groups of deputies governed by socalled oligarchs people controlling both financialindustrial and political resources as well as media the facts of democracy and human rights violations in ukraine during 20002004 became a subject of numerous resolutions of the council of europe the european union nato osce and other statesparticipants it caused serious political and image losses for the ukrainian state this period of the development of the national information space was completed with the mass media coverage of the ukrainian presidential elections in octoberdecember 2004 and of the orange revolution a campaign of protests meetings strikes and other acts of civil disobedience in ukraine on october 25 2004 the employees of 5 channel started a hunger strike demanding from the government to stop suing their channel and from the courts to cancel their decisions on october 28 more than 40 journalists of tv channels of inter ictv novyi kanal and ntn signed a statement against the censorship on their tv channels 7 journalists from 11 tv channel resigned under similar reasons before the end of november this statement was signed by 346 journalists from different tv channels thus in the national information space of ukraine tools of media community selfregulation appeared the european vector of the new information policy of ukraine declared at the 7th european ministers conference on policy in mass media 2005 was based on ideas and decisions of worlds summits on information society according to ukrainian scientists ratification of the european convention on transfrontier television by ukraine was a strategically important step on the way of adopting national legislation to the requirements and standards of the european union 2009 however ukrainian scientist isemenchenkos approach to the tendencies in national information space at that time in the conditions of globalization is quite critical he believes that the uniform information space in ukraine is absent during 20072014 also a paradox situation arose when despite the amount of printed media and volumes of advertisement the real audience of national printed media was significantly decreasing in may 2010 there was a public discussion of media diagnosis 2010 virus of censorship where a public movement of stop censorship was established one of the movements requirements was to establish public broadcasting in ukraine the final report on the parliamentary elections supervision 2012 in ukraine by the mission of the organization for security and cooperation in europe and office for democratic institutions and human rights in particular specifies that a financial factor more and more influences the ukrainian mass media covering the election the conditions in which the mass media worked were characterized by almost complete absence of editorial independence on television in february 2013 the cabinet of ministers of ukraine approved the plan of priority measures for ukraines integration into the eu for 2013 but on november 21 2013 within several days before the vilnius eastern partnership summit the resolution by the cabinet of ministers of ukraine suspended the procedure of preparing and signing the association agreement between ukraine and the european union this decision of the government in force caused euromaindan protests all over the country to support the eurointegration choice of ukraine which after violent crackdown of protesters and their beating during the night of 2930 november 2013 in kyiv grew into the revolution of dignity the protests were transformed from proeuropean into antigovernmental and became much more largescaled according to the analytical report of the national union of journalists of ukraine 271 journalists both of ukrainian and foreign media suffered during the revolution of dignity in february 2014 two journalists died in kyiv moreover within this period 14 attacks on media editorial offices 9 arrests and detentions 31 cases of threats of physical violence to media employees were registered social networks of twitter and facebook having spread the information about civil protests quickly encouraged people to protest during the revolution of dignity social media became one of the main channels for receiving realtime information for official domestic media outlets this development led to the emergence of «citizen journalism» in ukraine which further evolved due to the efforts of volunteers and civic activists in annexed crimea and the occupied parts of donbas information space of ukraine in the posttruth age and in the conditions of the russian military aggression in 2012 experts from 42 countries of the council of europe refused from traditional forecasting for the first time and specified media as the most complicated and the most problematic segment within the following 10 years after that 12 experts made up a high level group in the eu the management committee on media which made a forecast and recommendations until 2025 according to the conclusions of european experts traditional journalism is disappearing as it has shifted into the realm of services and has transformed into political and business orders at least it was exactly in europe2012 traditional media produced customized texts by 80 simultaneously a crisis of media technologies the spreading of digital products and the development of networks has a consequence that each person could be a media blogger and the posts of media citizens change the politicians and world leaders decisions according to l mudrak an independent media expert and multiyear representative of ukraine in the steering committee of the council of europe on information society and media media future lies in the internet without borders our time has introduced the term «posttruth» into social circulation where politicians and media manipulate to such an extent that it becomes difficult or even impossible to find the truth in the information flow as a response to the trend of posttruth there appeared a defending move the us faculties of psychologies have been already teaching the course of truth search in the posttruth age along with the concepts of basic journalism counteracting manipulations as well as selfpreservation have become a way of life during the euromaidan and the revolution of dignity in 2014 all the miscounts of ukraine in the information area within previous years were evinced that was the period when the aggressive information policy of the russian federation had an impact on distorting and misrepresenting the image of ukraine in the world particularly within russia itself only due to active elucidation of these events by european and world media was a longterm practice of reception of information about ukraine from the russian sources broken at the same time social media platforms became actively engaged in the deliberate dissemination of information about ukraine abroad becoming one of the main channels for receiving realtime information for traditional media outlets for example the information resistance group systematically pursued a policy of exposing and debunking false information about events in ukraine about the relations of ukraine and russia the materials in different languages prepared by the experts were mostly translated by volunteers and spread by information channels of the worlds media the use of citizen journalism and maximally wide online elucidation of what was occurring in experts opinion became the most efficient tool which held back the aggressive campaign of the russian federation both at the information and real level in the beginning of 2014 in the territory of the autonomous republic of crimea beside the deployment of russian federations troops ukraines population was under psychological pressure by mass media of a foreign state information expansion into the national information space of ukraine was seen strategic facilities of the ukrainian telecommunication infrastructure were captured all those occurred against the background of a massive and aggressive information attack of the russian propaganda which contrary to the european standards in the area of mass media was trying to incite hostility and separatist sentiments in ukraine and thus encroached on state sovereignty and the territorial integrity of ukraine responding to the decision of the national security and defense council of ukraine on urgent measures concerning ensuring national security sovereignty and territorial integrity of ukraine in march 2014 the national council of ukraine on tv and radio broadcasting addressed associations of program services providers demanding to stop rebroadcasting the programs of russian tv channels of rossia 24 ort rtrplaneta ntvmir in their networks additionally in 2017 ukraine imposed sanctions against the russian network resources such as yandex mailru ukraina vkontakte odnoklassniki etc as of that time it became obvious that further development of democratic processes and civil society institutions in ukraine are almost impossible without public broadcasting public television and radio broadcasting as the ukrainian experts believe have to be based on fundamentally different grounds rather than on stateowned or commercial television and radio organizations this is a form of broadcasting that is created for society financed by society and under its control the introduction of public broadcasting in ukraine was also one of the requirements for signing the association agreement between ukraine and the european union the law of ukraine on international broadcasting system of ukraine launched work to create ukrainian information content for foreign consumers on october 1 2015 the multimedia platform of international broadcasting of ukraine was launched having united the resources of tv channel uatv and the national news agency ukrinform in april 2016 an active stage of the channel transformation in compliance with the worlds standards of international broadcasting started as of the end of 2016 contracts were signed with 58 cable networks operators of foreign countries in december 2015 the public diplomacy department was established in the structure of the ministry of foreign affairs of ukraine whose functions include the implementation of imagebuilding programs abroad in 20162017 the ministry of foreign affairs implemented several largescale cultural and social promotions that drew attention of the worlds community to the issues related to ukraine in may 2018 the government of ukraine approved the brand of ukraine now developed by the creative company of banda agency ukraine now has become the most largescale international marketing campaign of the ukrainian government its main purpose was to form a positive image of ukraine among the international community to draw attention of foreign investments and to enhance tourism potential within the period from 2015 to 2019 in compliance with the norms of the ukrainian legislation and european convention on transfrontier television rebroadcasting of 86 foreign programs originated mostly from the russian federation was terminated in the cable networks of ukraine together with the oblast offices of the security service of ukraine cases of illegal content broadcasting in public access institutions were promptly stopped according to the «report of the national council of ukraine on television and radio broadcasting for 2019» such measures indirectly contributed to the emergence of new national including «niche» satellite television channels now 131 ukrainian satellite programs are broadcast in ukraine and the list of foreign programs whose content meets the requirements of the european convention on transfrontier television and the legislation of ukraine amounts to 178 items in the information space of ukraine various foreign elements of information influence are functionally present however the presence of «external» subsystems in the state information space should not be perceived as a crisis of the system according to domestic experts the state information policy of ukraine should take into account the environment of its existence and based on this build a system of its own information security the main strategic purpose of the state information policy is to ensure the transition to a new stage of development for ukraine the building of an information society and the countrys integration into the global information community the main strategic direction of activity is the formation and development of an open information space of the state ensuring its integrity and unity as well as its integration into the global information space taking into account national interests and specificities with a focus on ensuring information security at the domestic and international levels all social transformations in the nearest future as l mudrak thinks will relate to media new media are interactive electronic editions combining various formats of providing information video online radio tv broadcasting animation sound arrangement and the text itself can be the content of new media new media are different from traditional ones by the user content they are open to interaction with their readers and provide them with a possibility to create and modify the content of messages in the digital world each person without exceptions is a media citizen crisis of media technologies forecast by the international experts for 20202025 led to the situation when people create media environment themselves unions of people by interests needs priorities activities in social networks thus they produce content daily information flow set conditions priorities form ethics in the network as a result a new media ecosystem has been created that is exactly what the theses of analytical forecast by the high level group in the eu meant globalization of the information space as well as increased volume of false information in the posttruth age require widening the opportunities for media education developing critical thinking and increasing the level of citizens media literacy their ability to stand against manipulations of both national and foreign origin propaganda concerns a whole range of the social life areas that is why reaction must be from all the societys strata it is necessary to study the phenomenon itself to reveal fake stories and tell people about that as expert ismolenova thinks it is important to increase the level of education in general because propaganda is efficient as long as someone is ready to believe it conclusions transformation of media systems in central and eastern europe began from the changes occurred during perestroika and hlastnost in the soviet union during 19861987 and later covered the countries of centraleastern europe in 30 years it became obvious that postsoviet countries chose different ways of their media systems transformation the clearest dividing line is now between the countries that joined the eu and those which are even not oriented at the membership the establishment of the newest ukrainian journalism and national information space was in mutual dependence with social and political economic cultural and educational development of the independent ukrainian state media were simultaneously a mirror and a catalyzer of social and political processes during 19942004 national information space of ukraine became structured its main players were determined media market leaders were formed new information policy of ukraine during 20052014 was formed taking into account the reality of the global information society information threats and needs of information safety being proeuropean in its development vector since 2014 the development of ukraine in the conditions of the russian military aggression and increased information threats have remained topical a necessity to protect the national information space to enhance the information security and information operations counterstand system to decrease negative consequences of external information influence in the conditions of escalated threats ukraine is facing in the information area it remains topical to protect information sovereignty to preserve the ukrainian peoples cultural values to develop their national selfidentity and civilization unity to form a developed information society in ukraine to develop national information space to transform ukraine into an informationally advanced state and a fullfledged participant in the activities of the european and global community references

sociopolitical changes in the end of the 20th and the beginning of the 21st centuries in the conditions of geopolitical processes specified by the collapse of the soviet and socialistic systems rapid development of informationandcommunication technologies have transformed information space contemporary ukrainian journalism and its national information space have been established in interdependence with sociopolitical economic culturaleducational development of the independent ukrainian state media were both a mirror and a catalyzer of the sociopolitical processes ukraines development in the current conditions of the military aggression and increased information threats creates a necessity to protect its national information space to improve the system of information security and resist to information operations and to decrease negative results of the impact of external information globalization of the information space and the increased scope of untrue information in the posttruth age require an expansion of the opportunities for media education a development of critical thinking and enhancement of the level of citizens media literacy their ability to counterstand manipulations both from inside and outside

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introduction of the australian population 20 lives permanently in rural areas 12 the trend in population mobility has seen regional australia attract more people than it lost to capital cities 3 consecutive census data from the previous decade affirm more than 12 million people either moved to regional australia or moved around regional australia from one location to another 3 regional rural and remote communities include primary producers indigenous australians and others who contribute to the rich fabric of the nation these individuals and communities need access to health social and education services the same as the rest of the australian populations the allocation of state government funding has responded to this with a clear focus on building infrastructure in rural and regional victoria to enable access to localised timely health care one of the main challenges to providing these services is the recruitment and retention of health care professional staff to these services in response the australian government has established a longterm funding scheme currently referred to as the rural health multidisciplinary training program one of the main goals of the rhmt program is to create sustainable health student placement opportunities in rural and remote areas of australia the premise is that if student health professionals have positive placement experiences in rural and remote areas they will be more inclined to seek employment in these areas once they have graduated complementing this is the longheld notion that a health professionals decision to work in rural settings is influenced by having a rural background and family connections 4 another approach to developing a rural and remote workforce is to enable students to complete their entire training in their rural or remote contextendtoend training this requires the provision of the educational infrastructure and personnel including academics to be in the location the student is learning for the duration of the individuals learning there is some evidence that this approach results in more professionals working in rural areas in a comparison of dental graduate outcomes johnson et al 5 reported 54 of graduates from a regional endtoend program were working rurally whereas 33 who did their training in a metropolitan program with an extended rural placement were working rurally after graduation thus whilst several studies have been published on the location of graduates who have completed extended rural placements for medicine and some allied health disciplines other than in dentistry we are not aware of any data on the outcomes of endtoend regional rural training of other allied health and nursing professions therefore the aim of this study was to describe the rural workforce outcomes for nursing allied health and dental students who undertook endtoend training in regional and rural victoria noting the potential inclusion of a metropolitanbased placement for speciality practice not available in rural or regional victoria method sample data collection and analysis the la trobe university human research ethics committee confirmed this evaluation did not require research ethics approval therefore we extracted a list of students in health disciplines that required registration with the australian health practitioners regulation agency to practice who graduated in dentistry midwifery nursing oral health occupational therapy paramedicine physiotherapy and podiatry from la trobe rural health school as well as pharmacy graduates and those graduating from the regional psychology program all students who graduated between 2015 and 2019 were included using internal administrative databases we extracted the number duration and location of all placements undertaken by the students manual electronic searching of the publicly available ahpra register of practitioners was then undertaken to identify each graduates current recorded place of work this address was then added to the other variables in the database the school attempts to secure all what is already known on the subject • recruitment and retention of health care professionals into rural and regional australia is a persistent challenge • health professionals decision to work in rural settings is influenced by having a rural background and family connections what this study adds • establishes that the more time individuals spend on placement in a metropolitan area the less likely they are to work in regional rural areas • identifies that the locations where students did their placement is a significant predictor of their primary place of practice placements in regional and rural areas however some students complete placements in metropolitan victorian locations due to the low availability of some specialist placement experiences in regional victoria spatial methods as postcodes do not map directly onto the modified monash model and to reduce human error in identifying the appropriate mmm code we used automated geocoding to identity the rurality code for each location the mmm classifications were extracted for each location using a spatial join in arcgis the mmm accounts for geographical remoteness using the australian statistical geography standardremoteness areas coupled with town size and road distances the mmm was chosen for describing geographical access due to its contemporary policy relevance 6 statistical analysis data on students place of origin placement location and place of work were coded into 4 categories metropolitan regional rural or remote based on the four categories in the mmm using their placement data we calculated the number of placements and the number of placement days the student completed in a regional rural or remote area and the number of placements and the number of placement days the student completed in a metropolitan area as different programs have different requirements for placement days we then calculated a ratio of rural to metropolitan days to predict place of work after graduation we ran a multiple regression analysis with predictors entered using a forward stepwise method variables entered were years since graduation rurality of origin placement days in rural areas number of placements in rural areas number of placements in metro areas placement days in metro areas and placement rurality index results of the 5506 graduates from the la trobe rural health school 4153 were able to be matched on the ahpra register when stratified using the mmm rural areas accounted for 40 of the graduates place of origin with almost 23 of midwives being from rural areas overall the primary place of practice of graduates was split relatively evenly between metropolitan regional and rural areas notably 56 of graduate midwives 38 of nurses and 35 of our paramedics were working rurally a summary of graduate primary place of practice in relation to students origin shows that the vast majority of students are working in the same geographical classification they came from in addition 16 of metropolitanorigin students are now working in regional and rural areas and 12 of regionalorigin students are working in rural areas however some metropolitan migration was evident with 20 20 and 17 of regional ruraland remoteorigin students respectively now working in metropolitan areas during the 20152019 period 45 of placements were in regional areas and 48 in rural australia rural placements were typically shorter than metropolitan placements accounting for only 44 of placement days multiple regression analysis indicates that where students are from is the strongest predictor of where they end up practicing accounting for 33 of variance the number of years since graduation was a significant predictor of current work location with the more years since graduation the less likely they were to work rurally the locations where students did their placement was also a significant predictor of their primary place of practice the more days individuals spent on placement in a metropolitan area the less likely they are to work in regionalrural areas and the more placements they completed in rural areas the more likely they are to work in regional and rural areas that is on average if a student completes 22 weeks of placement in a metro location they are likely to drop one level in the rurality of their current workplace however years since graduation and placement location added an additional 2 of variance to the prediction of workplace location as nurses made up over 50 of the sample we repeated the analysis separately for nursing and all other disciplines the results for the two groups were ostensibly the same and the same as for the whole sample for nurses two additional variables were significant predictors of work location both relating to the measure of placement location with 29 of variance in workplace location accounted for however the impact of metro placements is higher for nurses on average if a nursing student completes 8 weeks of placement in a metro location they are likely to drop one level in the rurality of their current workplace for the nonnursing students whilst the actual time spent in metropolitan placements was no longer predictive of workplace location the ratio of rural to metro placements was this regression model accounted for 32 variance in workplace location discussion through extracting modified monash model classifications based upon existing university records and linking to ahpra ppp data we were able to identify the origin placement location and place of work of over 4000 graduates of endtoend rural programs for a diverse range of health disciplines this approach addresses the issues of scale and policy relevance identified by walsh et al 78 since its inception la trobe rural health school has trained more than 4000 health professionals two thirds of which are now working in regional rural and remote australia and as such is a major provider of the rural health workforce by applying the mmm these findings have direct policy relevance to the rhmt policy that is focused on areas outside mm1 areas whilst la trobe rural health school regional campuses are largely based in regional cities students undertook just over half of their placements in rural health services furthermore although the strongest determinant of where graduates are now working is where they came from it is important to note that where students did their placements also influenced where they work these results show higher retention in rural workplaces than was reported for dentists completing endtoend training previously 5 and much higher than is seen for the extended rural placement model most commonly advocated 59 this speaks to the need to support regional and rural higher education capacity as essential for training a sustainable rural health workforce victoria has four university departments of rural health along the borders with new south wales there are two more university departments of rural health and another on the south australia victoria border resulting in a competition of securing rural placements for students therefore we suggest that where there is conflict in providing placements priority should be given for students undertaking endtoend programs over students undertaking extended rural placements from metropolitanbased programs however it is also important to note that rural origin and rural study does not eliminate migration about 20 of graduates in this study moved to work in metropolitan health service contexts whilst there was only a 16 migration from metropolitanorigin students thus there is still a net loss to metropolitan areas it is acknowledged that recent internal migration patterns counter the prevailing trend of migration of rural people to metropolitan areas 10 however more qualitative enquiry to understand this migration what influences it and what options we can provide to minimise this is required it could be these are temporary shifts to gain expertise or specialist knowledge not available in regional and rural areasa longitudinal investigation is needed to better understand these dynamics we also only located 75 of our graduates with the remaining graduates unable to be located in the ahpra register this might be due to graduates changing careers changing names and taking career breaks but this is a loss to the system and work needs to be done to understand these factors this points to the need for longitudinal tracking of graduates from rural and metropolitan programs such as work being undertaken in the nahgot study conflict of interest tcs iks ls and mb are all employees of the la trobe university

objective to determine the work location metropolitan regional rural and remote of graduates in nursing allied health and oral health disciplines who complete their professional training endtoend training in a regional or rural area noting the potential inclusion of a metropolitanbased placement for speciality practice not available in rural or regional victoriawe tracked the place of employment from the australian health practitioners regulation agency ahpra of all graduates from a regionalrural tertiary education provider the student home address at enrolment locations where they undertook all placements and their current place of work were described using an objective geographical model of access the modified monash model results seventyfive per cent of 5506 graduates were located in the ahpra database about one third of graduates were working in metropolitan areas 13 in regional cities and 13 in rural areas students origin accounted for 13 of variance in current workplace location the more placement days students completed in regional rural areas was also a significant predictor of working in a regional or rural areaendtoend training in regionalrural areas is an effective approach to retaining a regionalrural workforce student origin is a strong predictor of working rural or regionally as is undertaking placements in rural areas this suggests that priority for rural regional student placements should be given to students in endtoend regional rural programs and students from a regional rural backgroundeducation rural and remote education rural health student placements workforce

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introduction in 2001 the united states department of education passed the no child left behind act in which states and school districts were required to report the progress they were making on closing ethnicracial achievement gaps a focus was placed on closing the whiteblack and whitehispanic achievement gaps in the content areas of reading and mathematics in 2015 a new education policy the every students succeeds act was enacted with mandates of a continued focus on the narrowing of achievement gaps maintained in this new law was state and school district accountability to continue to work toward closing racialethnic achievement gaps despite policies targeted at closing these achievement gaps many researchers have established that the achievement gap is not closing at an appropriate rate in fact researchers have documented how students of color enter school with disparities which continue to be present as children progress through school also mandated in the previously mentioned federal laws were that state education leaders and school practitioners must disaggregate student assessment data to ensure all student groups are mastering the content according to the nations report card only 41 of grade 4 students in the united states were at or above the proficient level on the national assessment of educational progress mathematics assessment within that percentage 70 were asian 52 were white 27 were hispanic and 20 were black these percentages are congruent with previous researchers who established that asian students had the highest test scores followed by white students hispanic students and then black students in mathematics these data are indicative of a 32 gap between white and black students and a 25 gap between white and hispanic students compared to 2009 the whiteblack achievement gap and the whitehispanic achievement gap decreased three and four percentage points respectively over 10 years in grade 8 one third of the students in the united states were at or above proficient on the national assessment of educational progress mathematics assessment of those students 64 were asian 44 were white 20 were hispanic and 14 were black the whiteblack and whitehispanic achievement gaps present for grade 8 students were almost identical to the gaps present for grade 4 students with regard to the state of interest in this study texas achievement gaps by ethnicityrace in reading have been well documented in 2018 harris addressed the presence of ethnicracial differences in the reading performance of texas grade 4 students analyzed in her study were three years of data from the statemandated reading assessment the state of texas assessment of academic readiness reading exam to determine whether ethnicracial differences were present in her study statistically significant ethnicracial achievement gaps were present in reading for all three school years regarding the three reading reporting categories asian students outperformed white hispanic and black students similarly white students outperformed hispanic and black students in all three staar reading reporting categories hispanic students had higher reading test scores than their black peers with respect to passing rates harris also documented that asian students had the highest passing rates on the staar level ii final satisfactory performance standard in reading followed by white students hispanic students and then black students consistent with the national scores previously discussed racialethnic achievement gaps in reading were clearly present on the texas statemandated assessment for grade 4 students mcgown conducted a similar study of texas grade 3 students she analyzed the texas statemandated reading assessment for the same three school years as harris with the difference being that her sample consisted of grade 3 students and the harris study sample were grade 4 students established in the mcgown investigation were the presence of statistically significant ethnicracial differences in reading similar to harris statistically significant differences were present for all four student groups regarding the three staar reading reporting categories asian students outperformed white hispanic and black students similarly white students outperformed hispanic and black students in all staar reading reporting categories hispanic students had higher reading test scores than their black peers with respect to passing rates mcgown also determined that asian students had the highest passing rates on the staar level ii final satisfactory performance standard in reading followed by white students hispanic students and then black students consistent with the national scores previously discussed and with the harris investigation on grade 4 students racialethnic achievement gaps in reading were clearly present on the texas statemandated assessment for grade 3 students in another study conducted in texas schleeter addressed differences in reading achievement by the ethnicityrace of grade 3 english language learners analyzed in his study were the same three school years of data as harris and mcgown from the texas statemandated reading assessment similar to harris and mcgown statistically significant differences were present for all four student groups regarding all three school years asian english language learners outperformed white english language learners followed by black english language learners and then hispanic english language learners as of this investigation only one published article was located in which performance on the texas statemandated assessment in mathematics was addressed in that article davenport and slate analyzed the degree to which differences were present in the staar mathematics performance of texas grade 3 students by their economic status at the approaches grade level meets grade level and masters grade level performance standards grade 3 students who were not poor had the highest passing rates on the approaches grade level performance level followed by the moderately poor group and then by grade 3 students who were extremely poor a clear stairstep effect was present at the approaches grade level performance level similarly at the meets grade level performance level grade 3 students who were not poor had the highest passing rates followed by the moderately poor group and then by grade 3 students who were extremely poor finally for the masters grade level performance level grade 3 students who were not poor had the highest passing rates followed by the moderately poor group and then by grade 3 students who were extremely poor thus at all three indicators of mathematics performance a stairstep effect was present with respect to economic status the highest passing rates were consistently present for students who were not in poverty the next best passing rates were present for students who were eligible for the reducedprice lunch program and the lowest passing rates were present for students who were eligible for the free lunch program in a comprehensive analysis of the previous texas statemandated assessment the texas assessment of knowledge and skills alfordstephens analyzed the mathematics performance of texas high school boys by their ethnicityrace she analyzed data from the 20042005 through the 20112012 school years in her multiyear statewide analyses she documented the presence of statistically significant ethnicracial differences in mathematics performance in each of the eight school years examined throughout the 8year time period asian boys had the highest met standard percentage followed by white boys white boys had a higher met standard percentage than hispanic boys and black boys for all eight years analyzed black boys had the lowest met standard percentage a stairstep effect was present with respect to ethnicityrace at the met standard proficiency level these findings were consistent with previous literature of ethnicracial achievement gaps in mathematics statement of the problem since the united states supreme court decision in brown vs the board of education of topeka education has been viewed as a way for all individuals regardless of their background to succeed in life however researchers have established achievement gaps based on ethnicityrace are still present although some researchers have discussed how gains have been made that have resulted in slight decreases in the gaps from 1998 to 2010 reardon and galindo reported the gaps in achievement between white and hispanic students were narrowing at a faster pace than the gaps between white and black students documented in the 2019 nations report card was a mathematics achievement gap of 32 percentage points between white and black students in grade 4 and a 24 percentage point gap between white and hispanic students in grade 4 the state of texas gives school campuses and school districts accountability scores on their closing of achievement gaps between the subpopulations they serve researchers have established the presence of achievement gaps in texas which are consistent with national research on ethnicracial achievement gaps in that asian and white students are achieving at a higher level than their peers who are black and hispanic in the area of reading an extensive search of the extant research literature however revealed the presence of only one published article on the mathematics performance of texas students purpose of the study the purpose of this study was to determine the degree to which ethnicityrace of texas grade 3 students is related to their mathematics performance specifically addressed herein was the degree to which differences were present by the ethnicityrace of texas grade 3 students on the staar mathematics reporting categories also examined was the extent to which ethnicracial differences existed in the percentages of texas grade 3 students achieving at the three performance levels the final purpose of this study was to determine if any trends were present in the reporting categories and performance levels across three school years by the ethnicityrace of texas grade 3 students significance of the study prior researchers have documented the presence of statistically significant differences in the reading performance of texas students on the statemandated assessment over a 3year time period alfordstephens established ethnicracial differences in the mathematics performance of texas students on the previously used statemandated assessment over an 8year time period currently the published research literature regarding the mathematics performance of texas students by ethnicityrace on the current statemandated assessment is minimal findings from this study can increase the literature on this topic in addition policymakers and practitioners can use these findings to understand how students from different ethnicracial backgrounds learn and understand different mathematical concepts research questions in this study the following overarching research question was addressed what is the difference in mathematics performance by the ethnicityrace of texas grade 3 students specific subquestions under this overarching research the first seven research subquestions were addressed for three school years whereas the last research question involved a comparison of results across all three school years method research design for this study the research design was a quantitative nonexperimental causal comparative because the independent variables and dependent variables had already taken place a causal comparative design was used to find relationships between independent and dependent variables in this study the mathematics achievement of grade 3 students in texas was analyzed to determine the extent to which ethnicracial differences might be present the independent variable in this study is the ethnicityrace of grade 3 students in texas the dependent variables in this study were the staar mathematics reporting categories and the three staar mathematics performance levels for grade 3 students in texas participants and instrumentation participants in this study were grade 3 students in texas who had taken the staar mathematics assessment during the 20162017 20172018 and 20182019 ethical considerations only archival preexisting data were analyzed in this multiyear investigation the texas education agency that provided the data to the authors of this study first deidentified all student data so that no students could be identified accordingly no ethical risks or harm was possible from conducting this investigation results prior to conducting multivariate analysis of variance statistical procedures its underlying assumptions were checked specifically examined were data normality boxs test of equality of covariance and the levenes test of equality of error variance although a majority of these assumptions were not met the robustness of the manova procedure made it appropriate to use in this study results of statistical analyses by the ethnicityrace of grade 3 students in texas who took the staar mathematics assessment will be described by mathematics reporting category in chronological order for the 20162017 20172018 and 20182019 school years overall results across all three school years with respect to the 20162017 school year the manova revealed a statistically significant difference in overall mathematics performance by the ethnicityrace of texas grade 3 students wilks λ 90 p 001 partial η 2 04 small effect size regarding the 20172018 school year the manova yielded a statistically significant difference wilks λ 88 p 001 partial η 2 04 in overall mathematics performance as a function of student ethnicityrace according to cohen the effect size for this statistically significant difference was small concerning the 20182019 school year a statistically significant difference was again present in overall mathematics performance wilks λ 87 p 001 partial η 2 04 using cohens criteria the effect size was small in all three school years effect sizes were small for the statistically significant differences in overall mathematics performance of texas grade 3 students by their ethnicityrace mathematics reporting category 1 results across all three school years following the overall results of the manova univariate followup analysis of variance procedures were calculated to determine whether statistically significant differences were present in staar mathematics reporting category 1 scores by student ethnicityrace for all three school years concerning the 20162017 school year a statistically significant difference was yielded on the staar mathematics reporting category 1 by ethnicityrace f 666225 p 001 partial η 2 09 moderate effect size for the 20172018 school year a statistically significant difference was present on the staar mathematics reporting category 1 by ethnicityrace f 516669 p 001 partial η 2 08 moderate effect size with respect to the 20182019 school year a statistically significant difference was again revealed on the staar mathematics reporting category 1 by ethnicityrace f 594650 p 001 partial η 2 10 moderate effect size on the staar mathematics reporting category 1 the effect sizes for the statistically significant differences on the staar mathematics reporting category 1 by ethnicityrace were moderate for all three school years to determine which ethnicracial pairings were statistically significantly different scheffe post hoc procedures were conducted statistically significant differences on the staar mathematics reporting category 1 were revealed for all of the ethnicracial comparisons with respect to the 20162017 school year asian students answered 072 more items correctly than white students 168 more items correctly than hispanic students and 231 more items correctly than black students similarly white students answered 096 more items correctly than hispanic students and 159 more items correctly than black students hispanic students answered 063 more items correctly on average than black students black students were the lowest performing group on the staar mathematics reporting category 1 for the 20162017 school year for the 20172018 school year asian students answered 060 more items correctly than white students 142 more items correctly than hispanic students and 211 more items correctly than black students similarly white students answered 082 more items correctly than hispanic students and 151 more items correctly than black students hispanic students answered 068 more items correctly than black students again black students were the lowest performing group on the staar mathematics reporting category 1 for the 20172018 school year concerning the 20182019 school year asian students answered 070 more items correctly than white students 160 more items correctly than hispanic students and 215 more items correctly than black students similarly white students answered 090 more items correctly than hispanic students and 145 more items correctly than black students hispanic students answered 055 more items correctly than black students black students were again the lowest performing group on the staar mathematics reporting category 1 for the 20182019 school year for staar mathematics reporting category 1 a clear stairstep effect was present for all three school years in all three school years asian students outperformed white hispanic and black students white students outperformed hispanic and black students and hispanic students outperformed black students black students had the poorest mathematics scores in all three school years descriptive statistics for these analyses are contained in table 1 mathematics reporting category 2 results across all three school years concerning the 20162017 school year a statistically significant difference was yielded on the staar mathematics reporting category 2 by ethnicityrace f 619578 p 001 partial η 2 08 moderate effect size for the 20172018 school year a statistically significant difference was present on the staar mathematics reporting category 2 by ethnicityrace f 671464 p 001 partial η 2 10 moderate effect size with respect to the 20182019 school year a statistically significant difference was again revealed on the staar mathematics reporting category 2 by ethnicityrace f 680115 p 001 partial η 2 11 moderate effect size on the staar mathematics reporting category 2 effect sizes were moderate for all three school years following the three followup anova procedures scheffe post hoc procedures were for staar mathematics reporting category 2 a clear stairstep effect was present for all three school years in all three school years asian students outperformed white hispanic and black students white students outperformed hispanic and black students and hispanic students outperformed black students black students had the poorest mathematics scores in all three school years descriptive statistics for these analyses are contained in table 2 conducted mathematics reporting category 3 results across all three school years concerning the 20162017 school year a statistically significant difference was yielded on the staar mathematics reporting category 3 by ethnicityrace f 589483 p 001 partial η 2 08 moderate effect size for the 20172018 school year a statistically significant difference was present on the staar mathematics reporting category 3 by ethnicityrace f 503075 p 001 partial η 2 08 moderate effect size with respect to the 20182019 school year a statistically significant difference was again revealed on the staar mathematics reporting category 3 by ethnicityrace f 489795 p 001 partial η 2 08 moderate effect size on the staar mathematics reporting category 3 effect sizes were moderate for all three school years next scheffe post hoc procedures revealed the presence of statistically significant for the staar mathematics reporting category 3 a clear stairstep effect was present for all three school years in all three school years asian students outperformed white hispanic and black students white students outperformed hispanic and black students and hispanic students outperformed black students black students had the poorest mathematics scores in all three school years descriptive statistics for these analyses are contained in table 3 differences mathematics reporting category 4 results across all three school years concerning the 20162017 school year a statistically significant difference was yielded on the staar mathematics reporting category 4 by ethnicityrace f 405893 p 001 partial η 2 05 small effect size for the 20172018 school year a statistically significant difference was present on the staar mathematics reporting category 4 by ethnicityrace f 321155 p 001 partial η 2 05 small effect size with respect to the 20182019 school year a statistically significant difference was again revealed on the staar mathematics reporting category 4 by ethnicityrace f 253516 p 001 partial η 2 04 small effect size on the staar mathematics reporting category 4 effect sizes were small for all three school years scheffe post hoc procedures were next conducted and revealed the presence of statistically significant differences on the staar with respect to the staar mathematics reporting category 4 a clear stairstep effect was present for all three school years in all three school years asian students outperformed white hispanic and black students white students outperformed hispanic and black students and hispanic students outperformed black students black students had the poorest mathematics scores in all three school years table 4 contains the descriptive statistics for these analyses results for the staar mathematics approaches grade level standard across all three school years student performance on the staar mathematics approaches grade level standard was examined next through the use of pearson chisquare procedures this statistical procedure was the optimal statistical procedure to use because dichotomous data were present for the staar mathematics approaches grade level standard and categorical data were present for ethnicityrace as such the pearson chisquare is the preferred statistical procedure when both variables are categorical because a large sample size was present the assumptions for using a chisquare were met with respect to the staar mathematics approaches grade level standard by the ethnicityrace of grade 3 students the result for the 20162017 school year was statistically significant χ 2 1168395 p 001 small effect size cramers v of 24 statistically significantly higher percentages of asian students met the staar mathematics approaches grade level standard than white hispanic and black students asian students had 65 more students who met the staar mathematics approaches grade level standard than white students 211 more than hispanic students and 349 more than black students white students had 146 more students who met this standard than hispanic students and 286 more than black students hispanic students had 14 more students who met this standard than black students black students had the lowest percentages who met the approaches grade level standard for the 20162017 school year table 5 contains the frequencies and percentages for this school year concerning the 20172018 school year a statistically significant difference was revealed χ 2 960503 p 001 small effect size cramers v of 23 as delineated in table 5 asian students had 53 more students who met the staar mathematics approaches grade level standard than white students 187 more than hispanic students and 32 more than black students white students had 134 more students who met this standard than hispanic students and 267 more than black students hispanic students had 133 more students who met this standard than black students regarding the 20182019 school year the result was statistically significant χ 2 965793 p 001 small effect size cramers v of 24 as presented in table 5 asian students had 47 more students who met the staar mathematics approaches grade level standard than white students 181 more than hispanic students and 317 more than black students white students had 134 more students who met this standard than hispanic students and 27 more than black students hispanic students had 136 more students who met this standard than black students with respect to the staar mathematics approaches grade level standard a clear stairstep effect was present for all three school years in all three school years asian students were the highest performing group to meet the approaches grade level standard followed by white hispanic and black students white students had the second highest percentage of students who met this performance standard followed by hispanic students in all three school years black students had the lowest percentage of students who met this mathematics performance standard results for the staar mathematics meets grade level standard across all three school years with respect to the staar mathematics meets grade level standard by the ethnicityrace of grade 3 students the result for the 20162017 school year was statistically significant χ 2 167285695 p 001 small effect size cramers v of 28 as regarding the 20182019 school year the result was statistically significant χ 2 1584813 p 001 moderate effect size cramers v of 31 as presented in with respect to the staar mathematics meets grade level standard a clear stairstep effect was present for all three school years in all three school years asian students were the highest performing group to meet the meets grade level standard followed by white hispanic and black students white students had the second highest percentage of students who met this performance standard followed by hispanic students in all three school years black students had the lowest percentage of students who met this mathematics performance standard statistically delineated in results for the staar mathematics masters grade level standard across all three school years with respect to the staar mathematics masters grade level standard by the ethnicityrace of grade 3 students the result for the 20162017 school year was statistically significant χ 2 1520524 p 001 small effect size cramers v of 27 as hispanic students had 8 more students who met this standard than black students statistically delineated in regarding the 20182019 school year the result was statistically significant χ 2 1538309 p 001 moderate effect size cramers v of 30 as presented in with respect to the staar mathematics masters grade level standard a clear stairstep effect was present for all three school years in all three school years asian students were the highest performing group to meet the masters grade level standard followed by white hispanic and black students white students had the second highest percentage of students who met this performance standard followed by hispanic students in all three school years black students had the lowest percentage of students who met this mathematics performance standard trends in mathematics performance by student ethnicityrace in analyzing the mathematics achievement of grade 3 students in texas across the three years of data that were examined trends in scores were present by ethnicityrace in each staar mathematics reporting category and in all three years investigated a clear stairstep effect was observed in all instances asian students had the highest mathematics achievement followed by white students then hispanic students and finally black students concerning the staar mathematics performance level standards the same stairstep effect was present statistically significantly higher percentages of asian students met each of the three staar mathematics performance level standards followed by white students then hispanic students and finally by black students these trends are revealed in figures 1 through 7 connections to existing literature as revealed in this study ethnicracial differences were present in the mathematics achievement of grade 3 students these findings were congruent with the results of other researchers who established the presence of ethnicracial achievement gaps being present for students in texas their investigations as well as the findings discussed in this article provide evidence for a clear stairstep effect in student mathematics achievement asian students consistently outperformed white students hispanic students and black students in addition results are commensurate with national research of substantial ethnicracial academic gaps the nations report card revealed a similar clear stairstep effect as this study with asian students having the best performance followed by white students hispanic students and black students implications for policy and for practice based upon the results discussed herein several implications for policy and practice can be recommended black and hispanic students continue to be outperformed by asian and white students in mathematics achievement first with respect to policy funds should be provided to districts and schools who have a high population of black and hispanic conclusion the purpose of this research study was to determine the extent to which differences were present in the mathematics achievement of texas grade 3 students as a function of their ethnicityrace analysis of three school years of texas statewide data yielded statistically significant differences in the mathematics achievement by ethnicityrace in all three school years a stairstep effect was clearly present asian students consistently outperformed white hispanic and black students in all four staar mathematic reporting categories as well as all three staar mathematics performance level standards white students outperformed hispanic and black students black students were consistently the lowest performing ethnicracial group findings were consistent with prior researchers author statements on ethics and conflict of interest ethics statement we hereby declare that researchpublication ethics and citing principles have been considered in all the stages of the study we take full responsibility for the content of the paper in case of dispute statement of interest we have no conflict of interest to declare

in all three years analyzed statistically significant differences were revealed in overall mathematics achievement and in all four mathematics reporting categories inferential statistical analyses revealed a clear stairstep effect asian students were the highest performing ethnicracial group in all four mathematics reporting categories and all three performance level standards followed by white hispanic and black students suggestions for future research and implications for policy and practice were provided

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introduction regular physical activity is vital for childrens physical and psychological health 1 on the other hand sedentary behaviours particularly some screenbased are associated with unfavourable body composition metabolic profiles and mental health outcomes 2 considering that children spent most of their time at home even before the pandemic 34 and ecological models posit that behaviour is most likely influenced by the environment in which it occurs 5 the home is an important sphere of influence on childrens pa and sedentary behaviour 67 parents are particularly influential in the home 6 indeed parental pa support and coparticipation are strong correlates of childrens pa 7 8 9 sedentary parents are likely to have sedentary children and parental limits on childrens screentime have been associated with less sedentary behaviour in children 610 the physical environment at home also has an importance influence media equipment availability has been positively associated with sedentary time 7 while musical instruments are negatively related 7 conversely pa equipment is positively associated with pa 1112 and inversely related to sedentary time 611 albeit not at home 711 on march 11 2020 the covid19 outbreak was declared a global pandemic by the world health organisation 13 on march 23 rd 2020 the united kingdom government announced a national lockdown and ordered the entire population to stay at home to mitigate the spread of the virus members of the public were only permitted to leave their homes for food medical supplies and for a short bout of local daily exercise 14 children no longer had access to schoolbased physical activities such as physical education and break time and walking tofrom school team sports leagues and fitness and activity classes such as dance martial arts and gymnastics were also cancelled or postponed such measures profoundly limited childrens opportunities to be physically active and increased sedentary time as a result 1516 in addition the physical distancingisolation measures and resultant stressors may have negative shortand long term mental health consequences including anxiety depression and behavioural problems 17 the combination of inactivity and social distancingisolation measures could have a synergistic effect on childrens lifestyle behaviours and their mental health and wellbeing 18 investigating the impact of the pandemic on childrens pa and sedentary time during covid19 is essential not only to prevent the inactive behaviours from becoming permanent but also to support children as they continue to experience pandemicrelated stressors several studies report that children were less active and engaged in increased screentime at home during covid19 161920 a small number of studies have investigated the correlates of the decline in pa and increase in sedentary behaviour 2122 yet few studies have explored environmental correlates 1523 indeed ecological models posit that the environment has an important influence on childrens pa and sedentary behaviour 2425 during covid19 homes became the everything space places for play work school eating and socialising which led to significant changes in daily life at home for children and their families 2627 we hypothesised that these enforced changes would impact on the physical and social home environment and in turn childrens pa and sedentary behaviour during covid19 to the authors knowledge no study has investigated the activityrelated changes in homes during covid19 and their impact on childrens pa and sedentary behaviour at home further studies using devicebased measures of childrens pa and sedentary behaviour pre and during covid19 are scarce 1523 the ukhomespace study measured childrens pa and sb and environmental factors in the home prior to covid19 728 allowing a unique opportunity to repeat these measures on the same cohort of children during the pandemic the aims of the homespacecovid19 study were to 1 identify changes in the social and physical environment at home and childrens homebased sitting pa standing and sitting breaks in response to the covid19 pandemic and 2 examine the impact of changes at home on childrens homebased sitting pa standing and sitting breaks materials and methods participants and settings two hundred and thirteen children and their parents participated in the homespaceuk project between november 2017 and july 2018 of the 213 children 102 children and their parents agreed to take part in the homespacecovid19 follow up study during the first covid19 lockdown as a thank you for participating families were given a £20 amazon voucher and personalised feedback reports from the follow up study the protocols for the precovid19 and during covid19 studies were approved by the swansea university ethics committee a target sample of 96 participants was set based on crosssectional data from the same sample in which multiple regression generated r 2 values of 021 to 025 for home based sitting standing sitting breaks mvpa and total pa after controlling for covariates 7 using the r package pwr and targeting 80 power and alpha of 005 a sample of size of 87 was required to run a general linear model 29 the target sample size was increased by 10 to account for data attrition physical environment of the home the validated homespaceii instrument 30 was used to assess the home physical environment in relation to childrens pa and sedentary behaviour both precovid19 and during the first covid19 lockdown parents were asked to walk around their house and garden and complete an audit of the presence amount and accessibility of 41 media musical pa and seated furniture items for each area of the house and garden for each item accessibility was rated on a scale of put away and difficult to get to to in plain view and easy to get to in addition there were questions relating to electronic media and equipment that could not be captured in the audit the number of individual items were summed for pa equipment musical instruments media equipment and seated furniture lastly summary scores were created for each item category by multiplying each item by their accessibility score the higher the summary score the greater overall presence the item has in the home all items used in this study have strong testretest reliability 3132 and criterion validity 30 homebased pa sitting and sitting breaks before and during the first covid19 lockdown total and moderatevigorous physical activity and postural behaviours were assessed with the actigraph gt9x and the activpal3 micro accelerometers respectively precovid19 monitors were fitted at schools to ensure correct attachment this was not feasible during lockdown because most children were not attending school at the time of data collection instead the monitors were delivered to families homes with instructions on correct attachment children were asked to wear the monitors continuously for seven consecutive days precovid19 and eight consecutive days during the first lockdown to allow for possible delays in attaching the monitors parents completed a diary recording when the child was at home 7 asleep illness days and periods when the device was removed the activpal has previously been validated in children 33 briefly activpal data were downloaded using the manufacturer software and the subsequent eventcsv files were processed in palv11 with a validated algorithm that identified waking hours prolonged nonwear time and invalid data 3435 diaryreported nonwear periods deemed plausible were removed additionally sittinglying or standing bouts lasting ≥ 3 h with no transitions were also classified as nonwear and removed 36 the actigraph gt9x was placed on the childs nondominant wrist 37 the device data was collected at a 30 hz sampling rate 38 and summed over 5s epochs files were initialised downloaded and processed using actigraph software wristworn vectormagnitude cutpoints 39 were utilised whereby tpa and mvpa were categorised as ≥ 306 and ≥ 818 counts5 secs respectively an algorithm was used to identify nonwear time 40 parentreported time at home imported into the actilife v6133 and processing pal software were paired with timestamped data allowing time spent in pa and postural behaviours at home to be estimated respectively to be included in the analyses children needed at least 3 days with ≥ 3 h of data at home when the device was worn for ≥ 75 of the time 41 minutes in total physical activity and mvpa and postural behaviours were divided by wear time at home and multiplied by 60 constituting the dependent variables as averageshr 42 a more detailed explanation of the activity monitoring protocol and data processing techniques can be found elsewhere 7 childrens demographic and anthropometric measures precovid19 children had their stature and body mass measured by trained researchers at their respective schools using a portable stadiometer and electronic weighing scales respectively using standardised procedures 43 during the first lockdown this protocol was not feasible due to social distancing measures therefore parents were given directions on measuring stature and body mass using a tape measure and standard bathroom scales respectively 43 indeed parentreport reported height and weight has reasonable validity when compared with objective measurements 4445 body mass index zscores were calculated using world health organisation growth reference data 46 additional measures parents reported their childs age sex whether they owned or rented their home education status family situation annual household income before tax home postcode whether they owned a dog and the number of children living at home season of measurement included spring summer autumn and winter were also recorded the welsh index of multiple deprivation calculated from postcodes was used as an indicator of socioeconomic status 47 the wimd scores take into account eight domains of area deprivation employment health income housing community safety access to services education the environment for descriptive purposes ses was stratified into tertiles according to wimd scores low medium and high family social and individual factors items from the homespacei instrument were used to assess parental and child perceptions preferences and priorities within the home space 48 all items in the present study have been shown to exhibit at least acceptable reliability 31 and internal consistency 4948 the following social and individual factors were assessed importance of childrens activity at home importance of home features and equipment child and parent activity preferences at home and child social preferences parents perceptions of space for play safety and connection between areas and the presence of rules relating to outdoor safety media and indoor play at home were also assessed these items are described in full elsewhere 48 the outdoor safety rules score summed yes responses on three rules stay closewithin sight of houseparent do not go into street do not ride bike on street 50 the media rules score summed yes responses on three rules no screenuse before homework a maximum number of hours per day of screenuse and no screenuse at the dinner table 51 lastly the indoor rules score summed yes responses on two rules no running in the house and no ball games in the house 5253 factors relating to home life during covid19 six questions were included to capture factors created by the pandemic firstly parents were asked if the child children taking part in this study were attending school no they are at home yes most days of the week yes sometimes and yes but a different school parents were also asked if their children were being home schooled and how the day was structured around homeschooling the parents completing the questions were also asked if they were working from home whether both parents were at home and if the other parent was at home whether they were working from home 5 categories ranging from yes a full day every day to not at all see instruments provided as supplementary files statistical analysis complete activpal actigraph physical and social environment data were received at both time points for 88 90 101 and 102 children respectively cases with missing data were deleted listwise the data are presented as means and standard deviations or absolute and relative prevalence for categorial variables unless stated otherwise differences in key baseline characteristics between families that only participated precovid19 and those who participated both precovid19 and during covid19 were explored by independent ttest or chisquare test categorial variables for families that participated precovid19 and during covid19 the average change from baseline to follow up was also calculated differences in home environment parameters at baseline and follow up were evaluated using wilcoxon signed rank test paired ttest or chisquare to examine the associations between changes in the five homebased behavioural outcomes and the home environment change scores between precovid19 and during the first lockdown were calculated for both the predictor and dependent variables that showed significant change repeated linear regression analyses were conducted in r version 402 using the stats and lmtest packages the unadjusted associations between the change in each physical and social environment variable and variables capturing the family situation during the first lockdown and the five homebased outcomes were examined using linear regression model 2 adjusted for the following predetermined covariates age sex and bmi zscore of the child home ownership raw wimd scores season the number of siblings at home dog ownership and family situation a final statistical model was run for each of the five outcomes including all significant variables from model 2 and adjustment variables to determine independent associations between change in the physical and social environment factors and the child homebased outcomes the significant results from this final model are presented in table 3 the results from model 1 and 2 and nonsignificant results from the final model are in supplementary material online the summary scores for each type of home feature priorities m parent perceived importance of the indoor living space at home 3 24 23 014 equipment were strongly correlated the total number of equipment variables were more strongly related to the outcomes on average therefore they were included in the final models 54 results the descriptive statistics for covid19 variables and participants characteristics are presented in tables 4 and5 children had a mean age of 102 ± 07 years and 128 ± 08 years before and during covid19 respectively participating parents were female owned their home had a university degree and lived in the highest ses location during covid19 the two parents were at home during the day with both parent 1 62 and parent 2 working from home at least some of the time in the majority of families additionally most children were not attending school and were homeschooled description of the precovid19 sample table 6 shows the key baseline descriptive characteristics precovid19 of the whole homespace project sample as well as the differences in these baseline characteristics between children that only participated precovid19 and children that participated in both precovid19 and during covid19 children who did not participate during covid19 had higher bmi and spent more time sitting at home at baseline there were no other differences between children who participated during covid19 and those who did not changes in the physical environment the changes in the home physical environment from precovid19 to during covid19 are presented in table 1 households had a significantly larger amount of electronic games smart phones fitness trackers seated furniture electronic media equipment overall and in the primary childs bedroom alternately the number of books and pa equipment decreased and subscriptions to streaming services increased there were no changes in the number of musical instruments or active video games at home changes in the social environment the changes in the home social environment are reported in table 1 parents had implemented more rules relating to indoor play and fewer regarding outdoor safety further parents placed less importance on active play equipment and more importance on electronic media equipment overall at home and in the childs bedroom but fewer enforced a maximum hday screen time rule in contrast childrens preference for physical activities and socialising with other family members at changes to the physical and social environment associated with changes in homebased tpa child preference for pa was positively associated with homebased tpa homebased tpa decreased in children who were attending school in the final model the positive association with child preference for pa and the negative association with attending school remained significant changes to the physical and social environment associated with changes in homebased mvpa child preference for pa was positively associated with homebased mvpa whilst attending school was negatively associated with homebased mvpa in the final model the positive association between mvpa and child preference for pa and the negative association with attending school remained significant changes to the physical and social environment associated with changes in homebased sitting the parent completing the questionnaire working full time at home was positively associated with homebased sitting pa equipment was negatively associated with homebased sitting child preference for pa and child preference for socialising at home were negatively associated with sitting at home the negative associations between child preference for socialising at home and child preference for pa at home remained significant in the final model changes to the physical and social environment associated with changes in homebased sitting breaks the number of media equipment items at home and the perceived importance of active play equipment at home were negatively associated whilst child preference for socialising at home was positively associated with sitting breaks at home only the negative association between the number of media equipment items remained significant in the final model changes to the physical and social environment associated with changes in homebased standing the number of pa equipment child preference for socialising at home child preference for pa and removing a screentime limit were all positively associated with standing at home in the final model the positive association with pa equipment remained discussion the aims of this study were to 1 examine changes in social and physical environmental factors at home and childrens homebased behavioural outcomes from precovid19 to during the first covid19 lockdown 2 report associations between changes occurring at home and changes in childrens homebased behavioural outcomes as a result of the lockdown this is the first study to explore changes in the home environment and their effects on pa and sitting at home during the covid19 pandemic childrens time at home increased significantly from 46 of waking time to 84 during the first covid19 lockdown demonstrating the increased importance of the home environment to the regulation of movement behaviours during covid19 not surprisingly such significant time at home also led to several changes in the environment and childrens behaviour at home further some changes in the home were also significantly associated with changes in childrens behavioural outcomes childrens pa standing and sitting breaks at home declined during the first covid19 lockdown while sitting increased compared with precovid19 the increase in sitting time is consistent with previous data reporting childrens sedentary time during covid19 1619205556 the increase in sitting time partly reflects children engaging in schoolwork at home due to school closures 57 however one study showed that school related sedentary time only accounted for 90 min of the day during covid19 16 suggesting that the increase in sitting time is more likely explained by greater time spent in sedentary pursuits such as tv viewing and video games as reported by other studies 1619 notably there were also corresponding decreases in mvpa and tpa at home in contrast an increase in homebased pa has been reported in us children during the pandemic 16 although this study did not account for the proportional increase in time spent at home while we found that total pa at home increased because overall time at home increased relatively children spent less time in pa at home during the lockdown restrictions more time spent in inactivity and screentime increases the risk of obesity and poor mental health in children and can also negatively impact on academic performance 158 during the pandemic both the physical and social environments in homes were more conducive to electronic media pursuits the amount of media equipment increased by 10 in the home and by 29 in childrens bedrooms from pre to during the first covid19 lockdown the number of families subscribing to a movietv streaming service increased by 17 and 17 fewer parents enforced a limit on screentime parents also placed more importance on having electronic media equipment at home and in the childs bedroom the changes may in part reflect the increased prevalence of leisure screenbased sedentary pursuits among children and their families 162055 and their families 19 this is partly due to parents working from home and using electronic media equipment to keep their children entertained while they engaged in work tasks 59 the greater accessibility of screenbased media during the pandemic 19 and its reinforcing nature 60 may also have had an impact consistent with the behavioural change theory that accessibility and reinforcing value influence the choice to engage in types of behaviour and activities 61 although some families may have used remote and streaming services to engage in pa which would have contributed to increased screen usage in a sample of american children aged 913 only 169 and 129 participated in team sports and activity classes or lessons remotely respectively 16 nevertheless the changes are concerning given screentime particularly tv viewing is associated with unfavourable body composition metabolic profiles lower fitness and poor mental health outcomes in children 2 and adults 62 in support of this the increase in household media equipment was associated with a decrease in childrens sitting breaks a greater amount of media equipment available for use at home may keep children entertained for longer resulting in more prolonged periods of sitting and fewer sitting breaks this is a significant problem given sedentary time of a prolonged nature is associated with less favourable body composition and metabolic profiles in children 58 whilst all other changes in the electronic media environment were not associated with behavioural outcomes the observed changes may result in children adopting new behavioural habits of such high sedentary and screen time and low levels of pa and sit to stand transitions that may be difficult to change when covid19 restrictions are lifted home environments became less supportive of pa during the first lockdown whereby the amount of pa equipment at home and the importance parents placed on it decreased children spent 79 of their time at home and the lack of outdoor space 63 resulted in children spending much of this time indoors 64 from a social family climate perspective parents view indoors as space for sedentary activities such as electronic media use and reading 65 reflected in the increase in the number of rules relating to indoor play in this study therefore the decrease in pa equipment and the importance placed on it may be indicative of parents restricting its use on the other hand it could also be attributed to families spending more time in sedentary behaviours and less in pa during the first lockdown 19 the decrease in pa equipment at home was also negatively associated with homebased standing during the first period of covid19 restrictions the reason why the decrease in pa equipment did not affect tpa or mvpa may be explained by a lack of space in most uk homes limiting childrens opportunities to be active while at home 63 active video games throwing a ball back and forth table tennis and trampolining are activities that require pa equipment can feasibly occur in most homes and are usually performed standing 66 physical activity equipment at home has the potential to not only reduce sitting by increasing ambulatory movement but it also serves to interrupt prolonged bouts of sitting given the limited opportunities to engage in mvpa at home purchasing more pa equipment for the home could be a feasible strategy for replacing sitting time with light pa whilst there are cost implications to purchasing pa equipment the weak association between ownership of pa equipment and income reported in other studies 6768 suggests it is not a major barrier childrens preference for being active at home decreased during the first covid19 lockdown compared with the period prior to the pandemic childrens preference for being physically active at home was also strongly positively associated with homebased tpa and mvpa and negatively associated with sitting these findings are in line with research that has shown a preference for being sedentary or physically active to be a strong predictor of childrens pa 552 and screenuse 69 interestingly childrens preference for interacting with other family members also decreased in the first lockdown during lockdown any conflicts between families members would have been exacerbated by reduced personal and social space 70 particularly in crowded households 71 childrens desire to socialise with family members was also negatively associated with sitting at home as a result of this social preference children may have spent more time alone in their bedrooms which is associated with greater screenbased sedentary time 7273 in addition during a time when physical contact with friends was limited increased time spent in bedrooms away from family members may result in heightened feelings of loneliness and depression 74 although some children used social media and online gaming to keep in touch with friends during the pandemic 75 over use of these can be harmful 76 in particular excessive social media use has been associated with anxiety and loneliness during the pandemic 7778 therefore strategies which encourage children to spend more screenfree time with their families could be important for their mental health and reducing their screenuse post covid19 79 the home situation during the covid19 restrictions has an important influence on childrens pa and sedentary time 80 in this study whether or not the child attended school was a strong predictor of behaviour which is in line with the structured day hypothesis and recognises the importance of the structure of the school day and how this regulates health behaviours such as pa and sedentary behaviour 81 specifically tpa and mvpa had the largest decrease in the group of children who attended school sometimes compared to the group who did not attend at all for many families home schooling provided more flexible days allowing more time for pa 80 due to increased opportunities to be active children who were homeschooled may have been more physically active at home compared to those who attended school another possible explanation for this finding is that children returning to school coincided with the end of sportsactivity class 82 children who engaged in sports once or more a week prior to the pandemic may have been doing this at home during the peak of lockdown but outside the home as restrictions eased 16 whilst increased access to organised sport and activity classes could have led to a net increase in overall pa the decreased pa at home remained a concern given pa would have been displaced with less desirable sedentary behaviours at home 58 methodological strengths of this study include the comprehensive nature of the homespacei and ii instruments used to capture the social and physical environments at home the repeated measures study design and the use of devicebased measures of sitting and pa as well as the homebased measure of behaviour moreover a large number of confounding factors were controlled for in the models which explained between 51 and 59 of the variance in the homebased behavioural outcomes albeit baseline values accounted for a significant proportion of this additionally to our knowledge this is the only study to assess the changes in the home environment as a result of the pandemic and the effects on childrens pa and sitting at home yet the study is not without limitations firstly from the precovid study sample only 49 participated during the restrictions and these children had lower bmi and spent less time sitting at home at baseline however the extent to which this biased results is unclear families from high ses backgrounds were overrepresented however the proportion of low and medium ses families was higher than most previous studies 4883 the study was also limited by the 2year gap between the assessments children become more sedentary 8485 and less active as they get older 8687 therefore the changes observed in this study may in part be a result of agerelated changes in behavioural habits rather than the restrictions in isolation however declines in mvpa tpa and sitting breaks at home in this study were more pronounced compared with typical changes seen in children between 912 years 8889 whilst the increase in sitting is not as pronounced as increases reported elsewhere 85 a possible explanation for this is that we measured sitting at home whereas others have measured it across the entire day indeed the change in sitting at home during the pandemic may be less pronounced than other behaviours given sitting time at home relative to other locations was already high even before the pandemic 711 the extent to which the 2year gap between measurements influenced results remains unclear however based on comparisons with other studies it is unlikely that the changes in this study are solely attributable to agerelated changes in behavioural habits conclusion the covid19 restrictions necessary to mitigate the spread of the virus required children to spend almost all their time at home during the first lockdown the homespace study provides evidence that childrens pa standing and sitting breaks at home decreased during the first lockdown whilst sitting time increased homes also became less supportive of pa and more conducive to electronic sedentary pursuits these changes also impacted behaviour at home an increase in pa equipment was positively associated with homebased standing and an increase in media equipment was negatively associated with homebased sitting breaks decreased child preference for pa and socialising with family members also impacted behaviour specifically childrens preference for pa was positively associated with tpa and mvpa and negatively associated with sitting lastly child preference for socialising with family members was negatively associated with sitting the findings are concerning given the health benefits of pa 90 and the association between sedentary time particularly screenbased and poor health outcomes 2 to avoid the negative changes in the home and possibility of childrens behaviour becoming habituated public health efforts are needed to reset and promote childrens pa and discourage their sitting at home postlockdown abbreviations additional funding the research was funded by the waterloo foundation grant number 11584281 the funder had no input in the study design the collection analysis or interpretation of the data in the writing of the manuscript or the decision to submit for publication declarations ethical approval and consent to participate the precovid19 and during covid19 studies were approved by the institutional ethics committee written informed consent and assent was obtained from all participants competing interests the authors declare that they have no competing interests

background during the 2020 uk covid19 lockdown restrictions children spent almost all of their time at home which had a significant influence on their physical activity pa and sedentary behaviour this study aimed to 1 determine changes to the social and physical environment at home and childrens homebased sitting pa standing and sitting breaks as a result of the covid19 restrictions and 2 examine associations between changes at home and childrens movement behaviours methods one hundred and two children had their pa and sitting standing and sitting breaks at home objectively measured precovid19 and during the first covid19 lockdown junejuly 2020 childrens parents n 101 completed an audit of their home physical environment and a survey on the home social environment at both time points changes in the home physical and social environment and behavioural outcomes were assessed using wilcoxon signed ranked tests paired ttests or chisquare repeated linear regression analyses examined associations between changes in homes and changes in the homebased behavioural outcomesduring covid19 households increased the amount of seated furniture and electronic media equipment at home the number of books and pa equipment decreased and fewer parents enforced a screentime rule childrens preference for physical activities and socialising at home decreased time at home and sitting at home increased during covid19 whilst pa standing and sitting breaks decreased both mvpa and tpa were positively associated with child preference for pa and negatively associated with attending school sitting was negatively associated with child preference for pa and child preference for socialising at home media equipment was negatively associated with sitting breaks whilst pa equipment was positively associated with standingthe covid19 restrictions forced children to spend almost all their time at home childrens pa standing and sitting breaks at home declined during the restrictions while sitting increased mostly negative changes occurred in homes some of which impacted childrens behaviours at home to avoid the changes persisting postlockdown interventions are needed to reset and promote childrens pa and discourage prolonged sitting time

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introduction the new zealand healthcare system is best classified as a variation on the beveridge model and tends to exhibit outcomes comparable with other developed democracies 1 however despite its universal coverage the new zealand system is consistently tainted by lower health outcomes in the indigenous māori and pacific islander populations 2 the reasons for these inequities are multifactorial and interconnected ranging from racism to socioeconomic disparities to policy 3 4 5 6 1 in response to this problem new zealand implemented a series of reforms designed to equalize outcomes through social policy targeting māori populations beginning in the early 1990s 7 however the process of reducing inequities has not been a universally successful story this is particularly evident in the development of policy addressing infant mortality disparities between nonmāori and māori populations new zealand initially established measures designed to address a nationwide problem of high infant mortality and subsequently adjusted this policy to directly target māori inequity as a result outcomes became considerably more equitable as such the sequence of infant mortality policies in new zealand provides a remarkable case study for understanding important components of successful inequityreduction specifically the recent reforms highlight the importance of considering the different strains of risk associated with disadvantaged populations these differential risks include variations in culture susceptibility to outreach extraneous factors which indirectly contribute to outcomes such as socioeconomic status and racism the underlying causes of health problems and the degree to which risks affect communities new zealand targeted these differential risks through equityfocused policy representative outreach team leaders targeted safety messages and culturally sensitive recommendations by disproportionately focusing on the more disadvantaged māori population these policies reflected a proportionate universalism approach to equity where services were allocated at a scale and intensity proportionate to the degree of need 8 in making significant efforts to anticipate and address these differential social risks inequityreduction policy is better able to successfully target disadvantaged communities like the māori subsequently decreasing inequities in health outcomes these efforts tend to generate greater inclusion of disadvantaged groups in making and delivering policy as well as changing public health strategies to fit the unique circumstances of these groups while the disparities of new zealand healthcare have not been 1 racism towards māori peoples is now thought to directly hurt the delivery of healthcare and outcomes 34 for example there is data to show māori may be prescribed lifestyle changes over prescriptions at a higher rate than their nonmāori counterparts according to a pharmac report published in 2019 with the underlying assumption that māori are in poor health because of poor choices 5 other determinants of health in nz which have been studied include socioeconomic environmentalgeographical behavioral historical access representation in health sectors and quality variation factors 46 similar to australia and other nations with a history of british colonization new zealand exhibits patterns of indigenous population disenfranchisement which have carried forward to the present day 6 2 amenable mortality is an important measure for inequity among populations and is defined in the wai 2575 māori health trends report as deaths below the age of 75 which could have potentially been avoided with effective and timely healthcare 10 3 according to stats nz pacific islander life expectancies were similar to māori rates male life expectancy was 787 years for females and 745 years for males in 20122014 11 eliminated there are still valuable lessons to be taken from the countrys efforts to correct infant mortality inequities between māori and nonmāori populations defining the problem in virtually every measurable health outcome māori and pacific islander populations score significantly lower than their nonmāori nonpacific counterparts 9 10 commonly macrolevel statistics are used to demonstrate this inequity these major measures of country health are testament to the health inequity problem new zealand currently has over the past three decades there has been a major push from the new zealand government to openly acknowledge these inequities and address them through governmental strategies plans and policy notably there have been three major reforms since the 1990s which together have acknowledged the inequities publicly committed to collecting data in this area reallocated funding to favor more disadvantaged areas containing higher māori populations and provided public commitments and goals for eliminating these inequities through carefullycrafted policy 1213 45 however despite these substantial efforts benefits have only improved māori health inequities in certain sectors of healthcare while notably failing in others additionally even amongst the improved sectors health outcomes are rarely equable 10 infant mortality a tale of three policies infant mortality provides one example where social policy shifts have somewhat improved health disparities as māori outcomes have improved at a faster rate than their nonmāori counterparts since 1996 importantly within the larger infant mortality criteria there are two major subcategories of interest sudden unexpected death in infancy and sudden infant death syndrome mortality sids is more commonly known as cot death while sudi is comprised of sids plus fatal sleep accidents our analysis of infant mortality primarily looks at these two measures the risk factors of sids and sudi which include smoking bedsharing and not breastfeeding are largely social and occur in the home because the policies we look at mostly address these risk factors a majority of the infant mortality data and trends are due to changes in sids and sudi as opposed to hospitalrelated infant mortality before analyzing this data it is important to understand the unique nature of the issue as well as the historical context unlike most social policy analyses in healthcare this issue is largely separated from the health institutions of new zealand this is because the risk factors of infant mortality such as bedsharing and smoking are primarily related to the home hence access to new zealands largely public health service has less of a role in the inequitable rates of infant mortality between māori and nonmāori populations this means that policy reforms need to focus less on treatment funding and more on outreach in other words infant mortality reform can be thought of as both educational and social policy in addition to classical health policy which is more focused on institutions and access the first reform the ministry of health national sids prevention campaign of 1991 new zealands infant mortality problem can be understood by looking at the historical progression of three major social policies implemented since the 1980s during this initial time period it became apparent that no statistically significant difference between māori and nonmāori is indicated by the label values are derived from the new zealand ministry of healths wai health trends report 2019 which has the most recent publicly available data as of 2019 10 infant mortality rates were drastically higher for new zealand than other comparable western democracies 7 this eventually prompted the ministry of health national sids prevention campaign of 1991 a prevention program which sought to address the major risk factors of sids a subsector of infant 6 these risk factors included facedownprone sleeping bedsharing and not breastfeeding however while this first reform movement saw nonmāori sids rates decrease substantially the māori sids rates were virtually unchanged in this respect the inequities were widened 7 7 the primary reason this first reform failed to redress infant mortality inequities was that the educational outreach targeting the three primary risk factors were heavily biased to be more favorably received by nonmāori audiences there are several aspects to this firstly māori were not adequately represented nor involved in the prevention campaign consequently messages were less likely to be listened to by the māori while there was an increase in māori turning their children on their back to sleep 14 which is likely the primary cause for the small decline in sids in māori populations māori rates of smoking and not breastfeeding the other main risk factors for sids did not decline to the same degree 7 while this result can be interpreted in the context of differences in socioeconomic status it is also possible that these risk factors remained as a product of māori receiving the information in culturally insensitive ways this second interpretation is consistent with research that shows a positive racial bias towards ones own race when internalizing messages for example in davis and highs research on racial gaps in 2019 it was found that certain groups perceive higher support when acquiring it from members of their own race 15 secondly the messages being put out by the program were culturally and contextually insensitive for example the risks associated with infantparent bedsharing and unsafe blanket use were targeted through antibedsharing and antiblanket messages both of which are highly valued in māori culture and consequently were not well received by māori groups 16 this resentment was furthered as a result of messages being delivered primarily by nonmāori workers thirdly the antismoking campaign was largely unsuccessful while the absolute decline in smoking was similar for both māori and nonmāori the higher smoking prevalence in māori meant that inequities actually increased 17 it is likely the combination of nicotine addictions being incredibly hard to overcome the lack of māori involvement and the overrepresented lower socioeconomic factors associated with higher smoking rates all contributed to this increasing inequity 8 the failure of new zealands first big infant mortality policy to address inequities demonstrated the shortcomings of social policy that does not take into account the distinct features associated with disadvantaged groups in this case there was a lack of māori inclusion and understanding in addition to a lack of effort put into addressing underlying problems such as higher māori smoking addiction which is in part a product of socioeconomic factors rather the program sought to address the problem in a uniform way without recognizing that causes varied by population group consequently while the outcomes improved for the country as a whole the disparity between the māori and nonmāori widened the second reform the māori sids prevention programme this inequity prompted the creation of the second big reform the māori sids prevention programme in 1994 7 this program intentionally set out to address the deficiencies of the prior reform by appointing māori program leaders who could connect with māori on a community level in a highly sensitive manner it then expanded on the basic social policy and outreach of the early 1990s by creating teams which traveled to these communities to provide support this new approach made it possible to address the risk factors that the prior policy had not been able to reach this included a goal of creating smokefree zones for infants which required a culturally sensitive push against a highly valued māori custom of bedsharing 1819 9 on the whole the more culturally sensitive approach is thought to have worked importantly it is difficult to make this claim definitively due to the definition of māori expanding soon after the policys implementation to include any degree of māori ancestry as opposed to the previous criteria of over 50 māori 7 this confounds the observed rates by disproportionately increasing the denominator leading to lower calculated rates however it was still concluded that the policy had done 6 sids as well as other measures of infant mortality all share similar risk factors so looking purely at sids is highly related to the populations overall infant health 7 nonmāori sids rates decreased from 36 deaths1000 to 16 while māori counterparts saw decreases of 74 to 69 as a result of this policy 7 8 there was evidence to suggest that disproportionately lower rates of māori taking up smoking so potentially the campaign would have had a longterm effect here given the easier task of preventing smoking prior to addiction 17 9 the māori bedsharing custom was so popular that a study found that 65 of māori mothers bedshared sometime during the previous night and 21 of māori mothers who smoke in pregnancy always or sometimes slept with their infant europeans on the other hand had 27 bedshare the prior night and 1 of smokers frequently share 1819 well in addressing infant mortality among māori as the rates either dropped or remained stagnant 7 additionally it is thought that stagnation is actually a mark of success because the other socioeconomic risk factors for sids increased during this time period 7 data past the immediate assessments of the policy shows that infant mortality and two subsections of infant mortality decreased at a higher rate among māori from 1996 to 2014 in fact this change was so dramatic that by 20122014 the specific portion of infant mortality this policy targeted no longer had a statistically significant difference between māori and nonmāori while there are some uncertainties around which aspects of the policy were successful the new approach was overall far more effective than the previous one in addressing inequities one area in which it is difficult to tell where the benefits came from is smoking following the policy māori and nonmāori smoking decreased at similar rates which suggests that smoking was not a factor behind the aligning of infant mortality rates however while overall rates had similar trends young māori smoking rates actually decreased at a faster rate than nonmāori 10 thus it is difficult to tell if the benefits which we saw with infant mortality and sidssudi came from other areas of this policy additionally it is possible that even though the overall smoking rates did not decrease for māori at a faster rate the creation of smokefree zones for children might have which could have contributed to the overall decrease in infant mortality inequities this analysis of the second major policy addressing infant mortality is important in that it represents the first major transition from general outcome targets to equityfocused outcome targets where more inclusive contextually appropriate and culturally sensitive methods were able to erase some of the inequities between māori and nonmāori outcomes by comparing this policy with the first one can see the importance of accounting for the different risks factors associated with disadvantaged groups when constructing policy that seeks to close inequity gaps analogously the first policy was like treating two populations with the same general disease using the same antibiotic medicine despite one of the populations carrying strain resistant to this antibiotic the comparison between the two policies demonstrates how different populations require different solutions the third reform wānanga wahakura the third and final social policy implemented by new zealand came as a subset of the second policy and was coined the wānanga wahakura 20 this policy targeted the sidssudi risk factors of bedsharing between infants and smoking mothers which was disproportionately high among māori 1819 data showed that bedsharing had not been declining in māori populations during the implementation of the other two policies this revealed the challenge of reducing both nicotine addictions and the highly valued bedsharing custom within one policy and the need for a new approach 20 rather than asking māori to quit smoking and bedsharing the new policy set out to reduce the risks of such practices in other words the policy shifted from an elimination strategy to riskminimalization the safer sleeping solution came through an infant sleeping basket with a mattress known as a wahakura which could be placed on a couples bed and allow for bedsharing with a degree of separation combined with advice on how to use the product safely this strategy dramatically improved infant safety it also had the added benefit of encouraging parentchild bonding and breastfeeding as the product was familiar and comfortable for the māori populations it was more readily received by them this also encouraged midwives to pass on recommendations regarding infant safety to other mothers and this form of communication was subsequently well received after success in initial trials the māori sids prevention programme began putting money into creating and distributing more of these baskets and this distribution became a major part of social policy targeting infant mortality inequities a problem for the policy in the early stages was that the baskets were difficult to make in the traditional māori fashion it soon became apparent that mass manufacturing and distribution was unsustainable without significant funding this led to the creation and distribution of the pēpipod which was essentially the same thing but cheaper and easier to make this became a popular alternative to the original design especially following the christchurch earthquake of 2011 which incited fears of isolated infant safety this prompted the creation of several other policies and variations of baskets and in this way the benefits of the original wahakura policy were extended among both māori and nonmāori populations while the distribution of the wahakuras and pēpipods initially went to only a little more than 1000 mothers in the opening months this distribution created an environment in which their usage became more mainstream and similar devices were readily available to be purchased cheaply across the country including by nonmāori this shows that there are two ways to view the expansion of benefits past the initial policy on the one hand inequity policy can be thought of as a means to helping the target community through ripple effects which lead to expansion of norms policy and better outcomes as we saw with infant baskets and safety education becoming more popularized on the other hand inequity policy can have secondary effects in other sectors of society as was the case with babybaskets becoming popular outside of māori populations this third big reform addressing inequities built on the previous reform in several ways and can be analyzed as follows firstly it was distributed to māori in a way which did not put any burden on them to acquire the device and was made easily understandable through simple instructions instead of trying to impose the policy on them the baskets were offered freely and the benefits were clearly articulated it is unsurprising that easing burdens and simplifying messages enhances the probability of individuals acting as the reform intended secondly the strategic choice of a māorimade basket increased cultural congruity building on the earlier 1994 policys considerations of māori inclusion a willingness to pursue the goals in a different way when the initial efforts fell short was a huge reason this policy was able to successfully target a risk factor which had previously seemed virtually unfixable without massive investment these two factors led to a high acceptance of the baskets 20 in contrast to the earlier approaches which set out to reduce smokerinfant bedsharing this success alongside the history of infant mortality reform in new zealand points to a wider theme in implementing inequityreduction policy successful policy tends to follow an evolution of successes and failures the need for such policy adaption is not unique to welfare issues for example jacob hacker argues that policy drift can lead to the effects of policy changing over time which left unaddressed can lead to unintended and undesirable outcomes 21 similarly in his discussion of new social policies giuliano bonoli argues that as societal context changes policy must adapt to changing societal demands and costs 22 the new zealand infant mortality policies extend these observations in indicating that policy adaptation is not just about addressing changing times and drift but can also address shortcomings of previous policy most often the initial form of a policy will not perfectly solve the problems it is targeting as problems are often multifactorial and unpredictable the babybasket reform showed a willingness to improve prior otherwise successful policies in the specific areas where those policies were not working these novel solutions involved cultural sensitivity and riskalleviation strategies that targeted the underlying risks specific to māori communities which demonstrated how compromised policy has the potential to deliver higher compliance and better outcomes compared to prior strategies this approach represented a shift in how successful health policy is implemented overall this case highlights the importance of reexamining policy as it progresses and indicates the value of the substantial research effort directed at māori inequity within new zealand over recent years this research emphasis demonstrates new zealands commitment towards longterm reform which can only be achieved when there is adequate data to consistently assess outcomes moving forward similar adaptive attitudes will prove beneficial in addressing even more difficult infant mortality inequity obstacles such as pregnant smoking and socioeconomic deficiencies current policy directions in light of the three major reforms which have taken place over the past several decades concerning infant mortality in new zealand there is still an inequity problem as seen in the higher infant mortality rates of māori populations however while additional targeted reform addressing infant mortality does not seem to be on agenda new zealands government has made recent efforts to improve health inequities across the board 10 for example labours health policy statements from 2014 include reducing health inequalities as the first of eight health priorities 24 additionally the latest budgetary conditions are driven by the principle of improving the wellbeing of citizens as opposed to the traditional priorities of productivity or economic growth 25 this unprecedented move means that new spending must hit at least one of five requirements one of which is addressing the inequalities faced by indigenous māori and pacific islands people 25 many of the other requirements are factors which have indirect effects on health disparities such as reducing child poverty these positions and funding shifts are not targeted policy and they have only been in place a short time and so it is not yet possible to say if how or to what extent they will reduce disparities between māori and nonmāori populations it is likely that placing inequity at the forefront of a governments agenda will promote the benefits of prior reforms and support further policy and population health initiatives of this kind this may ultimately lead to further reductions in infant mortality inequities one may also hope that the broad policy will encourage inclusivity and tolerance and decrease the negative health effects associated with racism there are further electoral incentives to tackle these problems given that the māori constitute a significant portion of the population of new zealand 1024 this suggests that the improvements in health equality that have occurred over the past 20 years may continue still as the initial reforms addressing infant mortality demonstrated policy is unpredictable and it would be premature to assume the exact direction or extent to which these macro shifts will take the problem of health inequity limitations there are many valuable lessons to be taken from analyzing the trends data and policy of reducing inequities in māori infant mortality however it is also important to acknowledge that other factors may have had a role firstly the new zealand health system underwent a number of reforms in the same time period especially during the 1990s one such reform was the transition to district health boards which was a system of funding allocation for different regions of new zealand this system included a formula designed to disproportionately favor regions of lower socioeconomic status which tended to have disproportionately more māori it is possible that the higher fund allocations towards māoriheavy areas could have impacted health inequities in infant mortality though the favoring of these areas is unlikely to translate into tangible benefits due to the primary causes of infant mortality being sids and sudi both of which have risk factors associated with the home and outside of the healthcare system as the policy progression shows simply putting more money into a problem does not always solve the problem the money must be used in the proper manner secondly the definition of māori broadened in 1995 and consequently more people with lower infant mortality were included in subsequent data this had the effect of making trends immediately following the 1994 policy seem more dramatic than they actually were for example the māori sids prevention programme saw a reduction of 8 to 35 deaths per 1000 though corrected data suggested the actual change being zero however this only affects the immediate time period following this specific policy and the trends continuing past the 1995 transition remain valid finally there are a multitude of additional factors which affect infant mortality and the broader publics health for example the socioecological framework in public health the whos commission on social determinants of health conceptual framework and the whos health in all policies framework all emphasize that role of poverty poor education poor housing and other sociopolitical and contextual elements as inextricably linked to racial health equity 2627 there is also evidence that health inequities are closing between indigenous and nonindigenous populations in other areas such as injuries which is largely due to changes in physical social and economic conditions 28 relatedly many argue that the best way to address infant mortality inequities would be to address social deprivation and poverty as these are strong predictors of infant health 20 this would be especially relevant for infant mortality because the risk factors of sids and sudi are bedsharing smoking unsafe bedding with back sleeping and not breastfeeding all of which are potentially influenced by socioeconomic status for this reason social factors changing over time may well have an effect on infant mortality rates just as a targeted policy might it is impossible to adequately correct for all of these factors some of which include socioeconomic status racism and education the trend over the past 20 years has been towards more programs targeting māori inequity in areas which tie back into health outcomes and it is possible that improvements seen in areas outside of infant mortality policy are reflected in infant health outcomes that being said it is highly unlikely that these variations were the reason behind the night and day differences between the initial reform of 1991 and the subsequent reforms of 1994 and on because the stagnant trends were so drastically changed following the implementation of 1994 policy it is still reasonable to conclude that this policy and the inclusive movement it fostered was successful and that the differences in the second round of policy were important causal factors in addressing inequities conclusion an examination of three policies targeting māori infant mortality inequity provides valuable lessons for future policy which seeks to narrow health gaps between privileged and deprived populations specifically the failure of the initial 1991 reform in addressing māori infant health followed by the relative success of post1994 policy demonstrated that disadvantaged populations carry differential social risks which require adjusting treatment accordingly in other words what works for one community does not always work for another especially when the other community is socioeconomically disadvantaged racially discriminated faces different underlying risk factors and has a different culture and environment policy that sets out to address inequities between populations must draft their policy around differential risk which requires cultural sensitivity and inclusivity towards disadvantaged groups as well as a commitment to proportionate universalism in order to appropriately focus efforts to where they are most needed 8 additionally social policy must be willing to adapt to changing circumstances and shortcomings of current policy for example the back to sleep campaign launched in the us in 1994 was highly successful in preventing sids but widened inequities between the those of high and low social class after ignoring differential risks 29 similarly australias 2008 closing the gap strategy to address infant mortality inequities failed to reduce gaps between indigenous and nonindigenous populations even though infant mortality declined in both groups 30 as new zealand and other countries facing inequities such as the united states and australia move forward they would do well to consider the lessons of new zealands infant mortality policy progressions authors contributions cr analyzed and interpreted the literature and wrote the manuscript sw helped edit and write portions of the manuscript the authors read and approved the final manuscript authors information cr received a ba in political science from kenyon college and is currently completing a pgdip from the university of otago in new zealand and an mph from unc gillings school of global public health he is the founder and ceo of medeqs a nonprofit dedicated to health equity sw is a lecturer at the university of otago bioethics centre in new zealand he has a ba pgdip ma and phd from the university of otago funding university of otago ethics approval and consent to participate not applicable competing interests the authors declare that they have no competing interests

background the history of infant mortality inequities among māori in new zealand provides a remarkable case study for understanding the shortcomings of policy which fails to consider the differential risks associated with disadvantaged groups specifically the failure of the initial 1991 reform in addressing māori infant health followed by the relative success of post1994 policy demonstrate that disadvantaged populations carry differential social risks which require adjusting policy accordingly literature on these policies show that differential risks may include disparities in representation access to resources socioeconomic status and racism the consideration of differential risks is important in analyzing the underlying causes of inequities and social policy deficiencies aim to describe and illustrate the need for policy addressing inequities to consider the differential risks associated with disadvantaged groups through an analysis of new zealands māori infant mortality policy progression methods the article is a commentary on a series of policies aimed at reducing infant mortality in new zealand it analyses three policies and how their differences are linked to the corresponding trends in equity between māori and nonmāori populations findings the progression of māori infant mortality policy clearly demonstrates that equitable social policy must be culturally sensitive and inclusive towards disadvantaged groups as well as willing to adapt to changing circumstances and shortcomings of current policy prior to 1994 health policy which did not account for the differential risks of māori populations caused inequities in infant mortality to increase despite infant mortality decreasing on a national level after policy was adjusted to account for māorispecific risks in 1994 infant mortality inequities significantly declined a comprehensive analysis of these policies shows that the consideration of differential risks is highly related to a decrease in corresponding inequities conclusions as new zealand and other countries facing inequities such as the united states and australia move forward in constructing policy they would do well to consider the lessons of how new zealand policy changed the frequency of infant mortality in māori populations the study shows that the consideration of differential risks associated with disadvantaged groups is necessary for policy to successfully address inequities

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accounts or academic studies whether qualitative or quantitative a second type of culture about crime is produced when selfdefined offenders give posthoc descriptions and explanations of why and how they became criminals a third variety encompasses entertainment depictions whether fictional documentary or ironical the last including images of criminality used to evoke humor an analyst may treat the same material as a resource for a study of the culture in or the culture about crime interviews of offenders are sometimes the best available information on how and why crimes occurred but if the analyst focuses on the situation of their production own stories autobiographies and autoethnographies may be analyzed as presentations of self which are made to shape the understanding of the interviewer a parole board a potential publisher or academic colleagues similarly an analyst may treat media accounts of crime as such or read them for evidence on the matters they report if they are to offer explanations of terrorist attacks most academics will have no alternative but to rely on media reports as transparent windows on the behavior they purport to represent others will put quotation marks around news coverage on terrorism treating it as a phenomenon to be studied in its own right it is not the material itself but the analyst who determines whether the value of the material is best exploited as a resource for attempting to contribute to knowledge about culture in or culture about crime a second major distinction is among the various ways that culture in crime and culture about crime may or may not interact with each other after clarifying the ways that processes of doing crime and processes of representing crime may relate to each other i draw on the socalled rodney king riots to illustrate the empirical necessity of making these distinctions an overriding objective is to demonstrate that the case for cultural criminology does not rest on postmodernism structuralism autoethnography or any type of hermeneutic turn in social science but on its utility for criminologys traditional quest to improve causal explanation we focus on the interaction between the culture in and the culture about crime because that interaction sometimes is causally critical in the formation of criminal behavior and in the projection to a mass public of images of crime and criminals level 1 culture in crime and culture about crime analyzed independently in the most elementary understanding of cultural criminology researchers study representations about crime that are made by the institutions of popular culture ie in journalism in policy making and political rhetoric and in entertainment products the study of culture in crime focuses on crime stories that criminals tell in situ as a casually critical means for committing crime for example robbers in order to get victims to cooperate in helping effectuate the offense must signal to their wouldbe victims something along the order of a crime is in progress when woody allen made take the money and run he not only made a comedy he also conveyed something real about the minimal cultural competency for committing robbery playing the role of a robber he handed a bank teller a demand note written with poor penmanship and then confronted a confused yet sympathetic teller who read gub for gun in order to commit robbery it is not sufficient to have a weapon intend to use it to compel a victim to hand over money and find a victim with money the offender also must perform as the director of a situational drama effectively defining the situation as a crime by casting and guiding others to play the complementary roles that the successful production of a robbery requires generally to commit personal contact crimes and crimes involving collaborating partners people must bring into social interaction a popularly understood folk sociology describing how crimes are done like all behavior but as an extreme case because of its brief and pressured enactment violent crime usually is to use the phrase of the ethnomethodologists highly indexical gestures are made brief phrases are uttered and robbers go into action on the understanding that the course of conduct they project will be intersubjectively understood by cooffenders victims and bystanders such that all parties can coordinate their conduct to fit and to create the scenario of an unfolding crime crimes generally cannot occur without the people involved using narratives about crimean understanding of the phases and transitions among phasesto make the crimes happen in the history of criminology the focus has been so overwhelmingly on background factors that might explain differences in crime patterns and the ethnomethodological perspective has remained so elusive that the rich potential in the narrative constitution of crime has barely been tapped studies of culture about crime make up a great bulk of cultural criminology this perspective appreciates that as a cultural resource crime is far too valuable to be left to criminals whether the area of research be the news media political debate or entertainment products ranging from mystery novels murders in shakespeares plays or hollywood movies the researcher here has the easiest task at least with respect to data gathering without any methodological reflection any undergraduate student can assemble a set of stories and analyze their content increasingly students use search engines to locate count and find associations with representations of crime common questions are what tropes are used how does the representation of crime in one or another area of popular culture compare to the reality of crime as indicated by data on crime patterns if patterns in the commission of crime do not explain patterns in the representation of crime what does in a more complex research design the researcher studies historical changes in how crimes are represented by different institutions of popular culture or by the same institution over time one might compare crime and criminals in dragnet a tv police show of the 1950s that was written from a police perspective with the naked city a tv police show that ran about 10 years later and was written from a social work perspective with crime and criminals in more recent police dramas which use crime to avoid issues of race relations highlight social inequalities dramatize bureaucratic constraints on creative freedom and celebrate state power as enhanced by technological sophistication because crime will always be a major focus of popular culture documenting change in the representation of crime in entertainment vehicles is a strategic focus for documenting changes in popular culture in general in a much more challenging research design the researcher tries to explain how the content of stories is related to the social process of producing culture a sociologist might link patterns in the culture about crime that an organization produces to how news rooms operate to the dynamics of political campaigns or to the patterns of collective action through which movies are made and at an even more complex level the researcher explains changes in the way crime is represented by linking them to changes in how the culture of crime is produced has the decline of the studio system for making movies and the rise of independent filmmakers been responsible for making film portrayals of crime more realistic or has the cinematic representation of crime just become by guest on may 11 2016 cmcsagepubcom downloaded from distorted in new ways given the rapidly diminished role of metropolitan newspapers in how people learn about society there are new challenges for the cultural criminology community by what mechanisms is the popular understanding of crime currently formed internet sites and postings of information describe crimes and criminals at arrest facilitate the production of ongoing crowdsourced portraits of individuals and make convictions stick to individuals for example by offering employers easily searchable criminal records and offering anyone access to the mapped locations of adjudicated sex offenders digital crime news is creating a new world of social interaction among readers alleged offenders and social researchers of the lay and the professional sort we can label studies as at level 1 when they treat only the culture in crime or only the culture about crime because they are relatively simple in their analytic character even if especially in the former case acquiring and processing relevant data may be challenging it is common for researchers of crime causation to neglect the literature on how crime is represented in journalism or law enforcement policy except as a foil highlighting their own contributions likewise researchers who address the institutional representation of crime can remain agnostic about issues of crime causation even while contrasting patterns of criminal behavior with patterns of crime as implied by what is shown to news readers political constituencies and entertainment audiences but even as level 1 studies continue to dominate cultural criminology it will be helpful for the research community to become more selfconscious when making presumptions of independence from the start the distinction has not been maintained systematically although this may be changing and presser and sandberg level 2 asymmetrical interactions between culture in and culture about crime that people when they are doing crime take into account aspects of culture about crime is a familiar observation the general point is captured by the irony of life imitating art young men adopt movie names to label their own gangs offenders play off of movie and music video scenes when they hold guns sideways which may look cool but is a poor choice if the primary consideration is accuracy yet if the theatrical gesture increases the chances of not having to shoot at all the method has a logic being successfully intimidating requires expressing oneself in a form that will terrify victims in a complementary way the production of culture about crime increasingly uses as a resource the culture actually used in crime movie depictions of crime are today much more naturalistic than they were in the heyday of the big hollywood studios in the 1930s and 1940s this change is part of a larger transformation actors now are likely to be known to the public with names they were given by their parents at birth movie executives no longer insist on the studios standard policy of conferring deethnicized names on contract players the contrast between the melodramatic gangster portrayals by edward g robinson in little caesar and key largo and the contrastereotype selfconflicted portrayals of gangsters in the movie goodfellas and in the tv series the sopranos and the wire is striking contemporary entertainment production plays off of long term journalistic documentation new yorkerstyle detailed prose writing and ethnographic investigation which introduces movie and tv audiences to local dialects references and styles level 3 symmetrical iterative interactions between culture in and culture about crime cultural criminology has emphasized the loopy relationships between culture in crime and culture about crime the moral panics the essentialist labeling and the biased selectivity by which mass culture represents crime the problem is that the comparison is too easy comparing crime as represented by the media and patterns of crime as described in empirical research researchers are virtually guaranteed to produce an informative and critical perspective researchers face a longer and more obstacleridden research path when they try to investigate the looping relationship between how culture creators and criminals see and respond to each other sometimes actors on each sidethose engaged in shaping what they understand to be criminal activity and those shaping public understandings of criminal activityform their behavior through taking into account how the other side takes account of them the tendency in cultural criminology to emphasize loopy relationships suggests that crime causation and the recognition of crime by media and law enforcement proceed on independent tracks but this perspective however productive risks ignoring patterns of empirical interaction for an initial example i recall an informal writing in which gerald suttles observed that chicagos street gangs shaped their geographic claims and geographybased names in response to the organization of gang control units in the chicago police department which had organized gang control units by imagining that it was reflecting a preexisting geographic reality in a way the attempted remedy produced the problem or at least its social organization as of this writing which was developed during the waves of protest that created a wake following ferguson the culture about crime is rife with a burgeoning set of claims about interactive effects with the culture used in crime formation the ferguson event and several subsequent killings characterized as a white policeman shooting a black man or boy were widely denounced by protestors media reporters and academic commentators as evidence of the harmful results of zero tolerance or broken windows policing 1 this policing policy was based on a criminological theory about how culture enters into the formation of criminal behavior the presumption of broken windows theory is that wouldbe offenders are reading culture in public space for signs of official indifference rigorous enforcement of laws against minor infractions it follows would change wouldbe offenders readings of street scenes interrupting their criminal calculations after ferguson in a social movement that picked up the banner black lives matter the mass media became filled with images of intense protests against police violence which often were triggered by zero tolerance policing such as arrests for walking on a roadway or selling cigarettes onebyone prominent law enforcement officials have claimed that in response to the culture about crime and criminal justice projected by the protest movement the police have become less willing to intervene aggressively and as a result the culture in crime has changed such that offenders have increased their willingness to commit crime this ongoing swirling controversy is based on ideas of an evolving looping relationship between the causation of crime and the culture of mass protests which attack not just police action in particular cases but the zero tolerance culture about crime one way that the research community can respond is to investigate independently each step of the claimed causal chain are police officers changing their behavior based on a change in the culture about crime and law enforcement are offenders changing their behavior in committing crimes based on a perception of the police as wary of becoming part of an episode in the mass narrative on crime and criminal justice an alternative but not mutually exclusive approach is to preserve the natural integrity of the interaction process and trace its development as a coherent case the looping relationships between the culture in and the culture about crime develop over stages forming discrete historical episodes if data sets of such episodes were created they might be analyzed for developing and testing hypotheses on regularities in their natural histories in order to illustrate the research agenda that would follow i will review the history of the rodney king riots this case which i characterize as an episode of anarchy is unrepresentative of everyday crime in ways that make it strategically useful the interaction between the causation of crime and the representation of crime was compact in time and space media representations were being read or viewed not only by the general public but by people who were contemplating committing crimes of arson theft and vandalism and unlike most street crime about which what is readily available is little more than the binary fact of occurrence or nonoccurrence we can make use of a variety of contemporaneous descriptions to trace the patterns of criminality in episodes of anarchy as they emerged transformed and disappeared which enables us to isolate the stagespecific impact of news coverage on crime and of crime on news coverage the concentration of episodes of anarchy in time and space and the dramatic nature of the events means that many peoplejournalists social researchers commissions investigating causescan focus descriptive energies to a degree unmatched by any other form of criminal conduct almost by definition riots or collective efforts at rebellion are especially likely to generate a recorded history in reviewing the rodney king episode i will focus only on those aspects which indicate interactions between the culture in and the culture about crime overall two patterns will be emphasized as to the culture in crime those on the street shaped their participation in anarchic behavior depending on their sense of their visibility to law enforcement and the media but not in the usual way usually we would expect wouldbe offenders to desist when they are aware that they have become visible to law enforcement but at critical turning points within episodes of anarchy wouldbe participants understand that the more visible they will be as a mass the less vulnerable they will be to punishment as individuals even though each is otherwise undisguised an ironic epiphany of invisibility is at the causal heart of anarchy as collective behavior the second pattern is that law enforcement media and politicians shaped their depiction of participants based on their estimation of how participants were and would be perceiving them the institutions that produce the culture of crime take account in the investigative interventions they make in the profiles they assume and in the narratives they put out for public consumption of how those participating in the anarchy are likely to perceive and respond to whether and how their anarchic behavior is socially constructed the upshot of this looping relationship is that the very definition of criminality becomes a moving line the dynamic interaction between the anarchic actors on the streets and the culture creators in the news media in politics and in law enforcement is at the unspoken heart of riot management within episodes of anarchy law enforcement cannot acknowledge the negotiated character of what will be treated as crime while characterizing the events as a riot police and military forces adjust their techniques of control so as not to exacerbate the anarchy but without announcing that they are deciding to let criminals off the moving line only recently has been appreciated by academics usually the response of university researchers is to abjure describing participants as arsonists looters and vandals and to jump onto the side of the debate that defines the phenomenon wishfully as a rebellion typically by pointing to background factors which cast the event as a cryptoprotest in a stroke sociologists lose contact with the sociological nature of the phenomenon considered as a distinct form of collective behavior the political meaning of anarchy is inherently ambiguous open ended negotiated an episode of anarchy is a duel between two competing efforts to interrelate the culture of and the culture about crime on the anarchist side the phenomenon is one in which at time 1 people selfconsciously participate in criminal conduct on the understanding that at time 2 institutions of law enforcement will as a practical matter be blinded to crimes that are happening in plain sight in the aspiration that at time 3 the volume of illegality that will have been enacted will be so great that the prospect of any individual offender being prosecuted will be miniscule on the law enforcement side anarchy is an event in which at time 1 those in power back off from treating behavior as criminal in the aspiration of getting control over the streets at time 2 such that at time 3 some of those now committing crimes and some of those not previously apprehended as criminal can be caught and punished the critical moment sometimes comes in a shift from a cat and mouse game when looters arsonists and vandals probe police capacities disappearing from the reach of police positioned to isolate them to the moment when a crowd is acting that shift is often glossed by media accounts which may describe the backandforth stage but then unreflectively pass over to describing the behavior of a collective noun on the 2011 english riots some of the group of around 200 young people knocked down walls and were smashing bricks into smaller pieces … to make them easier to throw at police what followed was a cat and mouse game with small groups roaming the streets looking for unguarded shops these groups simply melted into the back streets at the first sign of police only to regroup minutes later this waiting game continued until around 9 pm when the crowd started moving on mass shops began to be broken into and looted and rocks were thrown at the police news coverage and most sociological writing passes without pause from descriptions of individual action to descriptions of a crowd acting jumping over the most important interaction moments which are those in which participants come to know they have become a crowd because they see their perception as a crowd incapacitating police responsiveness if we analyze participants as interacting with how they are seen and if we appreciate the challenge on the side of the police as one of understanding how their perceptions of participants will be seen we need not stray into a 21st century version of the 19th century analysis of crowd behavior as irrational or nonrational nor do we need stanley cohens 20th century moral panic which bitingly and ironically transferred irrationality to the media and its citizen readers nor must we commit to the 20th centurys psychological portrait of rioters as rational actors as implied by the language used by economists and game theorists what happens in a flash takes many words to spell out but in no instance does lightning strike interaction sensibilities dead at the critical turning point participants on the street understand that law enforcement officials will gloss their individual identities for their potential status as a crowd and they are often right in the way that selffulfilling prophecies become true police or military forces are constantly assessing whether participants on the street understand that they will be hidden under the posture of a crowd riot control is inherently a business of interaction guessing no protocol can be used to train law enforcement personnel so that they do not make either the passive error of retreating before the participants have reached a widespread and irrevocable selfconception as a crowd or the active error of charging to arrest individuals who have already come to understand that they are part of an irresistible collectivity i use the term anarchy in an attempt at precise sociological description anarchy keeps the analytic focus away from a final political labeling of the event at riot or rebellion and on the quickly evolving hierarchically undisciplined antiauthorityantiestablishment thrust of actions which are distinctive in being premised on an understanding by participants that the forces of order have suddenly vanished the sort of event that clarifies that an episode of anarchy is in process is not a background of oppression injustice or group tensionwhich is neither a sufficient nor a necessary condition of anarchyand not just looting mixed with slogan shouting but indications that the aura of formally ruled social life has disappeared giving way to an extraordinary freedom to innovate action the analyst need not investigate or make claims about background injustices but knows that anarchy is going on when he or she sees cars driving on sidewalks to get around concentrations of people on the street neighbors trading weapons for food and the police standing aside as looters openly carry away goods a social history of the rodney king anarchy 1 the prephase in los angeles as in the us nationally crime rates rose in the 1980s and 1990s reaching an apex at about the time of the arrest of rodney king in 1991 in the year immediately prior to the peak crime level leaders of the africanamerican population in south central had joined with the mayor to support the police chief in engineering gang sweeps behind the law enforcement policy which was publicized by the lapd as operation hammer was an understanding of widespread criminogenic potential among the areas black youth this understanding was statistically expressed in a report by the areas top law enforcement official which calculated that roughly half of the young men in the area were gang members operation hammer implemented a crude version of zero tolerance any manifestation of gang affiliation as perceived by police officers most of whom had not worked in the area was a basis for arrest in related efforts that resembled military checkpoints in war zones the police blocked off streets and queried occupants of cars as the police typically had no judicially presentable evidence to back up the arrests the upshot of gang sweeps was that thousands of young men spent a day or several in jail and were then released even the local civil liberties union passed on condemnation the culture about crime represented by this repressive law enforcement policy was premised on assumptions about the culture used in committing crime the sweeps responded to demands of black community leaders that law enforcement increase its presence in south central to the purpose of discouraging wouldbe offenders what was effectively targeted was not in the first instance crime but symbols of gang affiliation culture about crime was deemed the cause of crime suppress the symbolic display of youth gang affiliation in public life and you would repress crime la under siege in the year between the arrest of rodney king and the outcome of the trial against police officers who beat him an ominous air came over los angeles the anticipation of potential rioting was thick dread became palpable lived in countless moments of avoidance apprehension warning ironically the counseling by political leaders in particular by the responsible leadership of the africanamerican community fed the dread the upshot was to position those who would start the riot as street people expressing opposition to the establishment this framing set up the outbreak of looting and arson as intrablack class antagonism and as an ambiguously politicalcriminal expression when the simi valley trial ended without a guilty verdict it was read by people situated across the usual political divides as a shocking official authorization of police brutality against blacks when the anarchy began it was not necessary for those committing crimes to announce a political framing of their behavior because they came immediately after the trials pronouncement of the official culture about crime and because of the crosspartisan condemnation of the verdict otherwise naked criminal behaviors of theft arson and violence against police and fire personnel were preframed as expressing a consensus protest in another more subtle way the verdict became an unwilling collaboration between the establishment and the wouldbe anarchists as with anarchy in general the ability of people on the street to coordinate with each other was essential to the outbreak beyond the substantive contribution that the criminal justice systems case made by unifying a narrative of opposition against authority the trial outcome was causally critical to the outbreak of the anarchy in a distinctly processual way anarchic action is not necessarily political as gary marx observed decades ago the causal process in race riots has many parallels in episodes of anarchy provoked by sports contests whatever the substantive narrative starting an episode of anarchy requires overcoming a kind of prisoners dilemma a necessary condition is collective consciousness in a strong sense the widespread understanding not only that everyone knows the same thing but a widespread understanding that everyone at the same time knows that everyone knows that everyone is focused upon the same matter particular mechanisms for establishing collective consciousness may be neither necessary nor sufficient but some mechanism is essential collective consciousness in this strong sense is extremely difficult to achieve opinion polls and elections can clarify that a substantive consensus existed at the time of polling but not that there is a widespread experience of the same perspective at the same time at most polls and elections show what the consensus view was at the time of polling soon after the results are known attentions have strayed along differentiated paths collective consciousness in real time is not a sufficient cause of riots but by focusing analysis on this processual necessity we can better understand the loose linkage to the social status of riot participants middle class middle aged adults are often collectively attentive to historic events in real time yet they cannot expect that their middle class middle aged associates will participate in anarchy also necessary for participation is a preestablished ongoing affinity with the ways of violence and vandalism whether that be acquired and sustained as familiar through gang life street crime bar brawls interpersonal attacks in prison property destruction in adolescent or college fraternal circles the daily physical subjugation of children and females participation in sports involving intense physical contact etc 2 the simi valley court by preannouncing that the verdict would be released to the news media at a specific clock time and the news media as well as political and law enforcement officials by using this schedule to specify warnings and to coordinate preparations for the possible outbreak of riots collaborated in solving the problem of creating collective consciousness in the la area a vast population knew that when the trials outcome would be revealed everyone would know that everyone would know the causal relevance of collective consciousness in the strong sense is not only an implication of theory leaders of the events that kicked off the anarchy have described how they used courtpromulgated timing to coordinate their actions the multistage development of streetbased narratives participants on the street interacted with the narrative proposed by the criminal justice system the substantive theme of reversal of narratives was seized upon to create kickoff events for the anarchy protests and criminal actions emphasizing the emotions behind the protests initially focused on parker center the local name for the lapds downtown headquarters this target was guaranteed to bring media attention parker center was also a strategic focus for actions that could overcome the prisoners dilemma the reversal metaphor was implemented literally by turning over police cars in the very face of central law enforcement authority the street action of attacking symbols of police control without resistance evoked an epiphany of invisibility the more visible the participants were while they were committing conduct that was unqualifiedly criminal and defiantdefiant not only because police were visibly observing but also because both the participants and anyone viewing could see that the crimes were being recorded by live tv camerasthe more the participants were insulated against arrest these two themes constructing an epiphany of invisibility and reversing the narrative of the verdict were exploited as mutually supportive resources for moving the anarchy into its most intense destructive stage arsonists who started operating in south central within hours of the announcement of the trial verdict seized on what appeared to be the solid foundations of social order and created an intoxicating mix of metaphor and material the fires they set turned retail shops and warehouses into clouds of smoke that soon transcended all social divisions in la in south central tv broadcasts showed residents consulting tv sets that had been hauled out to sidewalks simultaneously to watch street actions occurring a few feet away as well as those developing in other neighborhoods when lapd officers in south central responded to a confrontation with protestors in an area being looted they were soon told by a commanding officer to abandon the scene the order was generally known because that too was broadcast as helicopterborne television news cameras displayed the immunity of destructive action they became resources promoting anarchy in two ways everyone could see that everyone could see crimes being committed with impunity but also helicoptertransmitted images dramatically reversed an laspecific metaphor indicating the transcendent power of state control here entertainment culture about crime became a resource for propelling anarchistic behavior helicopters had become icons of militaristic social control at least since robert altman used them to set scenes in his koreanwar era m a s h movie when a tv series developed from the movies success the trope was used to preface each episode director francis ford coppola extended the imagery to the vietnam war in apocalypse now helicopters also flew over domestic lawandorder scenes in numerous police dramas set in la in blue thunder the helicopter became the narratives protagonist a kind of superhero mechanical police force in a movie released a year after the rodney king riots altman began his lafocused movie short cuts with a flock of helicopters spraying insecticide against medflies which for cinephiles was a sardonic reference back to his great success in m a s h tiny insects in los angeles now represented the same threat one no less invisible to the domestic population and no less anxiety provoking as had communist armies in asia both the narrative inversion principle and the epiphany of invisibility were dramatically reinforced in the beating of a truck driver reginald denny unaware of the verdict and the street actions in progress denny was traveling through south central on the afternoon when the verdict was announced when he was attacked the event in multiple ways inverted the beating of rodney king by the police a year earlier in both attacks the attack grew out of a forced stop of a motor vehicle several assailants took turns beating the victim playing to a larger audience of immediately local observers who were attending in an improvised amphitheater and whatever the motivations of the apparently sadistic individual attackers the attack manifested to their peers a rejection of disrespect for their community king had disregarded police orders to pull over drawing up to a dozen law enforcement agents into a chase whose high speeds put them in danger denny had been oblivious to the community he was driving through he treated the day as like any other despite the announcement of the historic verdict and in both cases the assaults were being recorded although in the case of the serial attack on denny the attackers unlike the police who attacked king were aware of the recording which was being effected by helicopters overhead watching the live broadcast of the attack on denny people across the city could see that overt criminality was effectively invisible to law enforcement in the second day of the anarchy the substantive theme initially used to coordinate participants was transformed a narrative transformation was necessary to sustain the epiphany of invisibility in an analogy to fire an analogy which helps explain the appeal of arson in riots and rebellions despite the selfdestructive material consequences to participants neighborhoods anarchy must grow lest it begin to die down but because of population changes that had occurred in los angeles since the watts riots of 1965 a racethemed narrative could not keep the fires burning in south central and even more so in the surrounding neighborhoods that the anarchy would have to involve were it to continue after the looting and burning of the first neighborhoods attacked african americans were in a minority the majority being composed of very low income by guest on may 11 2016 cmcsagepubcom downloaded from latin american immigrants notably the historic mexicanorigin population on the east side of los angeles did not join the anarchy notwithstanding the heavy pressure that for decades the lapd and the sheriffs department had brought down on young men labeled as members of the areas youth gangs it was even less likely that appeals to grievances against police authority would inspire recently arrived mexican and central american residents to mobilize politically themed protests many spanishspeaking residents were illegals vulnerable to deportation and had not yet developed any public leaders to protest their treatment by local police since 1979 they had been significantly protected from police abuse of their vulnerability by special order 40 an lapd order limiting inquiries into immigration status although living in proximity to african americans and often labeled people of color by university students and others seeking recognition of a demographically expansive progressive coalition my ethnographic research in hollywood found that at least until the end of the 20th century latino immigrants were socially distant from and often fearful of blacks in their everyday lives as the anarchy moved north of south central and into koreatown and hollywood there were dramatic instances of armed korean merchants patrolling from the roofs of their stores and occasionally shooting at armed men on the street but the dominant reality on the streets was of raids on stores by tens of thousands of latinos mixed with a proportion of blacks that diminished dramatically as the anarchy moved north tv broadcasts showed reporters interviewing sometimes surprised but still unabashed looters as they came out of stores incriminating evidence in hand no thematic complaints of a moral or political nature were expressed by the thieves instead of the racial tension and policeminority citizen narrative that dominated the onset of the anarchy the guiding motif was carnival when the looting reached koreatown the light comic theme that guided the looters was highlighted by a juxtaposition with the shock and terror experienced by merchants whose families and family businesses were physically threatened it was clear to all on the street that their very visibility as they engaged in theft was making the police impotent women hauling goods obviously looted from stores could be seen pushing policemen out of the way a scene that can be taken to cap the atmosphere developed at the sears department store which stood at an epicenter of hollywoodarea commerce oriented to latino immigrants as hundreds of local residents looted the store a man in a cowboy hat descended an internal centrally located staircase while strumming a ranchero melody on a guitar in rhythmic relation to his playing the instruments price ticket fluttered closure through a shift in the control of the dominant narrative the episodic events usually referred to as race riots have usually run their course in three to five days the decline has never been exploited for what it reveals about the responsible causal mechanisms this neglect is one of the costs of the correlational approach that has dominated a social science literature preoccupied with background features that remain constant before during and after riots typically a statelevel national guard or a federal militaristic force is deployed in mass numbers the use of a show of massive government force continues the pattern in the history of european pogroms and in classbased rebellions the replacement of the anarchic street population by the forces of authority shifts the dominant narrative and undermines the presumption of invisibility in the rodney king episode mass arrests developed in the third day after national guard troops were deployed to assist local police the arrests facilitated by curfews imposed on the night of the second day reached over 5000 by friday night televised images which previously had sustained a presumption of invisibility by showing reporters interviewing looters as they emerged from shops now undermined that presumption as they showed streams of residents mostly latino immigrants being corralled held prone on the ground and marched away by law enforcement authorities a tradeoff between enforcing the law and producing a visible image of law enforcement soon developed latino and black youth seen as gangbangers taunted the police and national guardsmen pointing guns issuing threats nosetonose shooting weapons in the air or at others and challenging soldiers to show they had ammunition for their guns the soldiers who witnessed these provocations and sustained these insults did so without attempting arrests in contrast latino looters acted in an unthreatening carnival atmosphere way and they became the bulk of arrestees the upshot was to generate an image of effective law enforcement while relinquishing the application of official power for the most egregious offenses even before however a folk understanding that individual visibility was the critical causal contingency led more affluent residents to mobilize against looters coming into their neighborhoods in the middle class area of western hollywood residents stood at a safe distance across the street from shops being looted and overtly took photographs of the individuals people driving in to the area and stopping near looted shops could see that bystanders were taking photographs of the license plates of their cars in the hollywood hills barricades were set up by volunteers who blocked passage into the area by insisting on the production of identification showing local residence in these operations residents exploited their ability to produce a double visibility showing would be criminals that even if they could not be stopped in the moment they would be identifiable later and showing their neighbors that there was collective strength on the side of repressing anarchy the police who had given way to looting as it progressed northward through eastern hollywood assembled on the commercial streets of the foothills in a pattern that continued the traditional responsiveness of the lapd to the business interests in hollywood the police effectively made a last stand on hollywood boulevard which was then a seedy stretch but still the areas most frequented tourist destination the northward progress of anarchy ended poetically at the doorstep of fredericks of hollywood a nationally famous erotic lingerie shop that since the pin up culture of wwii had served as a doubly faceted icon of entertainment and street level hollywood the rodney king riots enters a series of postanarchy narratives in popular culture for years after the streets had returned to normalnormal in the sense that businesses reopened and looting and collective patterns of arson disappearedthe meaning of what had happened in the rodney king riots was revisited in popular culture those in the general public who had not already appreciated the fact learned during the days of the anarchy that the majority of residents in the closein city were latino immigrants the image of the latino population portrayed by media coverage of the riots was of looters in contrast to the longpresent mexican descent population the new immigrants had no wellknown public figures to produce a respectable alternative to what the tv newscasts were showing culture about the anarchy evolved through a series of elections for mayor and governor and in the public discussions leading up to statewide plebiscites on several propositions consistently the response was conservative for the first time in decades a republican replaced the democrat partys mayor in los angeles and the symbol of an african american leading the city became part of the past a republican won reelection as the states governor his campaign began with a low approval rating which was dramatically reversed after he linked himself to a proposition restricting the rights of undocumented immigrants it appeared on the 1994 ballot under the title save our state during the immediate postriots years popular culture was repeatedly stimulated and crystallized by plebiscite votes against rights for illegal aliens against demands for greater academic and economic opportunities for african americans and for longer incarceration of adjudicated criminals the voters decided against affirmative action and for a three strikes measure that mandated life time criminal punishment for a large class of repeat convicts it is not possible to pin down exactly what role media coverage of the riots played in these elections academic researchers and leftleaning commentators argued against a backlash effect but their data did not cover the mobilization of sentiments in statewide votes images of criminal action surrounding the police attack on king and the looting arson and blackonwhite denny attack were in the near background of the political campaigns that led to a consistently conservativerepressive mass voter action against undocumented immigrants criminal defendants and affirmative action twenty years later the political meaning of the rodney king riots reversed again now turning progressive in the news coverage on the 20th anniversary of the events the consistent theme was the historic struggle against lapd brutality and the continuing vulnerability of latino immigrants without legal residency status no political or commentating voice used the events as a basis for more punitive policies toward the poor blacks or latinos the los angeles times ran several weeks of stories on the la riots twenty years later the themes were of police department reform improved community relations a public sense of greater safety continuing social problems despite the rebuilding of south central and a month later the death of rodney king at age 47 accidentally drowned in his swimming pool as the result of what a coroners report described as a state of drug and alcoholinduced delirium granularity temporality and interactions among narrative processes the warrant for research in cultural criminology is that the narratives about crime that traditionally have been and for the most part continue to be proposed for explaining crime point to background factors either ecological or biographical and they do not work whether it is the failure to explain variations in the occurrence of riots or the dramatic ups and downs that street crime has shown over the last 50 years the social research communitys reliance on demographics and neighborhood characteristics as constituting the story for understanding crime has been unsuccessful and given the expansion of academic research resources and government funding over this period the failure has been on a grand scale it is long overdue to refashion the approach to explaining crime by attending to the narratives created in the commission of crime itself a criminology rooted in the culture used to commit crime inevitably becomes critical of the culture of crime that is created by the descriptors provided by government agencies the narrative criminology community will be happy to reject positivist explanations that rely on background factors especially if background factors are measured quantitatively but the more specific challenge for those who would understand the relationship of crime and culture is to appreciate that there is not just one meaning of a crime and not just one meaning for each person studied this is especially clear when we consider episodes of anarchy it is not a question of whether a given event should be called a riot or a rebellion but a question of appreciating the distinctive interaction challenges that participants face in recognizing what the events mean to others and how in the course of a few days that challenge rapidly changes granovetter facilitated a turn from correlationalsynchronic approaches that rely on background factors to diachronic analysis that recognizes the changing meaningsmotivations of collective events including specifically riots as the situation changes for interpreting what othersingeneral will do his model is now some 40 years old perhaps because it was delivered in the rhetoric of game theory and rational choice perhaps because it was offered as an antinormativecultural values explanation granovetters approach has not been appreciated for the encouragement it offers to narrative criminology for those on the rioting streets figuring out what is going on depends on reading indications of what others in a collective sense the crowd and the police are doing and are likely to do in other words the progress of episodes of anarchy depends on the cultural criminology that participants develop in situ as they interpret what others are trying to do and as they perceive the narrative understanding of events that is being used by law enforcement officials who may see individuals committing crime or who remaining in barracks or maintaining a military gaze into the middle distance may blind themselves from effectively seeing individual participants narrative criminology may be seen as more comprehensive than cultural criminology or the former may be seen as a subtype of the latter depending on how phenomenological one is inclined to go narratives are understandings of sequentially related phases of behavior with beginnings endings and turning points between phases offenders invoke narratives in order to commit crimes offenders also draw on and are taken by cultural tropes images and aesthetic styles that are pregnant with meanings not necessarily spelled out as sequences for example on the way to a mass shooting an adolescent may equip himself with various means of committing violence without having worked out how they will be used in tandem even if assembled chaotically cultural fragments are often essential resources to individuals as they develop and sustain motivations to commit crimes but cultural fragments are not necessarily separable from narratives they may be appreciated as proto inchoate or indexical gestures to full blown narratives a range of thinkers including kenneth burke paul ricoeur and harold garfinkel may be read for the argument that any subjectively meaningful act is part of a narrative even if many meaningful acts are only narrative gestures ie incipient narratives that are quickly abandoned to systematize the knowledge that narrative criminology can produce we may wish to distinguish levels of granularity temporalities and interactions as to the different scale of the phenomena involved at the most micro level there is the narrative used by participants to commit crime for crimes committed during episodes of anarchy the distinctive critical contingency in members narrative construction is the epiphany of invisibility which is an inherently fragile understanding that because so many others are so visibly engaging in criminality ones own participation will be effectively invisible in application to isolated individual crimes at a meso level there is the antecedent biography of the event which includes streams of social life from which a given criminal project emerges in episodes of anarchy the subjectively relevant prestages can stretch over months or even years in the case of the rodney king riots the year between the revealing of the videotaped beating and the trial verdict became a period that can without exaggeration be analogized to the plague that came over thebes after oedipus was unwittingly but inexorably led to committing a primordial transgression in the royal house it is not just that both were in different senses attacks on kings in the greek myth and in the mythinfused development of the 1992 los angeles episode of anarchy there was a background of transgression then a moment of revelation then a period of dread as an eerie awareness grew that corruption at the center of authority had to bring disaster then overt social chaos and communal destruction in the viewing of the beating of king and even more so in the revelation of the jurys verdict there was a widespread sense of a shameless violation that would stir irresistible destructive forces nothing could better recommend the necessity of narrative criminology than a detailed social interaction sensitive history of the making of the rodney king riots or perhaps of any episode of anarchy at a macro level narrative analysis is equally essential but in the nature of the case more elusive after a crime or to continue with the example of this essay an episode of anarchy the meaning of the event enters multiple different narratives what are the effects for offenders and for others who only get involved after the fact when gun violence transforms in biographies from a crime into multiple medical cases what is the meaning of an episode of anarchy after the streets return to tranquility and popular culture picks up the events in a series of entertainment products and political events each with its own narrative in a movie or a political campaign a historic episode of anarchy will often play a background or supporting role for a focus on personal character yet as elusive as it may be that is how an episode of anarchy most often lives an extended life in a subterranean stream of images that play a diffuse and opaque role in setting the mood for understanding some other narrative on the front stage that is demanding an immediate emotional response after the event the crime is no longer important as a narrative project but it will often be significant as a narrative resource for a larger project such as a crime victims struggle to work out a way to live life as disabled or a geographically bounded populations encounter with the challenge of figuring out what the event means for the nature of the community mass culture enters the creation of anarchy long before it breaks out and mass cultural coverage of episodes continues to be used in the shaping of popular opinion for years after at each of these three levelsand three is arbitrary a matter of conventionthere are interactions between the culture used in committing crime and the culture used in generating interpretations about crime at the extreme the interactions become symmetric and recursive people shape their conduct in committing crimes through taking account of how the mass media and law by guest on may 11 2016 cmcsagepubcom downloaded from enforcement will see them while law enforcement officials strategize on interventions by taking account of how their actions will be covered by the media and regarded by potential offenders the two way interactions continue in a looping relationship the critical causal contingency in episodes of anarchy is the emergence and decline of an epiphany of invisibility the work of news media and of law enforcement or military agencies in describing and responding to crime is itself perceived by masses of individuals on public streets and powerfully affects how they in turn initiate develop pause recreate and abort anarchic behavior the media and the judicial system can inadvertently help people on the street solve the prisoners dilemma that usually deters anarchy watching in real time as media organizations contemporaneously show events occurring on public streets to mass audiences wouldbe participants can gain confidence that if they engage in behavior that usually would be treated as criminal not only will they not be acting alone they will be acting in a mass so large that they are unlikely to be singled out as criminals for their part law enforcement agencies are increasingly sensitive to how their actions in response to anarchy are being picked up by media and responded to by people on the street research indicates that in the riots in the us in recent decades a kind of negotiating process has informally developed people on the street literally and metaphorically push against and through barriers of order many are keenly aware of the media images they are creating indeed their motivation to participate may be specifically to create such images some bystanders watch tv coverage and respond by intervening to protect their property while others intervene to restrain involvement by people they know 3 the police surge and retreat in the boundaries of order they will enforce based on their sense of how their actions will be seen and taken up by the people on the street who will determine the next phase of the anarchys evolution 4 the looping relationship between the culture in and the culture about crime is at its extreme in episodes of anarchy in the wake of ferguson and its progeny in mass media stories there has emerged in the us a widespread controversy over policecriminal interactions especially in jurisdictions where arrests have declined and crime has risen some critics of the police argue that they are now restraining their intervention in street encounters with people they see as offenders in protest against the public damnation of recorded and disseminated police actions in prior encounters some law enforcement officials have suggested that wouldbe offenders perceiving or imagining a change in how police will respond are becoming less concerned about apprehension and more aggressive cultural criminology has suddenly moved onto the front page it is a good time to reflect on the analytical tools necessary to take advantage not only of this moment but of the ongoing dynamic interaction between the culture in and the culture about crime notes 1 i put the race labels in quotation marks to emphasize that the media played the story along racial lines which is not inevitable indeed in recent years news media have become wary of identifying the race of offenders as black lest they be charged with contributing to racism historical change in such variations is an area now ripe for research 2 rosenfelds analysis of the riots following the basketball championship victory of the chicago bulls in 1992 would have benefited from an explicit appreciation of the collective behavior dilemma that is a threshold condition for starting episodes of anarchy finding that virtually all participants were black and that commercial targets where not in fact ethnic others he argues that the background of the rodney king riots and the welfare cuts in illinois which had been forcefully damned in the black news media are grounds for considering the event as a commodity riot or uprising while his argument would have had more force had he documented a lack of grievances in the background of the several other bulls victories which resulted in no or less intense riots the association of episodes of anarchy with working or lower class and stigmatized minority ethnic status is clearly too strong to be dismissed as irrelevant to causal explanation but also clearly too weak to be considered sufficient 3 reginald denny was saved from further injury by africanamerican residents of south central who had witnessed his beating on tv more recently in what became a briefly famous incident in the street looting and violence that followed the death of freddy grey while in police custody in baltimore in 2015 a widely disseminated video clip showed a mother slapping and retrieving her son whom had she had seen participating while she was watching tv coverage of the event 4 see mcphail schweingruber and mccarthy for a detailed investigation of several employment and race themed riots in the uk and an argument that the police contribute to the outbreak and prolongation of anarchy by failing to treat overt criminality as effectively invisible see waddington jones and critcher a similar argument has been advanced in the analysis of us prison riots by useem and kimball author biography jack katz is professor of sociology at ucla

does cultural criminology have a distinct intellectual mission how might it be defined i suggest analyzing three levels of social interaction at the first level the culture of crime used by those committing crimes and the process of creating representations of crime in the news entertainment products and political position statements proceed independently at the second level there is asymmetrical interaction between those creating images of crime and those committing crime offenders use media images to create crime but cultural representations of crime in the news official statistics and entertainment are developed without drawing on what offenders do when they commit crime or vice versa at a third level we can find symmetrical recursive interactions between the cultures used to do crime and cultures created by media popular culture and political expressions about crime using the rodney king riots as an example i illustrate the looping interactions through which actors on the streets law enforcement officials and politicians and news media workers by taking into account each others past and likely responses develop an episode of anarchy through multiple identifiable stages and transformational contingencies

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introduction since the first decade of the 21st century groups of migrants emigrating from noneuropean countries to europe have become widespread thus for example 1250665 people of foreign origin currently reside in catalonia which has a population of 7747709 people 1 representing 1611 of the population the most populous community in catalonia is that of moroccan origin which represents 1905 of the foreign population and 307 of the total population this has always been the largest group of foreign migrants in the territory in 2000 they already represented 3346 of the foreign population in recent decades migratory flows have not only increased but are becoming increasingly feminised 2 this means that according to official data 1 more and more women are migrating the growth and composition of migration flows have revealed many inequalities according to one source a nalyses of social asymmetries and fragmentations focused primarily on inequalities in education and employment or income as a result of which social classstratum differences became defined as the most important indicators of social inequalities 3 these asymmetries are produced not only between the newly arrived population and the native population but also between the men and women who constitute the first group currently almost half of the people of moroccan origin residing in catalonia are women a significant number of these women do not work outside the home and those who do often occupy positions related to the domestic sector so they find themselves in a strongly gendered labor market where they take up precarious insecure jobs in areas where illegal economic activities flourish many of these women are on shortterm contracts or are undocumented subjected to the vagaries of their employers 4 both situations namely working at home and occupying highly precarious jobs provide women with few opportunities to use the host languages which moreover are typologically and genetically distant from their first languages linguistic competence in a host language is a fundamental tool for achieving the integration of migrants into the social dynamics of the host countries 5 6 7 8 9 therefore a person who does not know the language of the country in which they reside will experience more difficulties becoming an active part of the society in which they live in catalonia in the same way that there are numerous host entities and ngos that offer initial language courses for more than two decades now public institutions have been providing newly arrived people access to basic catalan and spanish courses it is common for courses at the most basic language level to be organised depending on the origin of the migrants and even according to other factors such as gender increasingly however these courses organise groups according to the level of the learners rather than the particular characteristics of the people who make up the groups since it is assumed that diversity is beneficial in the sense that the interrelation of different origins improves coexistence even so there is evidence that some difficulties and barriers regarding learning and ultimately early dropout rates from l2 courses have a greater incidence among specific groups including moroccan women 10 in light of the information given above the research question investigated herein is as follows to what extent and in what way do factors such as gender origin and cultural background influence the learning process and should these factors be taken into account by institutions when organising basic second language courses thus the aim of this study is to explore the difficulties faced by learners in consideration of their origin cultural background and gender in order to determine whether and how these factors affect their learning with a view to neutralising possible barriers to formal second language acquisition to this end we will focus on the population of moroccan women in catalonia which as we have pointed out is the group of foreign origin most present in the territory although there is a great deal of research on migration and gender the role played by gender in l2 acquisition in a migratory context has been scarcely analysed in order to achieve this objective we conducted semistructured interviews with eight teachers of reducedprice courses of basic levels of catalan and spanish as a foreign language including both those that were public and those organised by ngos the participants in these interviews were exclusively teachers this study constitutes the starting point of an investigation that aims to be extended in the future for the moment we considered it important to take the perceptions of professionals into consideration as they are the only individuals who have an overall view that includes both aspects related to the institution and to the reality of their students on the one hand they possess knowledge of the educational system with regard to the organisation of these types of courses and on the other hand as they have contact with the students they are aware of the difficulties faced by certain groups even so in subsequent studies the study will be extended through interviews conducted with other groups namely moroccan migrant women and those in charge of the organisations that organise these courses migrant women and second language acquisition research on second language acquisition suggests that numerous factors both external and internal influence the l2 learning process including age motivation aptitude attitude learning strategies first languages etc 11 in the case of migrants the variables that most influence the process of acquiring a second language are age time individual or group motivations environmental factors learning and practice possibilities and the efficiency of the employed learning method 12 to all these factors one should add gender which is associated with cultural values that can influence men and women differently in terms of the acquisition of second languages 10 gender and migratory trajectories of moroccan women gender when understood from a cultural point of view is a social construct through which it is established within a given context that men and women perform different roles and behaviours these constructs are socially shared beliefs transmitted intergenerationally through family and social relationships and they are strongly anchored to particular social contexts for an overview of the subject of gender as a cultural construct in relation to migratory processes see 3 gender is not a fixed construct rather it varies according to certain conditioning factors including cultural context 313 in migratory trajectories like those analysed herein these gender roles must therefore be analysed in relation to both the culture of origin and the host culture the migratory trajectory of a moroccan woman is different from that of a man from the same country 14 when accounting for the contexts of origin and arrival if analysing the context of origin from a legal point of view in morocco it is established that men and women are equal the constitution 15 within title ii in article 19 states the following men and women enjoy on an equal level the civil political economic social cultural and environmental rights and freedoms set out in this title and in the other provisions of the constitution as well as in the international conventions and covenants duly ratified by morocco in compliance with the provisions of the constitution the constants of the kingdom and its laws the state shall work to achieve parity between men and women lhomme et la femme jouissent à égalité des droits et libertés à caractère civil politique économique social cultural et environnemental énoncés dans le présent titre et dans les autres dispositions de la constitution ainsi que dans les conventions et pactes international dûment ratifiés par le maroc et ce dans le respect des dispositions de la constitution des constantes du royaume et de ses lois létat oeuvre à la réalisation de la parité entre les hommes et les femmes remaining in the legal sphere morocco has a religiously rooted family code called mudawana that regulates issues related to marriage divorce inheritance and child custody the mudawana is approved by the parliament and by the king thus this family code with religious roots legally regulates these vital aspects that we have mentioned despite reforms that have been implemented to achieve greater gender equity this code deviates from the message regarding gender equality present in the countrys constitution and it offers different provisions for men and women which in practice are detrimental to the latter 16 many of the existing studies that address the gender issue in moroccan society mention islam as the main factor to be considered when analysing the situation of women in muslim areas however islam constitutes only one part of the patriarchal structural system being a muslim does not necessarily imply having certain sexist attitudes 17 what has a more important impact on gender inequality is the degree and type of religious practice as these facets influence the practitioners ways of life and this influence in the end also has an impact on the relationships based on this patriarchal structure 14 in this sense islam would constitute a part of a whole that affects the position of women in society in the same manner as other factors such as educational level urban or rural origin social class marital status etc the factors that influence the construction of gender roles are diverse 131418 the amount and quality of education received can have an impact on the position occupied by women in society in comparison to men this conditioning factor can be related to the educational characteristics of women in migratory environments 10 if considering the relationship between education and immigration it can be observed that in spain a large number of moroccan migrant women do not know how to read or write especially women who have migrated to join their husbands women of moroccan origin with a higher level of education generally arrived as children or are part of more recent migratory flows although the most recent statistics on the education levels of female migrants in spain are at least a decade old 1 language services and assistance entities have confirmed that many moroccan women arriving in catalonia are illiterate 810 1 in moroccan society there is a spatial and vital separation between men and women that is marked by gender roles played by both parties this separation occurs in leisure spaces family relationships friendships and even in support networks in general and always in consideration of traditional models there are not many mixed spaces beyond the closest family environment it is true that as we have said there are differences according to social class in the roles assigned to men and women however the aforementioned separation of spaces occurs in all social classes this separation regulates the activities carried out by men and women in general according to the traditional pattern of the moroccan family and in terms of the jobs assigned to one or the other men are in charge of public activities while women stay inside the house and take care of the home the family and the children 14 despite the traditional division according to which the space outside the home is eminently masculine nowadays more and more women are working however the jobs they occupy are usually those of the informal economy with low salaries and the absence of social benefits 1419 traditionally women around the world experience some kind of inequality all societies share the same structural basis based on patriarchal relations that foster job insecurity for women the reduced presence of women in masculinised fields the greater responsibility imposed on women in terms of family and dependent care etc therefore this structure is reproduced in the context of migration the occupational differences based on gender cross spanish society as a whole and are imposed as one of the axes of labour market segmentation which together with the age and racialisation of immigrant women aggravate their labour subordination their working conditions and wages as well as the possibility of access not only to the labour market in general but also to certain sectors of activity 20 las diferencias ocupacionales por razón de género atraviesan toda la sociedad española y se imponen como uno de los ejes de segmentación del mercado laboral que junto con la edad y la racialización de las mujeres inmigradas agravan su subordinación laboral sus condiciones de trabajo y salario así como la posibilidad de acceso no sólo al mercado laboral en general sino también a determinados sectores de la actividad 20 it is true that there are differences between territories that have their origin in the construction of gender roles these differences are manifested in productive and reproductive activities in the relational sphere and in the use of public and private space 17 even so as we have pointed out in european migratory contexts forms of marginalisation and exclusion of migrant women are reproduced this situation maintains parallels with those described in the country of origin which are aggravated in this case by the very vulnerability of the migratory event eg in relation to the lack of knowledge of the language and customs or the employment of undocumented women as a labour force 4 gendered occupational structures including sex typing of jobs for women and men can exist in both the sending and receiving countries when this occurs migrant women are usually disadvantaged relative to men and to nativeborn women 21 this work situation in the host country in this case catalonia has an influence on insertion into society especially when it comes to developing relationships in the native society within the public and private spheres work is at the heart of integration it is a fundamental part of their lives and therefore the work situation clearly determines the feeling of integration el treball és leix central de la integració és una part fonamental en les seves vides i consegüentment la situació laboral determina de manera clara sentirse integrat 6 there are other elements that condition the sociocultural insertion of newly arrived moroccan women namely on the one hand male dependence and on the other hand their migratory endeavour and both aspects are interrelated 22 marriage has a great significance in moroccan society and conditions the social position of women therefore it can define their life expectations since the beginning of the 20th century migration has usually taken place within the framework of family regrouping 22 2 which is a legal procedure through which a person residing in spain can bring a family member over by granting them residence authorisation according to the spanish law regarding foreigners 23 a foreign person has the right to request the reunification of his or her spouse when he or she has held a temporary residence permit for one year and has permission to stay for at least another year in addition to other conditions that the aforementioned law details 2324 within this framework and in the case of moroccan women migration takes place so that women are capable of following their husbands to the host country so it may be an imposed migration project these women do not leave their country in search of work 3 and they replicate in the migratory context the role dynamics that predominate in moroccan society with respect to family organisation so the main occupations of women are still predominantly related to the completion of domestic chores consequently the difficulties in actively participating in the host society are increased 14 there is another smaller group of women who migrate alone and on their own initiative 14 this group consists of unmarried migrant women especially divorced women whose marital status is closely related to their migratory trajectory in moroccan society these women are not well regarded socially and have difficulty remarrying as they generally represent a family burden in morocco they do not usually encounter impediments to migrating moreover if they migrate they can help their families financially emigrating therefore is a very favourable option for them as in the host society they no longer suffer from the pressure to remarry that they would in morocco there are also single women who migrate alone their migratory trajectory differs from that of men in the same situation as they rely on informal networks that support migrants from departure to settlement in the host country these networks are made up of acquaintances who have already migrated 14 there is a relationship between the life projects and migratory projects of moroccan women and in order to analyse them the link between male dependence and the perpetuation of the traditional family organisation in the target society must be taken into account this dependence is also closely related to the employment situation of women and all these factors will determine the strategies of social insertion and consequently the acquisition of the spanish and catalan languages sociability of moroccan women and l2 acquisition moroccans arriving in catalonia generally speak amazigh andor moroccan arabic as their first languages despite a lack of reliable data several experts estimate that amazigh is the most widely spoken immigrant language in catalonia 25 26 27 in morocco french has an important presence serving as a former colonial language that is still used today in educational or administrative fields for the same reason spanish has a certain presence in the rif area 26 thus and with some exceptions due to the aforementioned phenomenon when women of moroccan origin arrive in catalonia they do not understand or speak spanish or catalan many of them do not speak french either so there is a great genetic and typological distance between the languages they speak and the host languages this typological distance may be an obstacle to the rapid acquisition of second languages but this distance is not the only factor that hinders the acquisition of spanish and catalan the fact that some women are not literate implies a difficulty not only in learning the second language but also one that can contribute to fewer job opportunities outside of the homedomestic sector catalan and spanish law 23 stipulates that adult education should include education for cohesion social participation and the formative reception of people who have immigrated in this way it establishes that newcomers can acquire through the first reception service the basic literacy skills required to access catalan language training despite the fact that there is legislation around this situation in catalonia the literacy acquisition process is generally very long and complex 10 other issues that are less linked to strictly linguistic factors and more related to socialisation can interfere in the acquisition of second languages as we have already mentioned many of these women work at home or have domestic and precarious jobs this fact has consequences for their socialisation as they have fewer opportunities to use the host language in conversation with catalan or spanish speakers and the less use the less acquisition 11 another extralinguistic factor that can affect socialisation and consequently the use of second languages is the stereotyped vision that natives have of moroccan migrants among the stereotypes that can affect communication between migrants and catalan or spanish speakers is the belief that people who have migrated do not know how to speak spanish or catalan and this results in native spanish or catalan speakers avoiding communication with moroccan migrants altogether this is especially important in the case of catalan being a minoritized language catalan speakers do not usually initiate conversations with strangers in this language especially if they presume that the interlocutor is a foreigner 28 the fact that some migrant women have relational circles in which they communicate in their native languages along with the prejudices of catalan and spanish speakers regarding their linguistic competence are extralinguistic factors that feed into each other 10 and greatly and negatively influence the l2 acquisition process moreover some studies 81029 report that some women who begin the formal process of learning catalan or spanish abandon it early which is likely due to reasons related to job instability changes of residence family priorities linguistic insecurity or a lack of spaces to practice etc in the case of moroccan women it seems that family factors are particularly relevant 10 the prioritisation of family needs may be a reason why many women drop out of classes and their learning is stalled especially at the most basic levels taking these factors into account we aim to determine whether organising catalan and spanish courses according to a students gender and origin could have an impact on womens continuation of their studies methodology to achieve the described objective we carried out a study using a qualitative methodology the participants of this study consisted of 8 catalanand spanishteaching professionals working in centres that offer basiclevel courses at reduced prices except for the ngos the rest are public centres namely adult schools specifically consorci per la normalització lingüística and escoles oficials didiomes cpnl and eoi are language schools that offer accredited courses in the ngos and the eas not only language courses but courses of all kinds are offered although all these centres offer initial courses the eois do not offer literacy courses the centres where the informants work are located in the province of girona a high percentage of the citizens of foreign origin living in these areas have moroccan origins 1 data collection has been carried out in two phases between the years 2021 and 202223 data were obtained through semistructured interviews lasting between 30 and 45 min interviews were carried out online in the first period due to the restrictions imposed by and in person at a participants place of work in the second period the interviews were recorded and stored as a wav file under a name identifiable only by the authors in order to preserve the anonymity of the participants the interview guide was structured based on the following general aspects data related to the professionals career data related to teaching migrants data related to basic l2 teachingparticularities data related to teaching migrant women and migrant men experience with teaching in gendersegregated groups perceptions of teaching in gendersegregated groups the interviews were transcribed in order to extract the most relevant units of meaning that emerged from the discourses they were grouped into categories that agglutinated those smaller units of meaning that had something in common the analysis of the results will be presented on the basis of the categories created all interviews were conducted in catalan and the excerpts reproduced herein have been translated by the authors of the study the informants participated in the study after having given informed consent they were given sufficient information to understand the implications of their participation participation in the study was anonymous thus informants are mentioned using the first two letters of their first names and the first letter of their surnames followed by an acronym of the type of centre where they work results the results presented below are organised according to the categories created in the analysis of the interviews professionals perceptions of moroccan women attending courses demand for courses exclusively for women all the interviewed professionals affirmed that in general moroccan women who start language courses have a preference for attending segregated courses it is more common for entities such as ngos and adult schools to form groups exclusively for women than for public institutions they prefer to go to a place where they feel comfortable where there are only women they dont want to go to mixed classes thats why the first years they didnt come here and when they asked if there were men you could see that they were reluctant because there were other places that offered this all the informants regardless of the type of centre in which they worked reported a demand for segregated classes from some users in this regard at the beginning courses were made specifically for moroccan women and for moroccan men because we saw that both men and women told us that they wanted to go separately they also asked us for the teacher to be of a specific gender regarding instances where groups are mixed some of the professionals expressed concern that some groups of moroccan women drop out of courses but that the presence of women increases when women of the same origin are already attending the courses i get the feeling that women carry women i think thats the best network explains mar otherwise it is difficult to even provide them with the information we do not know how to reach this group moroccan origin women we do outreach on the web on facebook but it doesnt reach them its a bit difficult we go to the halal stores to bring publicity to the mosque and when we tell them to tell their wives they say yes but they dont come because they have children and things its difficult reasons for preferring segregated classes socialisation in the classroom one of the most predominant reasons the informants provided in support of the organisation of exclusively female courses is that in this type of group the participants build a space that transcends language learning and more heavily concerns socialisation and the acquisition of knowledge that is useful to them in the early stages of their arrival from their countries of origin this is especially true with respect to the types of courses developed by ngos i believe that this organising segregated groups is an important differential feature that makes us reach a type of collective with more needs and more illiterate our classes are above all a meeting place for women the women who come are very illiterate and our objective is the welcoming and oral part for some women attending classes in segregated groups facilitates interaction with other participants however while the professionals maintained that it is beneficial for female students to socialise they also stated that the high level of interaction which often leads to the use of l1s may prevent them from achieving the objective of the classes there was a good atmosphere because they all got along they met each other they socialised but sometimes we didnt make progress in terms of work because they spoke more in their own language family reconciliation one of the issues highlighted by the professionals is that many women have young children some of whom are not yet in school when it is possible to create female groups efforts are made to choose time slots that allow women to perform tasks associated with family care even so faced with the problem of family reconciliation they sometimes bring their children to class in the centres where the interviewed professionals work this is not allowed and this policy has led to a decrease in the number of women attending the courses at the beginning they came with the children and i understand that it is difficult to leave the children but it is unfeasible first because the city council does not allow us to do so and second because children are children and they behave like children it used to be allowed but if you have one or two children in class you cant do anything it was very difficult for us to make them understand social pressures the preference of some women for segregated courses is also occasionally related to social pressures in some cases these womens families and society do not favourably perceive their attendance of mixed groups which have been composed of both men and women they say they cant because of their husbands because they dont want it they say people talk but when you ask what they mean they say no not you but the other people its a bit cultural motivations for formal learning moroccan women who attend language lessons have different motivations such as seeking to socialise with other women outside their homes to allow themselves to develop minimally in society to obtain a certificate for a residence permit to obtain some type of formal training because they had never been able to do so before or to be part of the educational community of their childrens school and thus help them with their homework i had a moroccan student who reached a very high grade c1 other women said they also wanted to learn catalan because they saw it as the language with which they could participate in their childrens school life and help them however some participants stated that that the moroccan female attendees start with a lack of motivation and they argue that this is an important factor that leads them to fail to recognise that the mixed classes are part of the cultural learning process and thus valuable 4 they have to be taught the importance of learning despite the fact that there are men because the purpose is to learn and the fact that the classes are mixed also helps them to learn that in this society public and private spaces are mixed sharing a space to learn since they do not know the value of learning they do not come if they knew that they are the ones who lose the opportunity for this reason in fact professionals believe that motivation is the most important factor to consider in the fight against early dropout from l2 courses and that all other factors that may hinder formal language learning will disappear over time it takes time it is the complementarity of all gender and training programs as they adapt to the social reality and that this is the offer that exists they will be adapted what happens is that the migratory movements have been exponential and this makes it impossible to raise certain mixed programs because they come from a reality where this still clashes too much 42 professionals perceptions about group organisation 421 ngos and adult schools the need for segregated groups despite the fact that the instructors believed that migrants sometimes misvalue the importance of second language learning interviewed professionals working for ngos or in adult schools explained that the demand for attendance at initial levels in nonmixed groups has remained stable over time that the courses are full and that they are demanded by some groups of women and that their courses are attended by a profile of women who would not attend formal mixedgender courses we have always had an excess of female students in courses for women because word of mouth enrollment never drops public language schools the need for mixed groups on the other hand professionals working in public centres for formal language teaching explained that they did not perceive a need to implement segregated courses because they perceived that there is no longer a demand for them at present 5 at the beginning we had a different profile of moroccan women than the one we have now very illiterate going from home to the school and back they did not socialise they did not integrate into the city the fact that there were men in the classroom made them very selfconscious when it came to speaking expressing themselves or giving their opinion on a subject in the segregated classes it was very different i remember these courses that the first thing they did when they arrived was to take off their headscarves they felt relaxed and in this sense it had advantages but now this no longer happens to us because we have a different profile of women who have no problems when it comes to expressing themselves to express their opinion they are not ashamed to do so now it would not work for us reasons for the decrease in the scheduling of gendersegregated courses although there is a demand for scheduling nonmixed courses as observed by teachers working in ngos or adult schools fewer and fewer nonmixed courses are being scheduled for various reasons in this regard a significant problem is the attendance in the same classroom of women with different language proficiency levels eg literate and nonliterate women women who have a greater degree of oral proficiency in the l2 than others etc at school level when you organise segregated courses you end up mixing levels because otherwise the groups would be too small and when it comes to work it is complicated because there are different levels this generates the need to prepare individualised content on demand if separate courses are offered for women and men it would be more important to combine levels in the same classroom than it would be if mixed classes were offered the difference in the proficiency levels of the learners in the same class is not the only reason for the disappearance of nonmixed courses especially in the public centres that offer regulated courses the philosophy of the public centres is one of integration inclusion and equality regardless of nationality and gender it was concluded that it was not too i dont know if i should say ethical to divide by gender right in the end they are people no matter where they come from and what gender they are and they all have to go in the same group if they have the same level the consorci is based more on their language level than on their nationality gender or these criteria we do not offer courses for a nationality i think it would go a bit against the philosophy of the school which is integration the best thing for me is to see that a woman from india a russian man and a moroccan woman are struggling to speak the language i teach them and they dont have english or any other language as a resource this is perfect discussion the starting point of this study was exploring secondlanguagelearning experiences while accounting for the gender origins and cultural background of the students to uncover the extent to which and in what way these characteristics may have an impact on the learning process and determine whether they should be taken into account in the organisation of formal l2 courses this study was based on the perceptions of l2 teachers in relation to moroccan women who attend courses in order to understand the needs of this group and the reasons and criteria regarding the organisation of language courses by public and private institutions at reduced prices before discussing the results it is important to remember that the role of gender cannot be considered immutably and in isolation this role changes and it must be studied in relation to categories such as ethnicity nationality educational level or social class 313 in this study we have focused on a group of migrant women of moroccan origin and we have observed that the interaction of these factors generates differences among these women for example certain characteristics such as the level of education and others conditioned by social class coincide with a greater desire to attend courses without a male presence thus in general terms interviews with teachers working in schools with different characteristics have allowed us to determine that cpnl is attended by women with a certain level of education without problems regarding socialising with men and women and with gender roles similar to those of the host society this same profile was found in with respect to eoi although this type of centre has a specific factor to account for it prepares students for official exams thus attracting more diverse profiles in terms of origin gender social class etc as can be seen from the results adult schools and ngos attract newcomers and professionals working in and for these schools and ngos report that there is a demand for the formation of segregated groups of moroccan women although group segregation is employed increasingly infrequently segregated groups have their own characteristics that need to be taken into consideration on the one hand the interviewed teachers maintained that such groups are attended by women who feel they are in a safe environment in which to socialise and thus speak with more confidence according to the participants the main objective of the women who request this type of group is not to obtain a certificate or reach a certain language level but rather to feel that they are in a safe environment according to the data this environment is partly due to the absence of men and this fact constitutes a key point to be analysed because of its important influence on the learning process 10 the fact that there is a vital separation in all contexts between men and women in moroccan society 14 allows female learners coming from these traditional contexts to feel more comfortable socialising in nonmixed environments one of the most important influential factors in second language learning is the attitude of the learners the more motivation that is produced with respect to the l2 the more the learning progresses 1130 in this sense having spaces where interaction between learners is promoted improves language learning class attendance for moroccan migrant women appears to be impacted by their culturally prescribed gender roles in various ways not only by the presence or absence of men in class but also by their family responsibilities some female learners are responsible for children who are not yet in school and not being able to attend class with them leads many women to abandon their l2 classes prematurely as the presence of children in class makes teaching difficult centres have stopped allowing their presence and this action might have led to a decrease in attendance by women the learners decision not to attend classes in the presence of men and the difficulties in reconciling school attendance with family duties is related to the role of women in moroccan society which is reproduced in the migratory context the situation in which these women find themselves is sometimes not perceived by some professionals who explain their refusal to attend mixed courses on the grounds of a lack of motivation they have to be taught the importance of learning despite the fact that there are men if they knew that they are the ones who lose the opportunity for this reason exclaimed cir a teacher at an adult school as can be seen from the results some professionals perceive that female apprentices have not identified language learning as a key point for their full societal integration despite the fact that this rejection of mixed groups by a certain profile of women seems to be a more complex issue in any case the possibility that language may be not perceived as a key point in the process of full integration is due to a large extent to the type of socialisation and the learners employment situation the former is a very complex issue since to a large extent it is the host language that will allow the learners to open their relational circles however since they are within the circle they do not believe it is necessary to leave it nor do they have opportunities to use the l2 and the fewer opportunities for use the worse the level of learning in addition the jobs these women perform are domestic or traditionally feminised tasks for which they do not need the host language despite recognising the demand for segregated groups all the informants pointed out that the organisation of groups according to proficiency level offers some advantages one such advantage is that organisation according to proficiency level makes it possible to reduce the presence in the same group of women who have different levels of l2 proficiency and this facilitates the formal learning process not only is the disparity of levels a barrier to formal language acquisition but the socialisation promoted in these female spaces ends up becoming an impediment to the acquisition of the l2 since it promotes the greater use of the l1 in the classroom but one should not forget the importance of affective factors with respect to second language acquisition being in a comfortable environment in which one is willing to speak seems to be more conducive to l2 acquisition 111230 so and although it may seem contradictory what emerges from the different points of view is that despite the added difficulty of the formal second language acquisition process resulting from the existence of mixed levels participation in mixedlevel language courses seems to be better than no second language acquisition at all which means that learners drop out of school because there are no appropriate classes for them however according to the teachers views in relation to the priorities of schools the fundamental factor of organising groups by levels and not according to the characteristics of the gender and origin of the learners is related to the criterion of equality and the perception of diversity as a richness and the teachers argue that this favours the acquisition of the host language and the learners integration in the corresponding community this relationship which seems indisputable from the point of view of the host society can end up contributing to increasing inequalities as mentioned some learners do not attend courses organised by public entities such as the eoi or cpnl which are specialised in formal l2 teaching instead turning to adult schools and courses organised by ngos the demand for this type of group exists despite the fact that teachers working in formal centres such as cpnl do not perceive it in this way and are often unaware that this cohort continues to exist but attends other types of centres the learning barriers of this group are a very complex issue as they involve extralinguistic factors that cannot be ignored it seems that a model closer to the one proposed by ngos and adult schools would contribute to the greater inclusion of the most vulnerable less literate groups of moroccan women however public centres such as cpnl or eoi have been moving in the opposite direction abandoning segregated courses and promoting organisation according to levels since the most vulnerable women cannot access centres dedicated exclusively to l2 teaching many end up attending courses organised by ngos and entities whose main objective is not l2 teaching and they also receive less adept help since the professionals working in ngos are generally not as highly trained as those in the public centres conclusions in migratory contexts l2 learning plays a fundamental role in overcoming the obstacles linked to their conditions as women and migrants although courses in catalan or spanish should not be organised around the needs of one group of students we believe that factors linked to gender origin social class and educational level should be taken into account when understanding why some migrant women are unable or unwilling to attend mixedgroup classes this cohort constitutes a group of people who find it difficult to participate in the host society for them learning a l2 means acquiring an instrument that allows them to create an interrelational network and access a less precarious labour market and these affordances can help them to change certain imposed gender roles although the ultimate objective of catalan or spanish courses is the acquisition of a certain competence in catalan and spanish the reality is that the needs of certain female learners of moroccan origin are related to other motivations that must be taken into account when analysing and describing their learning processes this study is not without its limitations most of which stem from the fact that the sample from which the results have been obtained is made up of exclusively teachers it should be borne in mind that teachers are aware of both realities namely that of the institution and that of their students the fact that they work in institutions with different characteristics has allowed us to acquire a more complete picture of the phenomenon under study thus their perceptions have allowed us to determine that there are indeed particularities that affect this group of moroccan women and considering everything described above we believe that a need for segregated groups could have emerged although it may seem that the fact that the public centres organise groups according to characteristics linked to origin and gender may be at odds with the criteria of equality that guide public education in the host territory the fact is that there is a group of women ie those most vulnerable within the analysed population who cannot attend mixed groups ignoring them means ignoring their reality and leaving them with fewer opportunities to hold better jobs and expand their social networks should they wish to do so as competence in the language of the host country is essential for the integration of migrants and refugees 45h course to obtain the papers darrelament but if the students do not try surely they will be spanish they will grow up 5 in the case of eoi when preparing for the official language exams one of which allows for the acquisition of citizenship the situation is a little different on the one hand they do not admit nonliterate people on the other hand some women attend these courses because there is no alternative despite the fact that some professors have observed the preference that they and their husbands or families would have for them to attend classes in segregated groupswith the a2 you can apply for citizenship our certificate is comparable to the cervantes certificate and there is a profile of people who demand it women sometimes come with their husbands i talk to them i try to explain directly to them the women because they are the ones who will stay in class they seem to be reluctant but it is necessary to get the level data availability statement the data presented in this study are available on request from the corresponding author the data are not publicly available due to a participants request for privacy notes 1 in this case we consider both the lack of knowledge of the latin alphabet and the alifat alphabet furthermore it is important to mention that there are women who are partially illiterate since they are familiar with reading but not writing the opposite case can occur but much less frequently there are also migration projects in which women emigrate first and men leave the country to join them and even joint projects in which the planning of migration strategies is shared both situations however are much less frequent 3 in addition family reunification precipitates the legal dependency of the reunited person with respect to the sponsor this means that the legal residence of the woman in spain is much more vulnerable than that of the man since in a divorce case the regrouped finds themselves in a situation of irregularity and illegality in the host country 4 although it is not the objective of this work for future studies it is important to consider the difference in the motivations and objectives of the students who enrol in spanish or catalan classesyes they see that spanish is something that will be useful to work to live to communicate because many people demand spanish rather than catalan catalan is good because they need a

in catalonia the largest group of immigrants is that of moroccan origin some moroccan women are conditioned by a traditional family model that is concretised by the spatial separation between men and women in all spheres of society a fact that influences the socialisation of these women and that in a migratory context may have an impact on their early abandonment of formal second language courses accordingly this study aims to analyse the importance of accounting for the culture and gender factors in language teaching in a migratory context we conducted semistructured interviews with eight teachers of catalan and spanish as a second language as they are the link between the institution and the students the results suggest that providing instruction to segregated groups might grant women who are unable to participate in mixedgender language classes the opportunity to increase their second language proficiency and thus facilitate their integration into the corresponding host territory offering genderspecific courses is a particular challenge for public l2 schools where groups are organised according to the learners levels and not according to characteristics linked to origin and gender as the latter practice may be at odds with the criteria of equality that guide public education in the host territory

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introduction the field of critical research is wellestablished across multiple disciples and is rooted in social justice principles specifically critical research has made important contributions to 1 interrogating power differences in research 2 using research to reveal sites for change and activism 3 foregrounding the voices of the oppressed and 4 creating changes in our understanding of diversity thereby broadening discourses within the field of critical research indigenous methodologies are increasingly gaining attention in academic institutions linda tuhiwai smith describes how research has been historically linked to western imperialism and colonialism historically research has been conducted by and for white people of european descent on indigenous research subjects as a result in academic settings indigenous peoples stories have been told by outsiders and this has led to misrepresentation and denial of peoples rights to selfdetermination based on this history tuhiwai smith defines research as one of the dirtiest words in indigenous vocabulary in response to injustices carried out in the name of research indigenous scholars have demonstrated how indigenous values can guide research to transform a dark academic history some of these values include 1 an epistemological position that differs from western thought and ways of knowing 2 accountability to family clans places and nonhuman beings or nature 3 knowledge emerging from relationships with the land as well as from nonhuman beings among others when indigenous values guide research the impacts can include 1 accurately representing people and their culture 2 individual and community healing and 3 the survival of identities the majority of case studies that examine indigenous values and ethics in research come from scholars working in the global north in countries such as australia canada new zealand and the united states of america there is however a growing theoretical and conceptual discussion about indigenous knowledges and how this relates to methodologies in the global south specifically in reference to african perspectives there has been a deep consideration of how hidden western discourses may influence and skew research mukherji argues for the need to debate the assumed universal application of westernised social science methodologies in the south asian context in latin america there is a growing dialogue about decolonizing academia by both indigenous and nonindigenous scholars despite a rich academic dialogue fewer studies examine how indigenous methodologies are applied in the global south our goal is to expand our knowledge of how to apply indigenous methodologies in the global south more specifically our work fills an important gap that is to better understand better how crosscultural teams working across northsouth collaborations can apply indigenous values to their research fisher shang and xie examined how to apply principles of critical research in a northsouth partnership however these scholars did not work with indigenous methodologies as we did in the present study understanding the application indigenous values in northsouth partnerships is important because many research and development projects in the global north are designed to support indigenous development in the global south the underlying political rationale behind such development projects requires illumination as these development projects can exert significant pressure to produce outcomes that are tailored to the needs of sponsoring western countries and their private andor government sectors even in cases where project goals may be compatible with some development goals in the south funding limitations and deadlines can promote research that does not dedicate the time or resources needed to do ethical research this fast productoriented extractive research can affect the quality of scholarship as well as reinforce the dominance of western values and the exclusion of indigenous ones with the aim of circumventing the negative impacts of outsider imposed fastpace research in a northsouth crosscultural research collaboration with indigenous communities we applied an indigenous research methodology to the first stages of our work specifically our research took place in costa rica and was funded by anonymous our topic was to better understand how the united nations sustainable development goals are relevant to indigenous peoples daily lives and realities the projects main aim was to bring together indigenous leaders from malaysia and costa rica to create constructive dialogues where grievances as well as solutions would be explored and presented as recommendations to inform national policy change the first phase of our work was in the talamanca bribri territory where we were guests exploring building research relationships and exploring the research questions because the first phase of this project was held in the bribri talamanca territory we chose to use a bribri indigenous approach to research applying a bribri approach was possible because anonymous has worked on this methodology for decades with his elders when we engage in phase two of this project we will be guests of the jakun people residing in the community in pahang malaysia there we will learn and apply jakun knowledge sharing approaches this research was approved by the anonymous community traditional authority who anonymous consulted with before any community visits for this project took place secondly this research was approved by the ethics committee the aims of this paper are to 1 describe how we applied bribri values to this projects methodology and 2 highlight our successes and challenges in the process we organize our paper as follows first we provide a background on the project its collaborators and their institutions second using the principle of reflexivity we analyzed all stages of the research process from building our collaboration to the publication of our results in order to highlight lessons learned our findings will be relevant to researchers and practitioners working within indigenousnonindigenous andor northsouth research teams who aim to minimize reinforcing power inequalities in their work the bribri talamanca territory and research collaboration details the research project is entitled being developed comparing the experiences of economic and social development among indigenous groups in malaysia and costa rica the rationale for this project was to explore the perceived impact of the united nations sustainable development goals on two nation states with indigenous populations but with differing sustainable development agendas the impacts of such agendas are experienced directly by indigenous communities in terms of their right to ownership and access of traditional territories and the rights to practice traditional lifestyles these rights are recognized in the un declaration on the rights of indigenous people to which both malaysia and costa rica are signatories costa rica and malaysia were chosen because the former provided a very useful comparison with the latter in terms of similarities and contrasts developing nations rich natural biodiverse resources an indigenous minority population clear socioeconomic development agendas as well as being signatories to the un sdgs which refers to indigenous people among other issues a second strong consideration is that the researchers have longterm academic experience working in these countries a third reason these countries were chosen is because our funding body would consider only those countries of low to middle income according to the world bank country classification index our project was an interdisciplinary study to enable indigenous leaders in malaysia to exchange knowledge and experiences with bribri indigenous leaders in costa rica and vice versa bringing indigenous leaders together in both countries has created a cycle of dialogues to better understand how sdgs can be made to work for the benefit of indigenous peoples locally leading to enhanced poverty reduction conservation of traditional territories better health and wellbeing reduced social inequalities and ensuring that habitats are more sustainable for all citizens the specific goals of this project were to better understand indigenous perspectives of development and the process was as important as the products our study of development was not limited to asking indigenous people what their perspectives on the sdgs or the national development agendas but also included community visits engaging in dialogue and practices using indigenous approaches to sharing and conversing practices that are examples of development the products of this research include jakun and bribri definitions of development as expressed in practices as well as cultural knowledge and values indigenous scholars have expressed the need to better incorporate indigenous perspectives with the 2030 development agenda and our goal was to contribute to this intercultural development perspective our research team comprised of 1 two uk researchers 2 one bribri researcher 3 a semelai researcher and 4 a canadian researcher for this first phase of our work in costa rica we worked in the talamanca bribri territory the talamanca bribri indigenous territory is located in the talamanca county and the limón province in the southeastern region of costa rica bribri people have lived in the talamanca region since time immemorial in 2011 there were 7772 bribri people living in this territory specifically we worked with family and residents of the anonymous community the majority of residents work in export agriculture and a few earn income as teachers and or labourers building a collaboration this research started when researchers from the uk contacted researchers from costa rica via email to invite them to collaborate in the project the main project goals were developed by the uk researchers however in early conversations explained the need to do research based on bribri methodologies to make space for indigenous protocols values and ethics in academic research been doing research based on bribri values for over three decades and was selected by his elders to do so applying indigenous values requires nonindigenous researchers to practice critical selfreflection of the biases and power dynamics we bring to collaboration and to be open to sharing these reflections in the rest of this paper we share our collective reflexivity regarding our research process framing the collaboration based on ulàpeitök a bribri way of working together ulàpeitök is a traditional form of bribri collaboration and translates to lend a hand traditionally this concept is used when a family requires extra help with a task and often it is described in the context of working on the land for example if a person is growing corn using shifting cultivation a person can request ulàpeitök of their relatives clan members or friends requesting ulàpeitök implies that the person requesting assistance will provide people working with a meal and blo this is not a direct payment of one meal for one person however it includes family members and children and people take home food to ulàpeitök shaped many aspects of our collaboration including how we negotiated the complexities of allocating western audited research funding appropriately at the community level explains that direct monetary exchange for food and accommodation is not compatible with bribri values nor with community development instead following ulàpeitök researchers are encouraged to provide an amount of money determined by a community collaborator and his family and relatives as a contribution to ulàpeitök this money is used to prepare food during a research stay for everyone not only the researchers and can be used by family members of the community collaborator for other purposes a pig is one example of something that can purchased with this money pig meat is prepared as food for both researchers as well as host families and extra pig meat is then sold to other community members to provide extra income for families hosting researchers other ways a payment for ulàpeitök was used in our case was to compensate community members to harvest local and wild foods money is thus not directly exchanged for food and accommodation in a way that only one household would benefit but rather used in a way that it provides food for researchers but also stimulates cultural practices such as traditional food harvesting as well as provides resources for multiple families and community members applying ulàpeitök also meant that there was an abundance of traditional food being prepared in s familys homes while we were staying here and while we were doing research this meant that when research participants were invited to come to his family members homes to participate in conversation interviews they were also offered a meal and this meal included traditional and wild foods that research participants received a welcome with a traditional meal further reinforces bribri values and culture in data gathering who has worked with this bribri community for a decade now explains that when she has done interviews on her own approaching individual homes she often resorts to bringing something she can buy in a corner store such as imported rice or packaged coffee although this offering is appreciated it reinforces a conventional and nonbribri way of doing research but when research is done within family homes sharing traditional local food prepared by host families research participants are welcomed with a practice that illustrates respect and prioritization of bribi ways of working together in western cultures money is often exchanged for goods and services and it is not uncommon that during research outsiders pay a set fee for food and accommodation explains that this is not desirable if one is seeking to respect bribri values furthermore paying for services defined by western values can further contribute to perpetuating research as a colonial intervention specifically if a researcher pays only for their individual accommodation or meals then the emphasis in on the individual whereas from a bribri point of view the emphasis is on collaborating with social units entire families and the community as a whole emphasis on the individual versus the community is a key contrast among western and indigenous research one example from our own research illustrates this point in common with most competitive research funding bids require evidence of cost effectiveness and due financial accountability from researchers in this initial stage costs had been based roughly on previous ethnographic studies undertaken in developing nations by the uk researchers however in discussion with the costa ricanbased colleagues it was explained that these were insufficient to cover the expectations of work in the bribri community based on these concepts of ulàpeitök this was a serious consideration as the existing budget did not cover this eventuality where it had been assumed that subsistence and stay would be cheaper in the community than commercial rates in the city there were also other expenses that had not been accounted for involved in staying with the community such as honoraria that now needed to be accommodated potentially offering a serious stumbling block to progress it was extremely fortuitous that these expenses could ultimately be met from two different funding sources in the uk where cultural expectations in respect of financial reciprocity made for a successful appeal this however shows some key differences between a western and indigenous perspective where in developed nations there is a focus on research auditing based on economic per capita considerations whereas an indigenous view may focus on relational and community conventions explains this we need to see this research through indigenous models or ways of life and ask ourselves how can we collaborate we cannot measure this collaboration based only on economic terms… ulàpeitök is a concept of community and social development every action that one does needs to be integral it needs to be an action that benefits many people my son my daughter my wife my husband my grandma everyone in the house where you are staying as margaret kovach states colonial interruptions of indigenous culture have occurred and continue to occur and they have become part of indigenous collective experiences people young and older experience these colonial interruptions in daytoday life and they are part of the takenforgranted normativity of western research therefore as researchers we need to be aware of past and current colonial practices to highlight how actions such as how we choose to plan for research room and board or how we share the benefits and costs of research can reinforce the suppression of indigenous values perpetuate narratives of what is legitimate as research and can exert the primacy of western approaches data gathering and knowledge sharing through conversation conversation has been described as an indigenous method that honours the oral nature of knowledge sharing the conversation method provides space time and an environment for participants to share their story in a manner that they can direct without the periodic disruptions involved in adhering to a structured approach as in an interview format beyond the ease that conversation as a data gathering method can afford research participants describes other reasons why conversation skõṕàkö is culturally appropriate specifically the meaning of skõṕàkö comes from se kṍ what we both know… our language does not put any one person above the other it says lets touch and feel our surroundings it puts our knowledge at the same level and implies that we both have the possibility and capacity to perceive our surroundings when someone refers to an interview or to asking questions this does not reflect our reality because indigenous people bribri cabécar and nasö do not ask questions asking questions for us is a way of measuring what the other person knows and therefore it is a form of aggression asking questions implies that you are looking to see if i know something underlying this is the message that you think i do not know due to the fact that the conversation method honours bribri culture we chose this method to gather and share knowledge for the benefits go beyond honouring bribri practices and are also related to the quality of information that you obtain in conventional interviews interview guides are often predesigned and interview sessions are scheduled at a set time this however for is not the way bribri knowledge sharing occurs this structured and scheduled format focused on product versus process can even elicit information that does not accurately represent bribri people or their way of life or can result in short responses that do not convey the complexity of a situation in such settings many bribri people in his community have historically and continue to respond explains either in a short concise way to questions andor people provide answers that they believe outsider researchers want to hear for these reasons describes why he does not use conventional interview methods he conveys this message while referring to his own experiences interviewing a highly respected elder and awá don francisco garcía when he was a youth i never work with people and say ok now tell me about a certain thing instead when they want to sit with me we will talk…this was even the case with my paternal uncle don francisco who asked me to record his teachings i didnt ask him to tell me about a specific thing i just listened remember that bribri and cabécar people feel things and when he don francisco felt the need to transmit something he would you could ask him to tell you about something… but he would respond two words and that was it then he would talk about something else he would talk for an hour or half an hour talking about something else extremely important as well but he would share what he felt like sharing not necessarily what you asked him this process of conversation as data gathering fits well with the nonindigenous researchers backgrounds in ethnographic research a process of immersion into and alongside community members where slowness and relationship building are key and where in contemporary ethnographic practices cocreation and coconstruction of knowledge and understandings sit conversation also respects as other indigenous scholars have written the view that there are stages of initiation to knowledge and that knowledge is contextual and requires the understanding of relationships patterns and cycles slowing down and focusing on process owing once again to budgetary restrictions fieldwork was at first visualized as reliant on intensive periods of data gathering by the academic team but where professional facilitation by the indigenous colleagues respectively would enable the community to work in a coresearcher paradigm this latter plan took root once it was established that an intensive fieldwork trip was better curtailed to a short stay where introductions could be made and the research questions explored and considered by the community data was then gathered by and his community for the first phase of the project as explains relationship building takes priority in order to avoid replicating fastpace extractive productoriented work that can constitute the kind of outputdriven costorientated efficiencies that are valued in western contexts rejects the latter form of research because it does not adhere to the bribri principle of building relationships nor does it produce accurate information about his culture and community members in reflecting on this process with his family members offers their view that in the end the visit to the community was too short bribri community members were still left curious about how the jakun and semelai people guests in their community live their lives explains that bribri people do not talk about things but rather they do them for this reason bribri community members also were left wanting to share more about their culture via actions such as forest walks farming harvesting food preparation andor artisan activities participating in community activities explains is more valuable than interviewing people about a particular topic participation demonstrates you really want to know about his culture modifying a research project to include more time and more community visits increased the economic needs of the research this required renegotiating with budget holders in the uk to release more funds than had earlier been requested which then had been based on the assumption that fieldwork could be contained within one period of time eventually two sources of additional funding were tapped an unusual and fortuitous circumstance and these sources accepted our rationale of the time needed and resources needed to comply with indigenous research protocol that this projects funding was increased is the exception rather than the rule and one reviewer of this paper importantly questioned what we would have done otherwise the latter was an important point raised by bribri researcher in our process specifically he highlighted how a lack funding to do research in a way respectful of his community protocol would have jeopardized community relationships thus to build respectful community relationships we need to decolonize funding bodies and academic institutions a process that can be supported by international guidelines specifically the international society for ethnobiologys ise code of ethics articulates the need to raise awareness within funding bodies and academic institutions about the increased time and costs associated with indigenous research that may be …in addition to or even inconsistent with the policies of sponsoring institutions research outcomes margaret kovach states indigenous methodologies require methods that give back to community members in a way that are useful to them giving back involves knowing what useful means and so having a relationship with the community so that the community can identify what is relevant mcgregor and marker outline important questions researchers need to ask themselves about reciprocity when working with indigenous people including 1 whose expectations are most important to fulfill …those of the research participants the community to which they belong the academic institution or research ethics board or the researcher themselves and 2 do university researchers ever offer people from communities something they really need our project was designed so that the outcomes of our work could be identified by community members themselves and required researchers to have close relationships with the community the uk researchers with over 20 years researching in malaysia have developed good working relationships with the malaysian community over the past five years and maintained contact with individual members through such means as social media and contact with indigenous activist networks is a member of the bribri community and has worked with bribri community members for 10 years these relationships allowed us to determine the most useful and relevant outcomes for this project as it evolves below we describe the written outcomes of our work and some of the lessons learned in this process however despite the importance of compiling stories and publishing our research outcomes the indigenous exchanges and dialogues were of the most valuable outcomes this includes exchanges during the research process as well as those that ensued once the official research trips were complete indigenous exchanges area a form of reciprocity via sharing knowledge something leaders felt important to carry forward within their home communities and activism projects more specifically bringing indigenous leaders together was reported by jakun and bribri leaders to be extremely valuable to see and experience common strengths as well as challenges hernan garcía bribri elder explained how it was important to see how stateimposed policies of development regarding mining and industrial agriculture without respect for jakun rights has led to areas of their territory that as he observed and stated were no longer alive he explained how it is important to share this message with his community because similar development interventions could happen to them at any time in their territory seeing indigenous rights violations in malaysia reinforced his view that bribri people need to continue to strengthen their rights jakun elder ismail muhamad who travelled to costa rica described how what he saw in the bribri territory reminded himself of his community years back specifically he was moved by the strength of bribri peoples collective strength in the defensive of their land and culture as well as the health of the land and forests after returning home he said he was motivated to continue his work on strengthening indigenous rights in malaysia leaders from malaysia and costa rica both expressed the importance of hearing inspiring messages from elders in other cultural contexts these messages they described helped them learn how they are not alone in their struggles and were important messages to share with community youth furthermore one bribri elder hernan garcía stated how he felt it was important to see how indigenous people in malaysia respect elders just as bribri people do he wanted to convey this message to him community owing to the importance of storytelling in indigenous cultures one of the research outcomes proposed by indigenous community members was the compilation of stories based on bribri and jakun perspectives on sustainable development as well as on other aspects of their lives and history indigenous researchers have expressed how the use of story without an understanding of cultural epistemology can create problems in accurately representing indigenous knowledge has decades of experience working with elders of his home community gathering stories and conveys the deep responsibility of ensuring cultural accuracy when oral story is transformed into written text our project illustrates how cultural accuracy is important not only in reporting indigenous stories but also when outsider researchers are the primary authors of academic publications one paper we wrote was reviewed by the indigenous researchers on our team where some terms and concepts were discussed in order to avoid cultural misrepresentation that could potentially perpetuate power differences that reflect colonial relations the word poverty was identified as one that exemplifies very different attitudes among the research team where it had at first been used to describe conditions in indigenous communities and is one of the challenges identified by the un sdgs after some discussion of language the terms poverty as well as village were substituted in our publication in respect of the meanings of these terms for the bribri community elaborates on this further when articles are published at least in costa rica people become easily influenced by them and attached to their messages if you use the word village people understand it as some abandoned area a society that is backwards…something like indiana jones…poverty is another erroneous term indigenous people are not poor the word does not even exist in the bribri and cabécar cultures the word is an outside imposition and it is something created from capitalism it poverty is a way to dupe people so that they believe that indigenous peoples are so poor with nothing and thus they can say anything they want or do anything they want to them it is an indirect way to invalidate knowledge wisdom identity local economy… poverty is used to say that because people are poor i can simply do what i want with them the fact that these indigenous peoples do not have access or production of metal coins does not mean they are poor they have a different development model a local economy one that is not based on dollars or colones or euros but that is a way of life therefore because in our project we are reclaiming indigenous models it seems contradictory to use terminology that illustrates to society that indigenous people are… poor living in a village and are a backwards… for this reason i recommend eliminating these terms they are subtle changes but at the same time very significant clearly illustrates three key points when supporting indigenous scholarship first the need to understand history and how indigenous people have been described and treated by the dominant culture describing indigenous people as poor in costa rica has been used as reason as explains to do impose education religion and healthcare practices that are not their own using this type of language can perpetuate erroneous stereotypes that have and continue to result in what refers to as cultural genocide second illustrates the need to decolonize ourselves kovach describes this as exploring ones own beliefs and values about knowledge and how it shapes practices third illustrates the need to redefine roles in academic research scholars question the place of nonindigenous people in indigenous scholarship and highlight how nonindigenous people need to support not weaken the work of indigenous scholars working on teams with indigenous researchers means ensuring that these researchers are not only names on our publications but are active authors of their cultural realities despite that the poverty does not carry negative connotations in the uk context for our research team and that it is a term commonly used within social policy academic and media contexts our work illustrates why in crosscultural research research articles must be reviewed by indigenous colleagues to avoid perpetuating erroneous stereotypes authorship and intellectual property rights and cultural rights were also discussed in early stages of our collaboration to respect indigenous iprs and cultural rights it was agreed that stories would only be written up by indigenous with guidance of their elders for example wrote up one bribri story that for him describes a bribri form of development with the support of his elders thus this story does not have any single author but rather belongs to bribri people and he is named as the cultural translator and interpreter and his elders are named as those who told the story to him these stories will be created into education materials for indigenous and nonindigenous audiences and will not be commercialized other outcomes of this project are peerreviewed publications we agreed that each researcher would take the lead on one article and thus will be its lead author each member of the research team will also be a coauthor on these publications institutional constraints associated with indigenous research academic and funding institutions also need decolonization as these will not always as amenable to some of the additional expenses associated with research with indigenous communities as the uk funding streams proved to be in our specific case and project as one reviewer of this paper importantly highlighted academic and funding institutions are governed by colonial policies laws and mandates with legal accountabilities and this complex system is extremely complex and thus challenging to decolonize nonetheless researchers can play an important role in this institutional decolonization process by including elements central to indigenous research such as increased time in a community to account for trust building honoraria for elders cultural and language translators dissemination in indigenous languages as well as other more context specific needs such as ulàpeitök in our case ethnographic research has long reflected upon the need for meaningful relationshipbuilding coproduction of knowledge collaboration in data analysis and dissemination and translation of results into multiple languages however we also need decolonization of institutional cultures so that researchers requests are honoured by funders and academic institutions commensurately berg and seeber discuss how universities research goals are becoming increasingly aligned with corporate goals and values which has created a push for research that is profitable something that is compromising intellectual community and knowledge diversity these authors call this the supermarket model of research a corporate model of research based on speed competition and profit one that threatens to exclude research that does not fit this model power and privilege interrogating privilege is central to indigenous research one critique of two of our authors previous research was the disparity in opportunities for research specifically that nonindigenous researchers often have the opportunity to travel to indigenous communities to learn about their culture but that the reverse is rarely the case our project was designed so that both indigenous researchers and community members would travel abroad to learn from cultures different to their own a key aspect of the project being dialogical encounters between indigenous peoples for transformational change despite creating opportunities for indigenous people to travel it may not be enough to include community members in travel plans without accounting for power and privilege three of our indigenous participants had never travelled abroad thus necessitating new passports being obtained as well as acquiring luggage and appropriate clothes furthermore participating in the research demands financial sacrifice for some of our indigenous participants regardless that subsistence accommodation and travel are covered by research funds one participant for instance is a farmer who is not paid a salary but rather paid based on the food they produce leaving his home community to travel to malaysia meant him losing over two weeks of work without any other income to fall back on this was equally true of our malaysian participants travelling to costa rica in phase one and exemplifyes the commitment of the indigenous participants to this study however to offset financial losses through payment for participation can create tensions in some contexts in the uk context particularly it can be considered questionable to pay research participants for involvement in research because this payment could potentially affect research findings the latter is being actively addressed in canada where many universities have established honorarium payment guidelines for indigenous people in the context of research and education conclusion we all hold the responsibility and challenge to provide space for indigenous methodologies and this is different than carrying out research in indigenous communities kovach shares that indigenous research frameworks provide opportunities for tribal epistemologies to enter the tightly guarded academic research community in the global south despite a strong literature on decolonization of academia few studies have been published regarding the practical application of indigenous methodologies in academic research filling this gap is important because a lack of literature on how to apply indigenous methodologies slows decolonization efforts in academia our research contributes to this gap and illustrates some of the successes and challenges of doing so in a northsouth research collaboration working on a team of indigenous and nonindigenous researchers our research specifically revealed three key findings first it was essential to have the important conversations early on in the project about how this research could be completed in a way that is mindful of colonial interruptions of indigenous culture and we could avoid reinforcing negative impacts more specifically we illustrate the importance of understanding how indigenous concepts of how collaboration and reciprocity are conceptualised before a project is planned or financed having the values for collaboration defined before funding is applied for will help ensure that there will be sufficient resources to account for elements of research that may not be common practice for outsiders to a community secondly we found that western academic concepts of reciprocity need to be decolonized to include indigenous ways of being and relating to others in our case reciprocity in the form of ulàpeitök includes more than onetoone exchanges and emphasizes the community over the individual third our project revealed the importance of language in research dissemination the use of the term poverty in our case was a key example in the bribri context using poverty to describe bribri people was described as reinforcing colonialindigenous relations used to perpetuate discrimination and inequality in the uk context poverty was seen as factual language analytically structural and in terms of empowerment a sociopolitical tool to challenge disadvantage the unpacking of meaning is increasingly possible when research is slowed down to devote time to examine crosscultural nuances in the writing of research results overall it is our hope that our lessons learned can inform other northsouth indigenousnonindigenous research collaborations and contribute to the wider process of decolonizing academic research

this paper represents our collective reflexivity in the process of applying an indigenous methodology in a northsouth crosscultural collaboration funded through anonymous the projects aim was to bring together bribri and jakun leaders from costa rica and malaysia for constructive dialogues about sustainable development specifically we applied ulàpeitök a concept of collaboration that honours family and community we also used skõṕàkö the bribri word for conversation a concept that translates to feeling the space around each other together we analyze successes and challenges and elaborate on lessons learned including 1 how and why indigenous collaboration and reciprocity should be understood before a project is planned or financed 2 why western academic concepts of reciprocity such as onetoone exchanges need to be decolonized to include indigenous ways of being and relating to others and 3 paying special attention to language in the cowriting of publications to avoid cultural misrepresentation our research can inform other northsouth indigenousnonindigenous collaborations that aim to contribute to decolonizing research

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introduction our work draws from an easily shareable statement it is preferable to live in a society endowed with a high level of cultural goods translating the above assessment into economic terms we can say that both the offer and the consumption of cultural goods generate a positive externality for society as a whole 1 often such externalities are not fully internalised by subjects cultural goods consist of tangible or intangible items of cultural significance such as heritage works of art literature and music etc in the same vein unesco 2 reported cultural goods are the results of individual or collective creativity include printed matter and literature music visual arts cinema and photography radio and television games and sporting goods in the case in question as in the general case of pure public goods leaving the job of supporting the supply of cultural goods up to individual contributions leads to inefficient levels of provision in particular for each subject not to contribute to the cultural goods offer and enjoy the benefits is a dominant strategy despite this theorical assumption positive levels of contribution of cultural goods are found in the real world economists provide several reasons for the benefits which individuals take from voluntary contributions among others we can cite the pursuit of more prestige 3 of social approval 4 the warm glow effect 5 and the principle of reciprocity 6 the most significant effect resulting from subjects choice to contribute is the accumulation of cultural capital which throsby 7 defined as an asset that embodies stores or provides cultural value in addition to whatever economic value it may possess the accumulation of cultural capital increases in turn the stock of cultural capital which refers to the quantity of such capital in existence at a given time in our model we assume that individuals join the process of cultural capital accumulation both through voluntary contributions and tax payment which determine cultural capital in each period however as suggested by 8 a relevant portion of people may not be familiar with cultural goods in order to fill this gap investments in cultural education lead to cultural capital accumulation which results in a more cultivated society in fact society starting from initial higher levels of cultural capital results in a faster flow of cultural services 9 in this regard molina et al 10 showed that education level positively affects peoples response to cultural matters in fact formal and informal education is found to be an important determinant of culturalartistic consumption 11 additionally we consider another crucial aspect for this model which is cultural sensitivity in particular greater quantities of cultural capital and individual contributions result in an increase in cultural sensitivity meant both as greater attention to the public goods offer and a greater satisfaction resulting from cultural goods consumption we fully acknowledge that the accumulation process deals with experiential goods carrying relevant positive externalities being almost public goods 12 however although it is undeniable that the agents base their decisions of consumption of cultural goods on quality variables more than prices 111314 the investigation of the role of quality characteristics on cultural goods demand is beyond the scope of this paper based on the above we can imagine the establishment of a virtuous circle as described in figure 1 indeed a higher level of cultural sensitivity leads to a growing interest in cultural goods and a greater propensity towards such goods consumption given the premises it becomes possible to witness an increase in individual voluntary contributions which thus triggers an increase in the cultural goods private offer once more such conditions allow for generating a higher level of cultural capital additionally individual donators choices to contribute are rewarded thanks to social approval by other members of society the significance of the aforementioned aspect able to modify individual behaviours was largely put forward by both the theoretical 15 16 17 and experimental literature 18 19 20 clearly the positive effects of social approval on cultural goods contribution level are boosted by a high level of cultural capital present in society our model based on the determinants of cultural capital suggested in the literature examines the accumulation and the effects arising from an increase in cultural capital in a society by using a dynamic approach analysing such accumulation mechanisms in detail we attempt to better define the attention to cultural goods an increase in the level of attention resulting from a higher level of cultural capital in the society may increase the return on the voluntary offer in the same period in fact by increasing sensitivity towards culture contributing subjects will receive greater social attention which is expected to trigger economic benefits therefore the accumulation of cultural capital also involves benefits to the whole society which are only partially internalized through the increase in the attention to cultural goods individuals also enjoy the mere existence of cultural activities even though they do not presently attend them 8 to make an example some people like living in a more cultivated society 9 and gain advantages from an increase in the number of theatres in their city though not making use of them although these individuals draw benefits from the creation of cultural goods they choose not to contribute to their offer in addition wellestablished experimental evidence shows that a portion of participants in public goods games play consistently as freeriders 21 the purpose of this paper is therefore to provide a dynamic analysis of the cultural capital accumulation process in particular we attempt to explain the relationship between an increase in cultural capital and an increase in the voluntary provision of cultural goods in fact a greater level of cultural capital present in society increases the attention level towards cultural goods and through social approval encourages subjects to offer constantly growing contributions later it is possible to determine the economys optimal level of cultural capital which allows a society to reach the voluntary contribution equilibrium values the model before starting with the formal analysis it is useful to summarily conceptualise our models underlying hypotheses for a better understanding of the mechanisms involved in the accumulation process of cultural capital • cultural capital depends on both collective and individual investments in cultural goods the mere presence of cultural goods cannot be considered sufficient to boost the accumulation of cultural capital in a society therefore it is undisputed that there exist several factors which could be considered to explain the phenomena being studied however we decided to focus on only one of such factors social approval in fact in addition to considering the presence of cultural goods we analyse the effects resulting from the reward to anyone contributing to the offer of cultural goods from the other societys members which is social approval • the model includes only one type of public good the cultural good it is reasonable to assume that the sensitivity towards culture goods is related to the level of cultural capital obtained in each period by the society 22 together with the achieved voluntary contribution level moreover such sensibility can affect both public choices and those of potential donators however for simplicity we will focus only on individual choices neglecting public choices about public goods financing • we assume that individuals can voluntarily contribute to the provision of public good and that such contribution causes a social reaction which depends on the societys cultural capital level which is positively assessed by the donator given such hypotheses a cyclical mechanism with the following steps is formed production of cultural goods → new cultural capital → social sensitivity level → new levels of voluntary contributions now we can move to the formal analysis of our model let us suppose that there is a society made of n individuals identical in terms of preferences and income levels we imagine that each subject who has an initial endowment which is the same for every individual at the beginning of each period has to decide how to allocate his resources among his consumption of private good x i and his voluntary contribution to the offer of cultural good g i the utility function is then the same for every subject u i u in this way individual preferences are driven by attention to cultural good by the consumed amount of private good and by the total amount of the produced cultural good the budget constraint which each subject must satisfy is given by e i g i x i such constraint indicates how the whole initial endowment considered net of the taxes paid by every individual must be allocated among consumption of the private good and contribution to cultural good however it does not contain the term a i because it refers to a nonmonetary factor affecting individual preferences on cultural good allocations though since we assume that individuals are identical we can consider both the utility function and the budget constraint to be the same for all the subjects moreover the utility function is the sum of three monotone and concave subutility functions which makes it monotone and concave as well the utility function which measures the attention level to cultural capital is u i f γzg i therefore attention towards cultural capital is positively correlated with cultural capital z with the individual contribution level g i and with the parameter γ measuring individuals sensitivity towards cultural capital it must be noticed that it is possible not to contribute to the provision of cultural goods and thus not to fully enjoy social approval but at the same time to have the pleasant feeling coming from the presence of a higher level of cultural capital in the society the total quantity of cultural capital is obtained through the following linear production function g n where clearly ng i is the total amount of voluntary contribution to cultural good and nτ i is the tax revenue which represents the compulsory contribution level established by the government therefore the utility function which refers to the amount of the offered cultural good is given by u i ρg g 2 by replacing the production function for the cultural capital into we obtain u i n ρ n finally we assume the third utility function as u i e α 2 g 2 i where α 0 α 1 refers to individual propensity to voluntarily contribute to the cultural good in order to investigate the evolution of voluntary contributions to changes in the economy cultural capital level we use a differential game approach to ensure the solvability of the problems defining the efficient and the equilibrium steadystate contributions and in turn to compare these levels we assume that the subutilities are quadratic in this way the dynamic interaction can be described as a linear quadratic differential game 26 such a technique allows us to obtain and compare different equilibrium levels of the state variable in the case of nash equilibrium with openloop feedback or closedloop strategies as well as pareto efficient strategies to changes in the individuals interactions over time indeed openloop strategies require that individuals own information only on the economys initial state therefore they are obliged to choose their strategies concerning the whole game in the starting period without being allowed to change them later alternatively feedback or closedloop strategies depend on the time and the piece of information of the economys current state consequently individuals can change their strategy in every period taking decisions after observing the systems current state notably we refer to the voluntary offer of public goods models in dynamic context developed by van der ploeg and de zeeuw 27 and fershtman and nitzan 26 openloop outcomes before obtaining nash equilibrium with openloop strategies we first need to define the necessary conditions to the optimal control using the pontryagins maximum principle given that in this case strategies only depend on time we can write the individuals intertemporal maximization problem making the subutility functions explicit max u i g i c i ∞ 0 e rt e α 2 g 2 i n τ τ γg i z i dt st z n τ δz z z 0 where the dynamic equation for cultural capital indicates how cultural capital level changes over time in the system as a function of contributions choices and the level of taxes decided by government which are exogenous the evolution of capital value is also negatively correlated with the depreciation level of cultural capital of the previous period finally z 0 represents the systems initial state of cultural capital in order to find the level of cultural capital corresponding to the nash equilibrium with openloop strategies we must write the hamiltonian equation referred to the current value ℵ and necessary and sufficient conditions for a maximum g i argmaxℵ λ λ γg i lim t→∞ e rt λ 0 where λ is the costate variable and r 0 is the intertemporal discount rate the hamiltonian equation then will be ℵ e α 2 g 2 i n τ τ γg i z λ n τ δz 13 maximizing with respect to g i we obtain g i α 2n 2 γz i nρ 2n 2 τ nλ ⇒ ⇒ g i γz i nρ2n 2 τnλ α2n 2 since in the steady state λ z 0 by replacing them we get λ 0 ⇒ λ γ 2 z i nγ nγ nγ z 0 ⇒ z o n n 2 γτ δ nγ in this way we obtain the optimal level z 0 by replacing in the first and second order conditions solving for g i we obtain the corresponding equilibrium levels with openloop strategies g o n α2n 2 γ nγτ nγ 2 δnγ nγ δnγ now we can calculate the pareto efficient level of cultural capital applying the same technique the only difference lies in the fact that we consider the total sensitivity level towards cultural goods instead of individual levels the hamiltonian function will be ℵ e α 2 g 2 i n τ τ nγg i z λ n δz first and second order conditions for equation become respectively nρ αg i 2n 2 nγz nλ 0 λ λ nγg i replacing in the first and second order conditions and solving for g i we obtain g i nρ 2n 2 τ nγz nλ α 2n 2 putting g i in steady state cultural capital equation we can determine its optimal level z e λ n 2 γ n 2 γρ nατ n 3 γ 2 τ δ α 2n 2 n 2 γ n 2 γ δ n 2 γ z e n n 2 γτ δ n 2 γ by comparing the equilibrium values obtained for nash equilibrium with openloop strategies and that pareto efficient we can say that z e z o noncooperative behaviour which allows a society to achieve the economys optimal individual level of cultural capital does not allow to obtain the levels predicted for the pareto efficient solution such a condition in fact requires that individuals have cooperative behaviours however it must be noticed that the existence of a maximum threshold for the parameter which represents the attention level towards cultural goods at which the previously described inequality will not be satisfied shows how it is possible to reach excessive levels of cultural capital so that a noncooperative solution becomes more efficient closedloop outcomes adopting the openloop strategies we carried out our analysis under the assumption that subjects can only observe the initial state of the game and that they do not know the other individuals strategies therefore their optimal choice is made in the first period and they are not allowed to change their decision until the end of the game since our model aims to analyse the effects of individuals interactions throughout the game it becomes necessary to make the strategies depend on not only time but also the systems state in each period in our case subjects can observe the level of cultural capital which is accumulated at the end of every step of the game as a result the new optimal level of cultural capital is a nash equilibrium with closedloop or feedback strategies to obtain such equilibrium we will draw from the technique used for linear programming we can now write the hamiltonianjacobibellman equation and obtain the first order conditions which feature nash equilibrium rv i ∂v i ∂t max e α 2 g 2 i n τ τ γg i z ∂v i ∂z n δz assuming the following concave and quadratic value function 28 v i θ o θ 1 z 1 2 θ 2 z 2 24 with θ 2 0 this allows us to obtain the maximum value for subject i referred to the whole game started at g g 0 and we can thus obtain the closedloop equilibrium strategies g f 1 α 2n 2 nρ 2n 2 τ γz n replacing the obtained values and the value function in the hamiltonianjacobibellman equation and putting z and z 2 equal to 0 we obtain two riccati differential equations in θ 1 and θ 2 taking together the parameter values for θ 1 and θ 2 the closedloop equilibrium strategies and the accumulation function for cultural capital in the steady state we determine the cultural capital level corresponding to the subgame perfect nash equilibrium z f nτ 2n 2 α n 2 ρ 2n 3 τ n 2 θ 1 δ nγ n 2 θ 2 where θ 2 nγ α 2n 2 n 2 0 27 θ 1 n α 2n 2 n 2 γ n 0 replacing the parameter values for θ 1 and θ 2 in the optimal level of cultural capital equation we obtain z f n 2 n 2 γ n α 2n 2 nγ 2nγ 29 by comparing the nash equilibrium with openloop closedloop and pareto efficient strategies for the optimal level of cultural capital we can determine the following conditions if 12 and γ 2n then z f z e z o otherwise z e z f z o this means that when individuals are given the opportunity to update their decisions throughout the game after observing the optimal level of cultural capital accumulated at the end of every step the obtained optimal level of cultural capital is higher than those reached through either the openloop or pareto efficient solution however this result holds only if conditions and are satisfied in other words this result holds with a reasonably low individual intertemporal discount rate and cultural goods depreciation rate at the same time the parameter γ measuring individual sensitivity to cultural capital has to exceed a given threshold using comparative statics it appears that the sensitivity threshold is positively correlated to r δ and n alternatively the inequality is partially reversed meaning that similar to what happens with open loop strategies the levels predicted for the pareto efficient solution exceed the level of cultural capital under the closedloop strategy condition in any case regardless of conditions and the optimal level of cultural capital in the case of openloop strategies is always lower that its correspondent level for the closedloop strategies conclusions in order to investigate the evolution of voluntary contributions to changes in the economys cultural capital level we used the differential game approach such a technique allowed us to obtain and compare several equilibrium levels for the state variable in the cases of nash equilibrium with openloop closedloop or feedback and pareto efficient strategies to changes in individuals interactions over time the starting idea is that subjects utility resulting from the consumption of cultural goods depends on their initial endowment of cultural capital in fact as shown by cheng 9 the greater the societys cultural capital the broader the consumption of cultural goods additionally we introduce another variable which is crucial for the scope of our analysis namely cultural sensitivity which increases the satisfaction resulting from cultural goods consumption and thus stimulates individual voluntary contributions our results show that under certain conditions the solution obtained for the nash equilibrium with closedloop strategies provides a higher optimal level of cultural capital even exceeding the pareto efficient solution notably whenever individuals can observe the level of cultural capital accumulated in each game period their choices determine the highest possible level of cultural capital the effect of cultural goods consumption on the accumulation of cultural capital has been also empirically investigated among others by diniz and machado 11 they show that cultural consumption in brazil is also affected by the level of consumers education additionally castiglione and infante 29 reported the addictive effect of past cultural goods consumption such as demand for theatre on current and future choices finally based on an empirical analysis of touristic flows in aosta valley alderighi and lorenzini 30 showed that when cultural capital accumulation is relevant tourists are willing to give up some of their current utility in order to get higher returns in future from a policy perspective our result is significant from two points of view first we provide support to the fundamental role of investing in cultural capital for instance by enhancing the opportunity to make the highest number of individuals in a society experience cultural goods policy makers can increase the positive attitude towards cultural goods and in turn the level of voluntary contributions to the provision of cultural goods second it implies that when individuals are made aware of the societys cultural capital level their decisions to contribute to the provision of cultural goods can lead to better solutions than when they blindly choose since the consumption and the creation of cultural goods benefits the whole of society 9 introducing a more accessible information system which spreads data on the societys changes in cultural capital level could drive subjects to make better choices in terms of their individual voluntary contributions which in turn increase the level of cultural capital thus creating a more cultivated society data availability statement not applicable author contributions conceptualization mfc im and dr methodology im formal analysis mfc writingoriginal draft preparation mfc writingreview and editing dr all authors have read and agreed to the published version of the manuscript appendix a closedloop outcomes let us replace the steady state individual contribution level to the cultural good g f and the value function in the hamiltonianjacobibellman equation after some tedious algebra we get collecting the terms with z and z 2 and setting them equal to 0 we obtain two riccati differential equations in θ 1 and θ 2 considering the first group of terms the last quadratic equation has two solutions namely given that we have assumed θ 2 0 we choose solution θ 22 considering the second group of terms and after some algebra we get taking together the parameter values for θ 1 and θ 2 the closedloop equilibrium strategies and the accumulation function for cultural capital in the steady state we determine the cultural capital level corresponding to the subgame perfect nash equilibrium after the usual tedious algebra we get

this study aims to offer a formal analysis which relates provision of cultural goods to the societys level of cultural capital such a level is assumed to already exist in society and is increasable thanks to individual support for the offer of cultural goods the achievement of the highest levels of cultural capital increases satisfaction coming from cultural goods consumption and then voluntary contributions social approval deriving from donations is positively related to societys existing cultural capital and triggers a positive externality for donators thus increasing contributions and generating a positive externality for the whole society the dynamic analysis provided in this study requires the adoption of a differential game where individuals interact making their choices on their voluntary contribution level we find that under certain conditions the solution obtained for the nash equilibrium with closedloop strategies provides optimal level of cultural capital that exceed the pareto efficient solution obtained through openloop strategies

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introduction life expectancies at birth as well as at adult ages have been increasing in europe for decades this trend in combination with the in many countries persistently low levels of fertility entails a shift in populations age compositions towards older age groups this development is prone to endanger financial sustainability in several areas of social security systems one of them being pension systems as many european countries provide public pensions on a payasyougo basis further reforms to national pension systems are necessary to adjust social security systems to ageing populations the timing when people leave the labour force and measures to support longer working lives are widely discussed at the country as well as the european union level with workers health being an important factor many countries have initiated and passed policy changes to gradually increase the official retirement age and general retirement ages are now above age 65 in several countries consequently labour force participation rates of persons 50 have been increasing and are expected to continue to do so one pertinent question in this context is how large the potential to increase working lives further is given peoples health status or put differently what is the health status of persons at retirement ages and how does it compare to present lengths of working lives on the microlevel a lot of research exists that looks at the relationship between retirement and individual health and depending on the model specification the direction of effects and their magnitude vary widely boissonneault provides an indepth overview of the impact of various aspects of health on retirement macrolevel studies that investigate the relationship between economic activity and health are rare in spite of their importance to understand developments on the population level in this study we take a macrolevel approach in order to analyse the relationship between working life expectancy and health status focusing on three selected health dimensions that cover a range of health outcomes general health physical strength and cognitive abilities our analysis builds on previous analyses where we presented developments of wle over time by sex across europe and presented comparisons of wle and healthy life expectancy at age 50 and wle by education at age 50 for the year 2009 in the current study we update our previous analyses and expand them in three crucial ways first we expand the analysis by two objective health outcomes and their development over time second we analyse heterogeneity in wle and all three health outcomes by education third while we previously looked at the situation at age 50 we now focus on partial life expectancies between age 5059 and 6069 respectively focusing on these two age intervals provides a an increasing number of studies analyse the development of working life expectancies in selected european countries with several of them including information on certain health aspects like disability depressive symptoms or selfperceived health the choice of health dimensions in our investigation is based on their relevance for individuals performance in the labour market the ageing processes in muscle strength and cognition may negatively affect work ability productivity and employability when it comes to physical ability adequate muscle power has been shown to be a prerequisite for optimal productivity while decreased muscle strength is a predictor of physical limitations handgrip strength is a good indicator of muscle strength it peaks at about ages 30 to 40 and decreases thereafter we use this measure to estimate physical ability when it comes to cognition studies have found that cognitive ability levels predict individual productivity better than any other observable individual characteristics and that they are increasingly relevant for labour market performance agerelated cognitive decline is usually characterized by having difficulty recalling facts but may additionally affect processing speed immediate word recall our measure for cognitive health status is a by now wellestablished indicator for cognitive functioning and abilities general health and performance in the labour market are investigated by a vast literature overall poor health was identified to reduce the capability to work and moreover disabilities and health problems have been shown to increase the risk to leave the labour market the analyses of the development of four life expectancy indicatorsthe aforementioned two labour marketspecific health indicators life expectancy in good general health and working life expectancyacross time and by gender for selected european countries as well as differences in these measures by education are the focus of this article we start by comparing the four indicators for men and women for two advanced age groups in 2017 in addition to the subsequent visual presentation of trajectories between 2004 and 2017 we analyse the correlation between the four indicators in the next step we investigate the educationspecific life expectancies of the four indicators in order to detect differences between socioeconomics subgroups of the population socioeconomic status and health status are strongly correlated and we expect to find significant heterogeneity between education groups when it comes to health and their ability to work beyond currently observed labour market exit ages methods data sources labour force participation rates by age sex and education were obtained from eurostat and are based on the european labour force survey the lfp rate represents the share of the economically active population in each age group economically active persons comprise the employed and the unemployed in line with the definition of the labour force by the ilo in 15 out of the 26 european countries in our study more than 50 of men age 6064 are in the labour force among women this applies to 8 out of 26 countries period life tables for ages 085 by sex and country were also provided by eurostat further educationspecific life tables were calculated using sexspecific life expectancy information at birth by educational attainment level from eurostat in 2016 for denmark and estonia and in 2017 for the thirteen further countries with available data we distinguish three education categories following internationally comparable isced coding at most lower secondary education upper secondary and postsecondary nontertiary education and shortcycle tertiary education or higher individual health capacities related to work ability are represented by good general health good physical functioning and good cognitive functioning we calculated prevalence rates of good general health as well as good physical and cognitive functioning with survey of health ageing and retirement in europe data from wave 1 to wave 7 including provided crosssectional sampling weights details on the sampling strategy can be found elsewhere good general health is measured by using the general activity limitation indicator this indicator is widely used to monitor health developments within the european union participants were asked to what extend they have been limited in activities they usually do because of a health problem within the past six months those who reported no activity limitations at all were categorized as having good general health handgrip strength is an established indicator for morbidity and mortality this measurement was taken twice per hand using a dynamometer with the maximum of the four measures considered we distinguish those with good physical functioning as having gripstrength above 37 kg for men and 21 kg for women episodic memory is very closely linked with working memory therefore we employ a word recall test in order to estimate our indicator for cognitive abilities participants had to immediately recall as many words as possible from 10 read out nouns within one minute whereat a recall of at least five words out of ten is indicating good episodic memory overall the share of the population 50 in good health is highest for physical functioning and lowest when looking at the share with no activity limitations statistical analysis we estimate the number of years a person is expected to be economically active and generally physically and cognitively healthycalled working healthy physical and cognitive life expectancy by applying sullivans method following a standard approach to compare estimates of life expectancy indicators over time and across countries prevalence rates are combined with life tables by survey year sex and country resulting in estimates for the expected remaining years in a certain condition given the period values for survival and labour market participation and health status respectively first we investigate the number of years a person is expected to be without activity limitations or economically physically or cognitively active in 2017 second trends in all indicators between 2004 and 2017 are investigated for these countries we present results whenever available for 26 countries that participated at least in the last available wave of share in 2017 third we analyse educationspecific patterns of the four life expectancies for 15 european countries that educationspecific life expectancies are available for we calculate educationspecific life tables using brass relational model combining life table information and educationspecific life expectancy data our descriptive investigations uncover variations between educationspecific partial life expectancies and the overall life expectancies uncertainty in four life expectancies due to usage of survey data is exemplarily provided by confidence intervals for all four indicators in 2015 where we had also most recent information on the sample size of sexspecific age groups of the eu lfs data further we present the 95 confidence intervals for the three health life expectancies by education in 2017 in the supplement in this study we calculate partial working healthy physical and cognitive life expectancies from ages 50 to 59 and ages 60 to 69 partial life expectancies allow comparing the number of years lived between the 50th and 60th birthday and 60th and 70th birthday respectively this concentration on the two decades covering late adult working life and the onset of retirement accounts for the fact that economic activity is very low after age 70 results differences in life expectancies across europe in 2017 in order to address the question to what degree wle is associated with healthspecific life expectancies we first compare the four indicators in 2017 for 26 european countries in most countries women have lower levels of economic activity than men in both age groups which is reflected in their lower wle exceptions are the baltic states finland and bulgaria where women aged 5059 show higher wle which remains true for women aged 6069 in estonia and latvia overall women aged 5059 have on average seven remaining economically active years and women aged 6069 have 23 years whereas their male counterparts aged 5059 can expect about eight remaining years and those aged 6069 can expect about 32 years the maximum remaining lifeyears that are possible in each of the two age groups is on average 99 years between age 5059 and 97 years between age 6069 for women and 97 years between age 5059 and 93 years between age 6069 for men these number of years represent the maximum values that would theoretically be possible for each of the four indicators a striking observation for women and men aged 5059 is that in all but six instancesthe exceptions being women in croatia cyprus greece italy malta and spainthe remaining wle is larger than the expected remaining years in good health for at least one of the three health indicators the number of years in good physical health is the largest of the three life expectancies in the majority of countries for men as well as women and good cognitive life expectancy in most instances the second largest one the conventional calculation for healthy life years based on the gali question reveals that the number of economically active years is larger than the number of healthy years in 19 out of 26 countries for women and in 22 out of 26 countries for men the two health measures that are based on indicators that are having clear relevance for work ability and employability provide a less dire picture for ages 5059 years with good physical and cognitive health are in most instances larger than working life expectancy for women for men the picture is more mixed wle and both of these health indicators are around equal length or wle ranges between the two health indicators with more often than not cle being shorter and ple being longer than wle a very different picture presents itself when looking at persons aged 6069 where wle is almost universally significantly lower than the expected number of healthy years for any health measure in most countries men and women can expect on average seven to eight years out of the possible ten years in good physical health while they can expect only six to seven years with good cognitive functioning when it comes to hle the average number of years without an activity limitation is 56 years for men and 53 years for women this implies that hle is lower than the number of remaining years in good health for the two other health life expectancies with the exception of bulgarian cypriot greek italian maltese spanish and slovakian men this overall pattern that also appeared already for persons aged 5059 might be due to the different nature of our health measures hle is based on selfreported information whereas the other two measures are performance measures another explanation might be that limitations that are picked up through the gali measure are mostly not directly relevant for individual labour market participation and allow being economically active in spite of their presence trends in life expectancies 20042017 our investigation of time trends of the different partial life expectancy indicators shows that wle increased for women age 5059 since 2004 in particular in countries starting at relatively low level such as austria belgium greece italy luxembourg malta poland slovenia and spain wle in countries like denmark estonia finland and sweden remained at a more or less constant level as women could expect about eight remaining years in the labour market already in 2004 interestingly women could not only expect many years in good physical health in 2017 this indicator has been at quite high levels during the previous decade and turns out to be the most stable over time of all four indicators the number of remaining years with good cognitive functioning increased over time in most countries and approached the level of good physical functioning womens remaining hle showed no uniform pattern over time for the 26 countries increasing for some countries stagnating for a few and decreasing for others women aged 6069 show a similar pattern as their younger counterparts with wle being the exception with a significantly lower number of expected economically active years wles for men age 50 to 59 have all along been at much higher levels than those of women and therefore show only a minor increase over time with exception of hungary poland and romania however between age 60 and 69 there is a clear increase in wle until 2017 for countries like austria bulgaria czechia finland france germany italy hungary malta poland and slovakia even when starting with two or fewer remaining economically active years in 2004 the trend of an increasing number of remaining years with good cognitive ability over the last decade for men in the older age group was similar to those observed among women of the same age the magnitude of the gap between economically active years and healthy years declined almost universally over time for 6069yearold men the trend of hle does not provide a clear pattern for either age group as hles of men increased in some countries and decreased or stayed about constant in others life expectancies which define the maximum number of years possible for each indicator stayed constant for women in both age groups and men this diverse pattern of increases decreases and stagnation across the four partial life expectancy indicators is also reflected in the estimated correlations between wle and the healthspecific measures overall life expectancies between age 60 and 69 show lower correlations than between age 50 and 59 as also indicated by inspection of the longitudinal trajectories wle and cle between ages 50 and 59 have the highest correlation with 043 for men and 047 for women the fact that wle and hle show the lowest and partly insignificant correlations could be interpreted as hle not being a very good indicator to measure work ability and employability educationspecific life expectancies the trends investigated in the previous section showed that the magnitude of the gap between wle and healthy years declined slightly over time as wle has been increasing in many countries but that there is still a considerable gap in most countries between the number of years spent working and the number of years in good health however reporting and comparing only country averages might disguise heterogeneities between different socioeconomic groups when it comes to economic activity and health status educationspecific differences in the length of working lives as well as the number of years in respective health conditions are the results of the combination of differences in life expectancies and in health status by education with both measures being positively correlated with educational attainment persons with higher levels of education in general not only live longer but they also spend more years working and in good health availability of comparable data on life expectancy by highest level of educational attainment restricts this part of the analysis to 15 countries we find the expected educational gradient for working life expectancy as well as our three health indicators but to varying degrees our results highlight that highly educated men and women aged 50 can expect to spend the great majority of the subsequent 10 years in good physical and cognitive health as well as economically active this is less true for upper and postsecondary educated where the number of economically active years is lower and the range of number of years in good health for the three health indicators increases on average the magnitude of the gap between remaining years in good health and economic activity peaks for those at most lower secondary educated while working life expectancy between countries varies more for women than for men aged 5059 it shows the smallest range of educational discrepancies next to ple for both sexes cle on the other hand shows the biggest educational discrepancies the general picture is similar for men and women between ages 60 and 69 the higher the education level the more years in good health can be expected however the variance between the health indicators within education categories is significantly larger for the older age group than for members belonging to the younger age group particularly men aged 60 and at most lower secondary educated can expect fewer years of remaining economic activity than those with higher education but they are also deprived when it comes to remaining years in good cognitive health or general health implying that there is also much less leverage to increase the number of economically active years in general the differences in life expectancy by education for persons aged 6069 are noticeably larger for men than for women this entails that the effect of differences in mortality between men with different education levels play a larger role for the values of the four partial life expectancy indicators than in the case of women for the latter observed education differences in the number of economically active and healthy years are mostly driven by differences in health prevalences discussion when only considering current economic activity the potential to increase working life is larger between ages 60 and 69 than between ages 50 and 59 this is nothing new and can be deducted from looking at participation rates alone however once we start to compare the number of years that someone can expect to be economically active with the number of years that he or she can expect to experience in good health the picture becomes much more nuanced jagger et al found large inequalities between european countries when it comes to health expectancies and hle at age 50defined in various waysvaried significantly across countries pointing towards the importance of countryspecific characteristics in shaping the disablement process our results point in the same direction however whereas their definitions of health focused on aspects of disablement our focus in this study was on health aspects that are related to employability namely ple and cle for the purpose of comparability with other health research we compared wle to the common health measure of hle in countries where female lfp is relatively high 5059yearold women can currently expect more years of economic activity than in good health based on hle while the number of years expected in good health based on our measures of the results for men are similar but since male labour force participation is higher in general 5059yearold men in more countries than women have already now wles that are larger than hle and even cle this implies more room to increase the number of active years between age 50 and 60 for womenkeeping in mind noticeable differences across countries when it comes to the number of years in good health for 6069yearold women and men wle is still significantly lower than the expected number of years in good health according to our health measures but also for this age group the size of this potential to increase working lives varies greatly across countries looking at correlations between wle and the three health indicators cle and wle show the largest and most consistent correlation for women as well as men for expectancies for both age groups we analysed 2 0 0 4 2 0 0 8 2 0 1 2 2 0 1 6 slovakia 2 0 0 4 2 0 0 8 2 0 1 2 2 0 1 6 slovenia 2 0 0 4 2 0 0 8 2 0 1 2 2 0 1 6 spain 2 0 0 4 2 0 0 8 2 0 1 2 2 0 1 6 sweden 2 0 0 4 2 0 0 8 2 0 1 2 2 0 1 6 switzerland wle h le ple c le le retired and employed persons above age 65 differ with respect to their type of occupation working conditions and health status providing evidence that increasing the length of working life will be harder on some population groups than others as our results demonstrate there are large heterogeneities within each indicator socioeconomic status is a strong predictor at the individual level of health status and these differences are reflected in the educationspecific calculations of our four indicators this confirms previous findings for example for france and for germany working life expectancy shows a clear education gradient for individuals in both age groups however this gradient also exists for each of the three health indicators this implies that the leverage to increase the number of economic active years that seems to be there across the board when comparing simple averages of the four indicators is actually distributed unevenly across individuals with different education levels while there is hardly any room to increase wle for men and women between ages 50 and 59 for the highest education group since it is already in most countries close to 10 years there is still room for those with less than tertiary education even when considering the health dimension for ages 6069 a different picture presents itself in spite of wle being higher for men and women with upper secondary education or higher than for the lowest education group the leverage to increase wle further seems also higher for the two higher education groups due to the simultaneously larger expected number of years in good health overall ples are larger than any of the other three indicators an observation that holds true for both age groups and sexes while this is good news it is clear from current and expected future job demands and the literature that physical strengthwhile still necessary for certain occupations and taskswill be less important for a lot of occupations compared to cognitive abilities these skills play already nowadays a pivotal role for employability and productive employment at older ages and will likely be even more important in the future thus it will be crucial to maintain high levels of cognitive functioning well beyond age 50 in order to match labour demand our finding that the number of years with good cognitive functioning increased in the majority of countries between 2004 and 2017 for persons aged between 60 and 69 is a positive development and might partly be due to shifts in the educational attainment structure towards higher education levels within this age group the presented results for three health indicators provide a snapshot of the current situation of older adults in the countries that were part of our analysis it should be clear that the observed prevalences and resulting health expectancies are not only the result of living and working conditions of persons above age 50 but that they are shaped by individuals experiences over their entire life courses if the goal is to increase the number of years that older adults enjoy in good healthfor their own good for keeping healthrelated costs in check and also against the background of further extensions of working lifea holistic approach that considers many aspects over the life course is warranted these aspects concern characteristics and circumstances of the individual as well as characteristics of the job what do our results imply for the future due to educational expansions in the past future older adults will be on average better educated than current ones those who are now 3049 years old will during the next 2 decades replace those who are currently 5069 years old if educational differences in health status prevailed at around the presently observed levels this replacement could entail on average healthier older adults and workers with the ability to work until higher ages still given foreseeable persistent differences in health status of persons with varying socioeconomic status adequate solutions will have to be found for those whose health does not keep up with further increases in statutory retirement ages considerations to prolong working lives within each country should be accompanied by a thorough analysis of factors including health that play a role for the ability to continue working in the given context as it was for example done by the dutch ministry of social affairs and employment the narrative for the need to extend working lives in order to react to increasing longevity and fears of labour shortages is prevalent at national levels as well as on the eu level while this narrative itself should come under more scrutiny in the context of each countrys individual demographic and economic circumstances there are several issues when it comes to longer working lives that to date are not being adequately dealt with these include but are not limited to issues concerning expected increases in social inequalities developments of the demand for older workers and the quality of future jobs and the provision of lifelong education opportunities limitations estimating health expectancies based on transition rates and the multistate life table method provides exact point estimates of the true period value the method allows the explicit inclusion of disability incidence and recovery the main drawback is the requirement of longitudinal data for health as has been shown by mathers and robine results for disabilityfree life expectancy calculated with the multistate life table method and sullivans method respectively showed very little differences in the results as long as changes in disability prevalence happen smoothly and relatively regular this makes sullivans method suitable to monitor health developments in the long term and at the population level changes in our three health indicatorsie the agespecific developments of their prevalenceshappen gradually and without abrupt jumps or drops discrepancies of a smooth trend are only found for men aged 5059 in germany poland and portugal as well as for women aged 5059 in portugal which are likely due to very small sample sizes in the relevant age groups the situation is trickier when it comes to using sullivans method to calculate working life expectancies the financial crisis years constituted a substantial effect on labour market outcomes as dudel et al demonstrated for spain estimates of wle based on the sullivans method can lead to biased results in cases where labour force participation rates are changing abruptly however the effect seems to be foremost the slower adjustment to new levels of wle after an exogenous shock for calculations with the sullivan method compared to markow chain calculations after a few years the values were at similar levels again since the situation in spain was more extreme than in other european countries and since we are using labour force participation rates and focus on longterm trends we expect that this approach is still valid for our purposes still this limitation has to be kept in mind when interpreting the results for wle in this paper particularly developments over time a general aspect why the multistate method is superior to sullivans method for calculations of working life expectancies is the fact that it allows for transitions between different labour market states this possible consideration of more detailed information on labour market statuses also allows for the estimation of the amount of time spent in these different states not just the economically active time such detailed analyses are usually performed for single countries and not in a comparative way due to the required nature of the data in this study we use objective and subjective health measures which might be attended by health misperception our objective health indicators are already at a high level thus a correction of the potential underestimation would result in even higher levels we might suspect overestimation in our subjective measure due to social norms or cultural differences in reporting but several studies verified the validity and reliability of gali further we acknowledge practice effects in repeated cognitive tests however literature shows that practice effects occurred mostly between first and second testing and that these effects are greater at the lowest performance level in this study we investigate a rather demanding cognitive level moreover we also attribute increases in cognitive performance by cohorts to the wellinvestigated flynn effect which was also shown for only first time participants with share data conclusions in this paper we took a macrolevel approach and compared developments of working life expectancies and health expectancies for health dimensions that are relevant for older adults work ability while we found large differences across countries overall there is potential to increase the expected number of economically active years for men as well as women between ages 60 and 69 however our educationspecific analyses revealed large differences between socioeconomic subgroups of the population when it comes to the size of this potential this heterogeneity between education groups when it comes to health and their ability to work beyond currently observed labour market exit ages has to be taken into account when working lives are being extended academy of sciences at the health economics and policy division of vienna university of economics and business this paper uses data from share release 700 waves 1 2 4 5 6 and 7 doi org106103share w1700 doiorg106103share w2700 doiorg106103share w4700 doiorg106103 share w5700 doiorg106103share w6700 doi org106103share w7700 the share data collection has been primarily funded by the european commission through fp5 fp6 and fp7 additional funding from the german ministry of education and research the max planck society for the advancement of science the us national institute on aging and funding open access funding provided by international institute for applied systems analysis open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit iveco mmons orglicen sesby40 appendix a additional figures see figs 7891011 and 12 year publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

europes population is ageing statutory retirement ages are commonly raised to account for continuous increases in life expectancy in order to estimate the potential to increase statutory and consequently effective retirement ages further in this study we investigate the relationship between partial working life expectancy wle and three health expectancies that represent health aspects important for work ability and employability between ages 50 and 59 as well as 60 and 69 for women and men in europe we also explore the association between these four indicators and the highest level of educational attainment we apply sullivans method to estimate wle and three selected measures that capture general physical and cognitive health status of older adults for 26 european countries since 2004 over time wles increased significantly in the younger age group for women and in the older age group for both sexes the expected number of years in good physical health have continuously been higher than any of the other three indicators while the expected number of years in good cognitive health have shown a noticeable increase over time the investigation of the relationship between education and each life expectancy confirms the wellestablished positive correlation between education and economic activity as well as good health our results indicate potential to extend working lives beyond current levels however significant differences in the expected number of years in good health between persons with different levels of education require policies that account for this heterogeneity

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introduction islam is a religion of dawah 1 the progress and setbacks of muslims are closely related to their dawah activities 2 alquran calls dawah activities ahsan alqaula 3 the dawah activities are carried out by competent and credible proselytizers 4 the technological advances also force proselytizers to follow existing developments so that their dawah material can be enjoyed by muslims 5 the dawah of islam can be carried out in various ways including dawah bi allisān bi alhāl dakwah bi albi alqudwah and dakwah bi alqalam 6 with the development of existing technology and media dawah must be formatted in such a way that it remains in accordance with current developments 7 the beautiful teachings of islam must be understood by people wherever they are and through whatever medium they are conveyed the proselytizers must improve their abilities and capabilities not only conveying dawah through pulpits or official religious forums but also the presence of digital dawah proselytizers 8 who can not only convey islamic messages through facetoface communication are required 9 but can also convey dawah messages on digital media such as facebook twitter instagram youtube and so on 10 with this complete and consistent spirit digital dawah mujahids can convey islamic teachings professionally and continuously for the sake of realizing the glory of islam and muslims nowadays digital dawah has become a significant trend among proselytizers and the general public 11 the development of communication technology especially the internet and social media 12 has brought major changes in the way dawah is spread digital dawah also has challenges such as problems with inaccurate content polarization and online harassment 13 therefore it is important for proselytizers to use this platform wisely follow good preaching ethics and always ensure that the messages conveyed are in accordance with true religious values the indonesian ulema council of south sulawesi province responds to the market share in the field of digital dawah which has great potential by carrying out innovative developments the iuc of south sulawesi province invites proselytizers to intensify digital dawah considering that social media users in indonesia reach 191 million people the proselytizers must understand the internet and social media and must enter into preaching there through digital dawah the idea of developing digital dawah at the iuc of south sulawesi province experiences its own challenges and problems because there are still many proselytizers who prefer to carry out conventional dawah the existence of iuc proselytizers in delivering digital dawah is an interesting highlight therefore digital dawah carries the role of a comprehensive dawah message methods this research was qualitative research conducted at the iuc of south sulawesi province located in makassar city the approach in this research was interdisciplinary by looking at societal phenomena more comprehensively across scientific fields and proselytizers in conveying their dawah via digital the data source was obtained from the iuc of south sulawesi province website at and the researcher conducted interviews with core administrators such as the general chairman secretary general commission for dawah and development of islamic society and communications and informatics commission at the iuc of south sulawesi province research on various sources was also carried out such as library materials journals and several literatures related to digital dawah the collected data was then analyzed critically and comprehensively using content analysis techniques within the framework of the digital dawah phenomenon the data analysis was carried out descriptively systematically analytically and argumentatively to provide a comprehensive understanding of the results the discussion would most likely explain the findings interpretatiosns and arguments obtained from the analysis as well as highlight the various factors that contributed to the success of the iuc of south sulawesi province in carrying out digital dawah results and discussions the iuc of south sulawesi province and digital dawah responses the iuc of south sulawesi province maintains its consistency in conveying religious messages to revive religion without having to abandon various new phenomena in modern life the iuc of south sulawesi province is also making innovations in responding to technology through digital dawah in todays digital era muslims pay little attention and forget the obligation of dawah the activities to encourage goodness and anticipate evil in society must be conveyed in various forms and abilities by each person various onesided views originate from the wrong perception that dawah is the responsibility of only ulema who are limited to conventional lectures in the pulpit muammar bakry 14 as secretary general of the iuc of south sulawesi province emphasized that the iuc of south sulawesi province always responds to the dynamics of digital forms of dawah in the era of technology 40 the proselytizers are transforming in response to the change from conventional dawah to digital dawah however it should be noted that the change to digital dawah must be in line with islamic comprehensive and integrated principles the proselytizers strive in digital dawah so that the spirit of dawah to bring about change is evenly distributed among muslims digital dawah plays a role in the lives of muslims these days 15 digital dawah is used as a mission sacre that must be encouraged in response to the needs of muslims islamic dawah must be actualized and follow developments in the conditions and places where islamic teachings are delivered the activities that have been keeping muslims busy lately have become inevitable but need to be controlled and reminded by proselytizers through digital dawah 16 dawah islamiyah is a business process that never stops and ends dawah continues to be needed to provide a positive way for the lives of muslims whose problems are very complex gurutta najamuddin safa 17 as general chairman of the iuc of south sulawesi province explained that proselytizers must be able to adapt to the 21st century which is the rise of information technology and communication media muslims in all generations have gadgets that have internet which has become a favorite that is very fast and unstoppable 18 in the context of the muslim community in south sulawesi the digital dawah phenomenon must progress the iuc of south sulawesi province encourages proselytizers to be technologically literate muslims dependence on technology is so great that it has even become a primary need like food and clothing nowadays muslims like to access lectures advice dawah and sermons via their smartphones 19 smartphones have become a medium for muslims to learn about islamic teachings in more depth digital dawah at the iuc of south sulawesi province exists as a response to the needs of muslims digital dawah has become a trend because of its influence in shaping the public in various ways as a new method digital dawah replaces conventional dawah methods digital dawah is a new media that is increasing in the practice of dawah every day digital dawah creates a dynamic muslim society in south sulawesi on the other hand with the advancement of digital dawah individual people or groups can remind each other and connect in accessing digital dawah islam outlines the importance of dawah in living life good dawah has many benefits including the spread of islam with wisdom and good advice 20 in fact clashes based on religious groups start from bad dawah dawah is an integral part of the islamic religion 21 digital dawah has clear principles because it will be difficult for a preacher to carry out dawah activities in a pluralistic society the digital dawah presented by the iuc of south sulawesi province is to prevent harsh dawah fighting against each other slander and other despicable things digital dawah remains the ultimate goal of the existence of dawah itself namely introducing islam as a religion that is full of love and teaches peace digital dawah has various twists and turns therefore digital dawah requires proselytizers to have the ability to adapt to existing facilities the proselytizers are able to open hearts and selves through digital dawah by providing communication that does not easily hit but rather embraces does not offend the hearts of muslims does not look for points of difference but rather seeks common ground therefore presenting the wisdom of digital dawah is part of the process of islamic dawah the digital dawah targets being intensified by the iuc of south sulawesi province have a variety of methods and approaches however of the many methods they only lead to two principles namely dawah bi alhikmah and dawah bi mauizat alhasanah those who do dawah via digital must be accommodating so that they know as well as threat maps and can avoid the possibility of friction among muslims digital dawah construction at the iuc of south sulawesi province the iuc of south sulawesi province uses digital dawah as a communication medium to disseminate arguments developed to enlighten the public 22 this digital dawah responds to actual issues that are developing in the lives of muslims with an approach to islamic studies and local wisdom that is inherent in the lives of the people of south sulawesi the iuc of south sulawesi province needs effective communication to market the scientific products of proselytizers the purpose of communication is to convey messages to the message receiver in this case muslims although in reality the dawah message is not always binding the digital dawah phenomenon at the iuc of south sulawesi province refers to the use of digital technology and online platforms to spread religious messages and islamic dawah this phenomenon has developed rapidly along with advances in information and communication technology the digital dawah of the iuc of south sulawesi province is developed through the channel the following are several aspects of the digital dawah phenomenon social media the iuc of south sulawesi province uses youtube facebook 11 instagram 23 tiktok 24 and wa channels as social media tools for conveying divine messages the youtube channel has become the main place for many preachers and clerics to share lectures religious lectures and dawah messages the proselytizers use this social media to reach a wider audience and interact with the muslim community the youtube channel of the iuc of south sulawesi province can be accessed at officialmuisulsel this account is made by the iuc of south sulawesi province to provide enlightenment to the wider community the proselytizers included in the video are competent proselytizers who have the capacity and are widely known by the people of south sulawesi source youtube asnawin as a member of the communications and informatics commission at the iuc of south sulawesi province reminds proselytizers that they are in the era of information the internet and social media the pin dawah must go to social media especially youtube the use of youtube media as a medium for dawah is increasingly promising and easier to do it is said that the connection between youtube media and dawah is the same target the same segmentation and the same needs 25 meanwhile most wellknown proselytizers have used youtube as a medium for dawah and made the best use of it there are also models of preaching on youtube which can be in the form of serial lecture videos short lecture videos lecture clip videos musicsong videos short story videos and live streaming podcasts and streaming videos apart from using youtube as a digital dawah medium the iuc of south sulawesi province is also developing digital dawah in the form of podcasts and streaming videos with a duration of around 3040 minutes wellknown lecturers and clerics appear for special podcasts which contain recordings of religious lectures and discussions as well as introducing the lives of certain ulema 26 it allows people to listen to or watch dawah messages anytime and anywhere source dawah communication website the iuc of south sulawesi province develops its website by enriching the website with a selection of tausiyah religious news sermons halaqah and iuc answers in response to direct questions from the public about religious issues the iuc of south sulawesi province creates a website containing religious articles videos and resources this website is often used to spread religious knowledge and answer religious questions source live streaming the iuc of south sulawesi province develops live streaming on social media allowing lecturers and ulema to interact directly with their audience they can answer questions in real time and discuss religious topics one of the live streaming routinely carried out every day is the recitation after the maghrib prayer which is streaming via all social media of iuc of south sulawesi province source facebook social campaigns and activism digital dawah is also developed by the iuc of south sulawesi province for the purpose of social campaigns and activism in an islamic context this includes campaigns for the welfare of muslims alleviating poverty and supporting various social initiatives 27 the iuc of south sulawesi province has responded to many public issues in the south sulawesi area one of which is by issuing fatwas based on local wisdom such as the fatwa regarding panai money also the iuc of south sulawesi province is encouraging the entire community to be moderate in assessing all the differences that occur the chairman of the commission for dawah and islamic community development at the iuc of south sulawesi province amrullah amri hopes that dawah must prioritize tolerance through digital dawah digital dawah still pays attention from heart to heart not mouth to ear digital dawah must emulate the sincerity of previous ulema in dawah ebooks and digital publications the iuc of south sulawesi province is developing digital dawah with electronic books and publications in the form of journals the religious books and publications are also available in digital format which facilitates access and distribution to those seeking religious knowledge asmullah as a member of the commission for dawah and muslim community development explained that digital dawah through esermons and online fatwas demonstrates the importance of communication via internet media in the islamic community sector and is a contemporary islamic study that has relevance to cyber society by using religious identity within the internet framework both ejihad and online fatwas can be formatted in such a way as to present content that characterizes the islamic concept of rahmat lil alamen instead of spreading and instilling a negative view of the sanctity of islamic teachings with this phenomenon of digital dawah development the iuc of south sulawesi province has made it easier for religious messages to be accessed by people throughout indonesia especially the south sulawesi region more easily and quickly than before it also allows preachers and ulema to communicate with diverse groups of people and respond to their questions and needs more effectively however as with social media and other digital technologies digital dawah also has its own challenges and risks that need to be managed wisely the phenomenon of developing digital dawah carried out by the iuc of south sulawesi province shows the need for muslims to master communication and information technology especially the internet this is no longer the time for muslims to forbid or engage in counterproductive discussions about internet technology islamic dawah through digitalization is essentially a dawah that can keep up with the times this is in accordance with the islamic principle alislām shalih li kulli zamān wa makān the digital dawah message developed requires people from south sulawesi to upgrade and update technological capabilities especially in using the internet for peaceful dawah activities taught by islam the beauty of islamic teachings which are full of love and mercy will be difficult for muslims to understand internally as well as for nonmuslims externally especially westerners who always see islam as a religion that supports violence and terror that in fact islam is not what some of them predict digital dawah with congregations that are also virtual will no longer be possible for dawah activists to avoid conclusions the iuc of south sulawesi province has adopted innovation in dealing with technological developments through digital dawah the advancement of digital dawah allows the iuc of south sulawesi province to convey islamic messages to individual believers or groups in a way that allows them to remind each other and connect when accessing digital dawah the digital dawah phenomenon at the iuc of south sulawesi province refers to the use of digital technology and online platforms to spread religious messages and islamic dawah the iuc of south sulawesi province has developed this digital dawah through its official website at overall the digital dawah that has been developed by the iuc of south sulawesi province consists of six main forms namely social media podcasts and streaming video dawah communication websites live streaming social campaigns and activism as well as digital book publishing and electronic publications the concept of developing digital dawah implemented by the iuc of south sulawesi province creates hope that proselytizers will be able to reach various groups in an effort to spread religious and prophetic messages apart from that to make this digital dawah can be more perfect the iuc of south sulawesi province is also pursuing further development this includes ideas for adding elements of islamic media applications dawah applications and online learning platforms that focus on islam in this way it is hoped that digital dawah can become a more effective tool in bringing people closer to religious values and islamic education

digital dawah is a response to the dynamics of technological development in the lives of muslim communities the proselytizers are transforming and adapting from the phenomenon of conventional dawah to digital dawah this research aimed to reveal the response of the indonesian ulema council iuc of south sulawesi province to the development of digital dawah construction amidst changes in the transformation of dawah with its various dynamics and problems this qualitative research was conducted at the iuc of south sulawesi province located in makassar the approach in this research was interdisciplinary by looking at the phenomenon of society and proselytizers conveying their dawah via digital the data source was obtained from the iuc of south sulawesi province website at and the researcher conducted interviews with core administrators such as the general chairman secretary general commission for dawah and islamic community development and communications and informatics commission at the iuc of south sulawesi province the finding of this research revealed that the iuc of south sulawesi province has innovated in responding to technology through digital dawah the progress of digital dawah allowed the iuc of south sulawesi province to explain islamic messages to individual believers and groups so that they reminded each other and connected in accessing digital dawah the digital dawah phenomenon at iuc of south sulawesi province referred to the use of digital technology and online platforms to spread religious messages and islamic dawah the iuc of south sulawesi province was developing digital dawah the digital dawah developed by the iuc of south sulawesi province consisted of six forms including social media podcasts and streaming video dawah communication websites live streaming social campaigns and activism as well as ebooks and digital publications the idea of developing digital dawah carried out by the iuc of south sulawesi province raised the hope that the proselytizers would be able to reach all groups in spreading divine and prophetic messages the perfection of digital dawah also needed to be developed as ideally as possible such as by adding aspects of islamic media applications dawah applications and online islamic learning platforms

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introduction climate change is part of natural disasters accompanied by the process of environmental degradation and harms human life holistically the impact of climate change has become a serious problem experienced by various society levels without any exception numerous scientific studies explain that climate change triggers various environmental changes that threaten the survival and welfare of society one of the real threats of environmental change is the sea level rise as confirmed in the intergovernmental panel on climate change report which estimated that within 100 years starting in 2000 sea levels will rise as high as 1590 cm with a definite increase of 48 cm in addition in 2021 the ipcc has issued a code red on the impacts of climate change that are expected to be faster than predicted susandi et al also projected the sea level rise for coastal areas based on their projection several regions in indonesia are threatened with losing some land due to the problem the projection results for 2010 2050 and 2100 show that the landmasses lost in a row are 7408 km 2 30120 km 2 and 90260 km 2 sea level rise threatens the physical loss of land and nonphysical environment in the form of coastal ecosystems including the lives of coastal communities demographic data shows that more than 110 million people 60 of indonesias population live within a radius of 50 km from the coastline one of which is the cilacap regency which is classified as the southern coast of java based on research by the sea level rise in cilacap regency continued to experience significant changes in their projection one of the ten districts in cilacap regency that would lose land the fastest was kampung laut district which was predicted to be inundated as the sea level rise by 2026 the monitoring of satellite imagery is shown in figure 1 the red parts indicate the land that would be lost and had a longterm adverse impact on coastal communities especially for the poor and marginalized living under pressure it was also studied by that the impact of climate change could also be noticed from the shift in seasons rain intensity impacts on the coastal ecosystem and human lives in it furthermore added that climate change might affect the availability of water impacting the potential source of welfare for local communities climate change can affect peoples lives in general 2016 exacerbate socioeconomic and cultural disparities and potentially result in social physical and human instability this situation encouraged adaptation and mitigation efforts carried out by various parties considering the very high level of vulnerability of coastal communities to the impacts of climate change climate change adaptation and mitigation is a form of adaptive action socially and ecologically to reduce vulnerability in coastal communities climate change adaptation and mitigation also become preventive and repressive strategies in controlling climate change a continuously developed program is the climate village program to improve adaptation and mitigation of the climate change impacts on the community based on the data collected from the ministry of environment and forestry 3000 villages of the climate village program were established in 2021 the program continues to be developed by targeting 20000 villages by 2024 one of the villages is ujungalang village kampung laut district cilacap regency central java province which received an award from the moef as the main category of the climate village program uniquely the implementation of the climate village program in ujungalang village involves social workers in the community empowerment process the involvement of social workers produces good results so that the programs sustainability can be achieved in the community the employment of social workers in climate change adaptation and mitigation efforts cannot be separated from the green social work approach according to gsw is a holistic approach to environmental crisis by encouraging social workers to internalize the principles values and concerns for environmental degradation and related disasters within the practical framework of society in addition dominelli emphasized that a social worker who internalizes the gsw approach in hisher professional practice is referred to as a green social worker thus not all social workers can be considered as green social workers green social work has its uniqueness in terms of internalization social workers can combine environmental sustainability and social functioning for a more prosperous community life through this approach dominelli ku argue that paying attention to physical environmental sustainability is an inseparable part of professional practise carried out by social workers a scientific study conducted by on the correlation between social workers and climate change found that social workers played a role in dealing with environmental issues such as climate change social workers in this case acted as researchers educators clinicians and community members the results were also reinforced by who examined the role of social workers in managing the impacts of climate change in tzaneen city south africa the study findings concluded that social workers should make social interventions in communities affected by climate change this form of intervention began with conducting an assessment and providing a disaster intervention strategy meanwhile a study conducted by explained that green social work in empowerment activities could mobilize community capacity to raise their concern for the environment the empowerment process is significant in raising awareness for local communities so that the program can operate sustainably it proved that the existence of social workers was critical in improving community resilience through various efforts to adapt and mitigate the impacts of climate change these studies encouraged researchers to participate in investigating and proving that green social work was developing in indonesia the emphasis of this study was on the implementation of gsw in climate change adaptation and mitigation efforts in the community the research was intended to contribute to science and technology on gsw in general research on gsw was still very limited and even considered rare in indonesia on the other hand the development of the social work profession would continue to grow along with the enactment of law number 14 of 2019 on social workers for this reason scientific studies on gsw were essential to provide a new framework of science values and skills for the future of social workers in indonesia this research was considered strategic to be conducted in indonesia since a professional practice of implementing green social work had not been carried out massively due to the absence of exploratory study on the implementation of gsw in dealing with various cases in communities affected by environmental degradation in this case climate change in indonesia thus an exploration was needed to prove that gsw can be developed in indonesia based on these factual reasons the topic of green social work was very worthy of research both in terms of academics and practice in addition as a theoretical framework the present study adopted the grand theory of green social work referring to gsw can develop through four things namely research policy education and field experience the field experience will later become an important basis for exploration through research therefore this scientific study made green social work the centre of interest to explore and describe the contribution of green social workers in addressing the impacts of climate change in indonesia method the present study explored and described the contribution of green social workers in addressing the impacts of climate change in indonesia case studies of ujungalang village cilacap regency central java province this research focused on a case study in ujungalang village kampung laut district cilacap regency central java province indonesia the focus of the investigation was on the study of roles concerning the theory of green social work by and a descriptive analysis of the role of green social workers regarding the conformity between theory and field practice overall this study employed a qualitative research method it is known as naturalistic because its implementation is based on natural conditions on this basis the qualitative research design in this study was carried out specifically by applying a supportive approach to data collection data analysis conclusion drawing and preparation of research reports the implementation of the qualitative method approach in this research was in the form of the application of a case study research method the determination of the use of the case study method in this research was because the case being discussed was considered unique and related to the role of green social workers in the climate village program which was being developed and implemented by the government on the other hand this study emphasized exploring and describing a particular case in addition the case study research method also aims to gather naturalistic facts the main strength of this method is the ability to provide more detailed and indepth information than other research methods because it involves an exploration known as its trademark the uniqueness explored and depicted in the role of green social workers in the climate village program was described to answer research questions based on actual conditions in the field this research method was expected to examine and develop preexisting theoriesconcepts regarding green social workers therefore selecting the case study research method was a very appropriate decision this study presented primary data and secondary data the primary data were collected by directly involving informants selected according to the criteria one of them was by using a key informant the key informant criteria in this study were social workers who worked in community development officer positions who practiced green social work in addition key informants actively assist the community in the climate village program in ujungalang village kampung laut district cilacap regency meanwhile the secondary data were collected from supporting references such as the environment and forestry office of cilacap regency and other supporting sources the stages of data analysis were carried out by giving meaning or interpreting data by organizing sorting grouping coding or marking and categorizing them into parts based on certain groupings so that a formulation can be obtained regarding the research problems results and discussion green social work is a new social work perspective that addresses structural inequality and environmental degradation this new method supports the overall approaches for all people and other living things including plants animals and physical ecosystems this approach emphasizes the natural relationship among all existing elements and then redefines the need to care for others including being responsible for preserving the earth as states gsw is a transdisciplinary holistic approach undertaken by social workers incorporating principles values and concerns to respond to damage and disasters related to environmental degradation into professional practice instead of daily activities the meaning of green in gsw is part of the vision carried out by social workers in holistically saving the environment from degradation social workers may adopt diverse roles in addressing environmental issues ranging from practical assistance coordinators to developing community and individual resilience in responding to disasters throughout the disaster cycle from prevention preparedness direct assistance recovery and reconstruction efforts the importance of adaptation efforts to the impacts of climate change is also stated by who emphasizes a contribution that can carried out by local people to improve their quality of life it is at the heart of strategic and important alternative solutions in reducing the impact of climate change in a region meanwhile view from the point of view of a condition of society which emphasizes on adaptability to climate change it is said that adaptation is the ability of a system to adjust to the impacts of climate change in a way reduce the damage caused benefit or overcome change with all its consequences adaptation to climate change is one of the ways that adjustments are made spontaneously or planned to providing a positive reaction to climate change thus adaptation climate change is a necessary strategy at all scales community to alleviate an impact that occurs the concept of adaptation from refers to the existence of a lead relationship the return between man and his environment this concept of adaptation emphasizes the existence of a reciprocal relationship between man and the environment because it is deep community life in an area to allocate and utilize resources that are seen as strategic in the face of an impact so that the community even with its limitations can still carry out life in the green social work corridor the concept of adaptation is defined not far away as opposed to the concept adaptation in the systemic sense refers to such process action or result that could enable a system or its elements to cope with manage or adapt more good for some change in condition stress danger risk or opportunity even though this approach is relatively new green social work is the key to professional practice to encourage todays society to align with the environment knowing the dependence between fellow living beings will also bring all existing systems and institutions into the realm of work the green social work value system upholds equality social inclusion equitable distribution of resources and a human rightsbased approach to meet the communitys needs for a sustainable and decent life ecological and social problems are now something that can no longer be understood and tackled separately at the regional and national levels instead these issues should be explored with a multilevel approach dominelli explains that the social worker can and must play a role in designing and establishing this perspective green social work is oriented toward the rejection of structural inequality and at the same time views the environmental aspect as the fulfilment of human needs and as something interrelated with humans it is recognized by the relationship between social justice and the environment dominelli claims that this concept fits into the practice of social work given its inclusive egalitarian and caring nature and also assumes that green social work puts a person at the core of its theory and practice green social work provides insights for social workers in the broader context of the environment of their service users by acknowledging the physical environment and preserving it for a better future on earth other scholars also support the concept of green social work alston describes that the concept of green social work can integrate the challenges of inequality in relationships into a policy portray social work as a holistic approach to understanding the interconnectedness of people and the environment this concept is beneficial in dealing with the problems of communities affected by environmental damage recommend green social work as a conceptual framework for explaining the dimensions of the global environmental crisis and assessing the social work profession in this research the green social work theory was used as a theoretical framework to explore and describe the role of green social workers in the climate village program in the coastal area of ujungalang village cilacap regency central java province the study results showed that the theory and practice in the field related to green social work did not show significant differences as explained previously green social work is a sustainable social work practice it considers that balancing the shared ecosystem across disciplines is an obligation for sustainability green social work provides a new paradigm for environmental issues that green social workers must address to achieve this goal it subsequently encourages social workers to become green social workers and go beyond the familiarized past zones by engaging in transformative social changes to create a prosperous and sustainable environment this research aimed to explore and describe the role of green social workers in the climate village program in the coastal area of ujungalang village cilacap regency central java province the present study proved that the green social workers as practitioners unconsciously implemented the green social work paradigm in the climate village program green social work became the primary theoretical reference used as the basis and the analysis guidance in this study furthermore the research findings illustrated that the green social workers were involved in the climate village program and played their proper role in realizing sustainable welfare the main point of green social work in the climate village program was to invite residents and experts using a holistic approach and encourage the community to work together to protect the physical social political economic and cultural environment in climate change adaptation and mitigation activities these dimensions were integrated parts and could not be separated in general integrated development with community movements such as business elements productive economy social elements society environment and even politics which involves policies having potential for interdependence and strengthening one another in indonesia the climate village program is a nationalscale program developed by the ministry of environment aiming to encourage the active participation of the community and all parties in carrying out local actions to improve resilience to the impacts of climate change and reduce greenhouse gas emissions the government rewards communities that have carried out sustainable climate change the climate village program could be developed and implemented in areas that were at least located at the hamlet level and a maximum equivalent to the village level in addition the climate village program could strengthen the multistakeholder partnerships in dealing with climate change and facilitate the dissemination and exchange of information on good practices for climate change adaptation and mitigation the climate village program was employed as an instrument to encourage climate change adaptation and mitigation action at the site level which was focused on strengthening local activities the level of community participation in climate change adaptation and mitigation activities varied significantly depending on the potential and conditions in each location the objective of the climate village program was to improve an understanding of climate change along with its causes and impacts encourage concrete actions to strengthen the communitys resilience in facing climate change and contribute to reducing greenhouse gas emissions activities carried out by green social workers in collaboration with local communities include conducting social mapping natural resources and climaterelated disasters the things done by green social workers are as follows 1 establish the topics or issues discussed in social mapping the determination of topics carried out through group discussions at the local level which are attended by multiparties discussions on climate change adaptation actions also need to be supported by data and field facts regarding extreme climate events climaterelated disasters and the impact of disasters on peoples incomes 2 identifying social mapping participants participants were carefully selected representing parties related to the topics discussed came from representatives of hamlets in the village and consisted of paddy farmers nonpaddy farmers farmer groups extension workers peasant women and facilitators 3 conduct meetings with community representatives to develop social mapping resources vulnerabilities and risks of climate change local communities are more aware of the situation on the ground such as the condition of water sources irrigation canals land locations land owners community leaders the activities of farmer groups the needs of various parties the obstacles faced the intensity of climaterelated disasters and climate change adaptation and mitigation actions that have been implemented 4 after the formation of the climate village profile map together the needs are formulated from the most important or most urgent and necessary to the less urgent the mapping results can be analyzed according to the focus of very urgent issues to be resolved in terms of sustainability the results of the mapping analysis can be formulated as input material to develop policies programs and activities for related parties the implementation of the climate village program applied a communitybased climate change adaptation and mitigation approach involving the principle of partnership with this approach stakeholders actively interacted in solving climate changerelated problems to strengthen social capacities at local and national levels in addition to the grassroots level of actions implemented by communities at the local level the topdown policy interventions were also developed so that local efforts could run effectively efficiently and sustainably concerning the program green social workers performed several roles that were slightly different from other professions as follows 1 helping to analyze and solve problems and respond to opportunities and challenges faced by farmers in managing their businesses 2 facilitating the learning process of farmers or forest farmer group in implementing good and sustainable business governance 3 assisting farmers forest farmer group or community groups in developing institutions to be competitive and productive 4 improving the leadership managerial and entrepreneurial skills of farmers forest farmer group or community groups 5 ensuring farmers access to information technology and other resources in business development and assisting as well as supervising farmers in increasing production and productivity 6 being a safeguard of state assets in the form of forests and inviting the community to know want and participate in maintaining and protecting forest resources from various forest security disturbances 7 encouraging the community to sustainably adapt and mitigate climate change 8 initiating the establishment of the climate village program the primary basis of the climate village program was community empowerment because a program might not run sustainably without going through the empowerment process the empowerment carried out by the green social workers in ujungalang village was closely related to the preservation of the physical environment the study of causeandeffect between the physical and nonphysical environment has become a concern for social workers however the term green social worker was still not massively recognized by social workers involved in the climate village program kemp palinkas responded to this circumstance recommending that social workers in general deal with the impact of environmental change more decisively comprehensively and innovatively erickson warns that if social workers choose to ignore the existence of environmental degradation in realizing social justice the role they carry out will ultimately not be handled optimally the climate village program was implemented by applying the concept of communitybased development in which the activities carried out by the communities and institutions in mobilizing and managing human and natural resources inside and outside the village were directed to strengthen adaptation and mitigation efforts to the impacts of climate change which were in line with the value system in green social work the principles of community empowerment in implementing the climate village program were communitybased local resourcebased and sustainable community capacity could be achieved through empowerment efforts so that the community members could participate in the process or through supporting institutions in the production process equity without distinguishing status and expertise security sustainability and cooperation all of which ran simultaneously as an educational process where individuals or adults become more competent in handling their skills attitudes and concepts in living in and controlling local aspects of their society through democratic participation this research shows an update in exploring the best practices of social workers in general because the practice of green social workers in indonesia has not been widely applied and through this research can be an important learning in the specialization of the social work profession in the future conclusion the present research encouraged the transformation of small actions into changes with a significant impact the climate village program implemented by the government one of which was in ujungalang village cilacap regency central java province had its uniqueness because of the existence of green social workers although the number of practitioners and the professions name were not yet well known they still had a critical role in collaborating with crosssector parties to tackle climate change in the coastal area as a recommendation for future scholars the green social workers in the region should be an inspiration in establishing the program in indonesia or other countries government commitment is needed in developing a green social work education curriculum to provide professional human resources

climate change is part of natural disasters accompanied by the process of environmental degradation and harms human life holistically the impact of climate change has become a serious problem experienced by various society levels without any exception numerous scientific studies explain that climate change triggers various environmental changes that threaten the survival and welfare of society climate change adaptation and mitigation become the preventive and repressive strategies for controlling climate change a continously developed program is the climate village program proklim the main basis of the program is community empowerment to be able to run sustainably the present research focused on the study of roles referring to the theory of green social work by lena dominelli the data were analyzed descriptively regarding the role of green social workers concerning the suitability between the theory and practice the application of the qualitative approach employed in this research was in the form of a case study the researchers decided to employ the case study method because the what was investigated in this study was considered unique regarding the role of green social workers in the climate village program which has been developed and implemented by the government the roles of green social workers were first helping to analyze and solve problems and respond to opportunities and challenges faced by farmers in managing their businesses second facilitating the learning process of farmers or forest farmer group kth in implementing good and sustainable business governance third assisting farmers forest farmer group kth or community groups in developing institutions to be competitive and productive fourth improving the leadership managerial and entrepreneurial skills of farmers forest farmer group kth or community groups fifth ensuring farmers access to information technology and other resources in business development and assisting as well as supervising farmers in improving production and productivity sixth being a safeguard of state assets in the form of forests inviting the community to know want and participate in maintaining and protecting forest resources from various forest seventh encouraging the community to sustainably adapt and mitigate climate change eighth initiating the establishment of the climate village program green social workers were indispensable in community empowerment especially in encouraging environmental improvement to remain sustainable for the communitys prosperity

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introduction context in october 2007 the world cancer research fund and the american institute for cancer research released their second report on food nutrition physical activity and the prevention of cancer they suggest on a population level the portion of the population that drink above the recommended amounts be reduced by one third every 10 years and on an individual level that the consumption of alcoholic drinks be limited to no more than two drinks a day for men and one drink a day for women the author noted that they would have been inclined to recommend lower levels were it not for the association between a modest level of consumption and reduced risk of cardiovascular disease among older adult consumers 2 in contrast an article in the torontobased globe and mail outlined what a host should stock for a new years eve party of 12 guests six bottles of champagne six bottles of wine 24 bottles of beer and one bottle each of vodka gin rye whiskey scotch and rum 3 our estimate is that this provides approximately 14 standard drinks 136 grams of ethanol 1 standard drink per person for the event 2 the article was likely to have been intended as a joke but was not signaled as such only one letter to the editor in the print version of the newspaper drew attention to the health and safety risks of heavy consumption and labeled the article irresponsible alcohol is consumed by 5090 of the adult population in many western cultures and is thoroughly integrated into social life in contrast there is extensive growing evidence that social problems trauma and chronic disease are associated with its use 4 5 6 7 lowrisk drinking guidelines have the potential to balance some of this ambivalence about alcohol use lrdgs have been around for some time with examples from greek philosophers dating back to 375 bc 8 evidencebased guidelines around the world have been created to assert a certain level of acceptability around drinking at the same time they can be justified as a basis for raising the profile of alcohol on precautionary grounds these guidelines however also create a number of challenges including balancing the risk of chronic disease and trauma where drinking thresholds associated with risks will vary by the individual 9 determining which caveats to include in documents designed to be userfriendly and how to handle competing interests eg public health and the alcohol industry a persistent challenge is that the guidelines upper threshold may be outofline with the reality of the drinking culture where some subsections of the population typically surpass the daily recommended maximums on a typical drinking day this may be cause to dismiss the guidelines for being too strict when this occurs it is tempting to allow popular advice and social norms to trump epidemiological evidence concurrent with the proliferation of lrdgs there has been extensive alcohol marketing and promotion including the use of many forms of electronic media sponsorship internet and product placement 1011 alcohol is often presented as an essential ingredient for any social gathering and for those planning events advice is available from numerous sources on the amount of alcohol to have on hand this paper contrasts healthoriented lrdgs with advice from retailers and the hospitality industry on the amount of alcohol to be provided for social occasions the following questions are addressed what is the underlying evidence base and rationale for healthoriented vs social occasion drinking guidelines given that lrdgs from different jurisdictions are not identical in recommended upper thresholds what are the range of standard drinks and upper limits per person from the lrdgs and the contrasting popular advice methods several methods were used in this pilot study including web site searches research literature consulting colleagues and brief email interviews they are summarized by foci 1 low risk drinking guidelines and 2 social drinking indicators first for the lrdgs we collected information on current guidelines for australia canada the united kingdom and the united states it was beyond the scope of the paper to undertake a comprehensive review of international drinking guidelines the guidelines reviewed here have the most relevance to the canadian experience second the information on social drinking indicators including responsible drinking messages 3 was collected by conducting a systematic search of web and print documents and consulting with hospitality organizations and licensed vendors using a brief email interview information on social drinking indicators was collected through a systematic search of websites and print materials and focused on information from canadian and us sources key words and phrases for the search were identified by the research team based on a preliminary scan of the literature see table 2a for a list of key words and phrases an online search was completed using google the scope of the search was expanded by conducting a manual search of all provincial liquor board web sites and current issues of several popular north american entertainment magazines to be selected for review articles had to provide quantitative advice on the amount of alcohol to stock or serve at a social function articles and postings from discussionbased forums were excluded unless advice was offered by an expert who was affiliated with the site furthermore a brief email interview inquiring about individual service and responsible drinking messages was distributed to hospitality organizations and licensed retailers licensed vendors were identified by entering the keywords hospitality and restaurants along with the respective province name ontario british columbia nova scotia and alberta into google the first 100 licensed vendors yielded by the ontario search results were selected to receive the brief email interview a similar process was used in order to identify vendors in each of the other provinces as well as hospitality organizations twenty vendors in each of the other provinces as well as 22 hospitality organizations were selected to receive the brief email interview an a priori template was developed for classifying information gathered for lrdgs and social drinking indicators extensive working tables were developed and the results were reviewed by the coauthors summary data were then assembled into the tables presented below results tables 1a and1b provide an overview of lrdgs and the caveats for males and females across four countries canada the united states australia and the united kingdom the 3 responsible drinking messages refer to messages that promote drinking of alcoholic beverages in moderation drinking that does not lead to loss of health or other harm to the drinker or to others 5 recommended limits of alcohol consumption vary ranging from a daily maximum of 14g to 42g of pure alcohol for women and 20g to 56g for men weekly limits range from 98g to 168g for women and 1904g to 272g for men as well each of the four countries identifies a different definition for a standard drink each of the eight organizations across the four countries profiled in these tables reports its lowrisk guidelines based on the most recent evidence to minimize the harm from alcohol consumption as it relates to health and social outcomes the rationale provided for these guidelines also include beliefs about educating citizens 12 and informing future policies and prevention initiatives 13 the drinking recommendations vary as the evidence base sourced for each of the guidelines differs the caveats indicate conditions when the guidelines do not apply table 2a provides summary information from our survey of social drinking indicators a total of 27 websites and print ads were surveyed for advice on social drinking indicators resulting in 59 articles providing social drinking advice the websites were colourful the recommended alcohol stock was easy to locate on the page and alcohol was always considered in the social occasion planning process as shown in table 2a advice was categorised by event type most of the social drinking advice on websites and in print media pertained to generic parties there was a wide range in the recommended number of standard drinks to serve both between and within the different event types overall the popular advice recommends serving the fewest number of standard drinks per person at luncheons and the highest number of standard drinks per person at special events such as stag parties or parties celebrating a milestone birthday however the number of standard drinks recommended per person per hour ranged on average from one standard drink at weddings luncheons and dinner parties to two standard drinks at cocktail parties several of the sources had social responsibility messages tips or guidelines however this varied greatly by event type with these messages being most associated with luncheons and least associated with weddings and special events none of the websites or print materials made reference to the lrdgs nor did they quantify in their materials what it means to drinkenjoyconsume responsibly furthermore some web pages offered conflicting advice for example in one area of a webpage a maximum of 12 drinks per person per event was recommended however this quantity was surpassed by the amount of alcohol suggested by the same websites online party calculator 5 furthermore many of the sites made serving recommendations based on etiquette and social norms rather than evidencebased safe drinking levels as contained in the lrdgs for example at events such as a back yard bbq or bachelorette party there was an expressed expectation that alcohol be served often in abundance the provision of alcohol was often associated with being a good hostess the websites and print media were both reinforcing and creating expectations of social norms around alcohol service and use images of smiling happy guests and the use of bright colours all create associations between the service of alcohol and a successful party and host table 2b summarises the advice obtained from a small scale email survey of hospitality organizations and licensed vendors overall 182 retailers were contacted and 19 responded responses were organised according to the type of event publicly accessible vs private function typically hosted by the responding organization the advice provided by bars and restaurants which host publicly accessible events suggests a more conservative range of standard drinks per person compared to that provided by hosts of private events it was recommended that between two and five standard drinks be served per person at publicly accessible events with the average recommendation being 325 standard drinks per person for private functions the recommended number of drinks per person ranged from 125 to 10 with an average recommendation of 525 standard drinks per person however the average recommended number of drinks per person per hour is similar for both private and publicly accessible events again several respondents indicated they had a social responsibility message as part of the information provided to their clients however this differed depending on whether it was a publicly accessible venue or a private event discussion this paper explores and contrasts recommendations for alcohol use from two main sources of information lrdgs which are informed by research on the health and social damage from alcohol and social drinking indicators and marketing which are informed by hospitality and business motives nevertheless as shown in the accompanying tables there is overlap between these two sources of information while the social drinking indicators data shows a wide range of alcohol amounts the modal amount per event assuming one event per day is not dissimilar from the upper daily limits from some of the more liberal lrdgs furthermore when taking event length into consideration popular advice typically does not promote drinking more than 12 drinks per hour and events where food is served are typically associated with lower alcohol consumption normative recommendations most commonly promote drinking above the lrdgs at private functions and special events it should be noted that the normative recommendations discussed in this pilot study are likely a conservative estimate of the amounts of alcohol actually served at social functions this is due to the fact that hospitality organizations and alcohol retailers may be susceptible to response bias these respondents may not accurately or willingly divulge the actual quantities of alcohol they typically serve at social functions especially if those amounts are excessive this may also be the reason for the low response rate for the brief email interview it is possible that normative recommendations are simply allowing for a greater selection in beverage choice however many of the sources examined accounted for differences in beverage preference and recommendations were often qualified by statements suggesting hosts keep their guests glasses full from the moment they arrive also responsible drinking messages are not commonly promoted alongside these special events and are typically vague from a harm reduction standpoint the messages promoted among the sources examined did not directly indicate that the use of alcohol can be damaging to ones health instead these messages focused on having the individual manage the risks associated with alcohol use by encouraging responsible use and the avoidance of drinking and driving this is one illustration of how by design or default health information or advice is separated from alcohol promotion even within a government agency the quality of these messages may reflect the fact that few canadian provinces have regulations that mandate the use of these messages this is an opportunity for government to initiate provinciallyregulated standardized messaging the inconsistency among the different guidelines highlights one of the challenges of conveying health information on a drug that is so extensively integrated into social life it also reflects a difference in interests while some lrdgs are influenced by alcohol industry stakeholders the guidelines primarily aim to reduce alcoholrelated harm whereas the socially oriented recommendations promote hospitality and aim to generate revenue from the sale of alcohol this dichotomy can be exceptionally challenging for government monopolies where liquor boards are responsible for the retailing of alcohol which involves providing hospitality advice to consumers while still upholding their social responsibility mandates through a harm reduction approach it is important for policy makers to facilitate a coordinated response that considers both retail and harmreduction practices in order to deliver a more consistent message when it comes to alcohol consumption in addition to the other challenges these guidelines typically do not provide concrete advice or specific guidance on how a person drinking above the guidelines should go about curtailing their drinking therefore they may have greater utility in clinical and counselling settings where this advice can be offered rather than as a prevention tool for dissemination to general populations as indicated by babor et al there is no evidence to date to suggest these guidelines had an impact on drinking levels or patterns in the population where they were promoted 6 for example in ontario alcohol consumption and highrisk drinking has increased since the extensive promotion of the lrdgs in 1996 14 however it is feasible that the increase in consumption and highrisk drinking might have been even greater without wide dissemination of the guidelines since to date there is no evidence that the guidelines alone will have substantial impact on alcohol consumption other resources should be considered in order to reduce the harm from alcohol guidelines may be a complementary tool when implemented in combination with other interventions with greater potential for impact such as minimum prices and controls on outlet density 6 social drinking indicators may have an impact on consumption although to our knowledge their specific impact at the population level has not been evaluated further work is needed to determine the quantity of alcohol provided and consumed in various settings key informant studies might explore the rationale and expectations on the part of hosts and attendees about alcohol availability where they obtain social hosting information whether they use different authorities for different contexts how they judge these sources and which sourcecontent combinations are likely to have the greatest impact on the behaviour of which consumers table 1b a comparison of low risk drinking guidelines in australia and the uk no more than 34day no more than 23day total per week no more than 14wk no more than 28wk no more than 21wk no more than 21wk no more than 14wk 4 comments and caveats at higher levels of drinking lifetime risk of alcoholrelated disease increases more quickly for women and the lifetime risk of alcoholrelated injury increases more quickly for men for women who are pregnant planning a pregnancy or breastfeeding not drinking is the safest option for those under 18 not drinking is the safest option regularly drinking every day or every other day of the week take a break for 48 hours after a heavy drinking session dont mix alcohol with any kind of medication dont mix alcohol with recreational drugs be careful if you have mental health problems such as depression as alcohol can make these worse none table 2a summary of survey on social drinking indicators factors mentioned by licensed vendors that affect the quantity of alcohol served include length of event time of day of the event gender with women drinking 25 less than men cash or host bar ethnicity type of event age group and the food being served table 1a a comparison of low risk drinking guidelines in north america

aimthis paper contrasts healthoriented lowrisk drinking guidelines lrdg with social drinking marketing and popular advice on the amount of alcohol to be provided for social occasions the questions addressed include what is the underlying evidence base and rationale for healthoriented vs sociallyoriented drinking guidelines what are the recommended amounts of alcohol per person from the lrdgs and from popular advice methodthis paper draws on existing research archival data web sites print media and key informant interviews the focus is on recent information on lrdgs and social drinking indicators in canada the us australia and the uk resultsthere is extensive epidemiological research indicating the associations between drinking pattern and risk for chronic disease and trauma as well as certain potential health benefits from drinking small amounts regularly this body of evidence is one resource for government or medicallysanctioned lrdgs in many jurisdictions in contrast for those planning social events where liquor is served information is available from the hospitality industry retailers and liquor control boards while some overlap exists between these two sources of information in some contexts normative recommendations support drinking at potentially dangerous levels discussionthe inconsistency among the different guidelines highlights one of the challenges of conveying health information on a drug that is integrated into social life and used extensively it also reflects a siloed approach to alcohol policy where retailing and harm reduction practices are managed by different sectors of government that seldom reflect a coordinated response

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background the incidence of cancer cases continues to rise globally simultaneously improvements in cancer diagnosis and treatment and in some countries access to that treatment have increased in the number of people living with cancer 1 in 2018 there were almost 30 million 3year and 44 million 5year cancer survivors worldwidenearly half of them living in lowand middleincome countries 2 the growing population of individuals with a history of cancer has raised concerns over posttreatment needs and challenges related to their physical psychological and social wellbeing 3 4 5 6 7 8 9 most research comes from highincome countries and is unlikely to be fully applicable to lmics as the experiences and challenges of cancer survivorship are culturally constructed and embedded in the existing in social context 10 contextually and historically situated circumstances contribute to peoples health beliefs illness experiences and behaviors 1112 and to the ways in which they adapt to living with a chronic illness such as cancer the term survivor was proposed by advocacy groups in the united states to encourage empowerment hope and solidarity between people with cancer 13 14 15 16 cancer patients in the us 36717 brazil 18 and puerto rico 15 are more prone to adopt the survivor identity than those in other settings such as the united kingdom 1920 and australia 2122 the proposed survivor selfidentity concept has been found to be associated with positive mood satisfaction with life and selfcare 101422 defining when patients should be deemed survivors in the cancer clinical trajectory is highly debated with some definitions proposing cutoffpoints of 3 or 5 years after cancer diagnosis 23 and others considering that patients become survivors after completion of primary cancer treatment 24 or even since cancer diagnosis thus encompassing acute extended and permanent stages of survival 13 those who reject the term survivor typically identify themselves as a cancer patient a person who is living with cancer had and no longer has cancer or a cancer victim 1622 mexico is an uppermiddle income country that shares historical and cultural features with other latin american countries while also possessing unique characteristics like many la countries mexico has a history of spanish colonization characterized by exploitation and domination of indigenous population which in turn explains the predominance of the spanish language catholic religious identity and ethnicallymixed population common cultural values and beliefs include an attachment to family 25 and gender roles that legitimize male dominance and justify female subordination mexico is also quite unique among low and middle income countries in the depth and breadth of health insurance coverage and particularly cancer through the seguro popular so that survivorship is becoming an increasingly important issue even among lower income groups 26 research from mexico and other la countries on cancer survivorship selfidentity lived experiences and challenges is scarce 14 one study from puerto rico of 23 young adults with a history of cancer treatment found that the most important aspects of their posttreatment trajectory were family faith and opportunities to help others 15 a recent qualitative study of 25 young breast cancer patients in mexico city identified common survivorship experiences including unmet psychological care and informational needs being less concerned with fertility increased family support narrowed social circles and barriers to employment 6 in addition the research on cancer survivorship experiences of latinos in the us cannot be generalized to mexican cancer patients due to differences in social context and health system organization between mexico and the us and the role of acculturation 6 qualitative research on cancer patients survivoridentity and lived experiences in lacs can deepen understanding of the survivorship phenomenon and on culturally appropriate strategies to address health and social challenges of this population in this study we address the research gap on the experience of survivorship in la focusing our analysis on mexico and on breast cervical and prostate cancer as these are among the most common cancers in the region the study seeks to explore how mexicans living with bc cc or pc experience and make sense of survivorship we want to learn what meaning they attach to the term cancer survivor and what similarities and differences in these topics exist among patients with these three types of cancer methods we conducted a qualitative descriptive study through indepth interviews from september 2014 to february 2015 in mexico city morelos nuevo león and puebla these cites were chosen because they have specialized cancer hospitals and varying socioeconomic levels low median and high 27 we used a qualitative descriptive methodology to gain insights regarding the target phenomenon by providing its accurate description without imposing a priori conceptualizations 28 data collection data were collected through indepth semistructured interviews guided by a list of predetermined openended questions based on study objectives to ensure consistency across interviews examples of openended questions include the following what do you understand by the term cancer survivor do you consider yourself a cancer survivor at what moment in time did you feel like a survivor how do you see your life in the future how have you been feeling lately have you had any health problems after finishing cancer treatment how do you feel emotionally the researcher conducting the interviews maintained a receptive attitude asking participants to elaborate on their unique experiences and statements the demographic data was collected during the interviews interviews were conducted at times and locations that were most suitable for participants and lasted approximately 1 h all interviews were audiorecorded and subsequently transcribed interviews were conducted by three researchers with doctoral degrees in science and expertise in qualitative methodologies who completed a prefield training session data analysis data were analyzed through inductive thematic analysis 30 this process comprised five stages creation of initial codes through an inductive process search for themes based on their explicit articulation in the interviews and grouping of smaller codes under common themes revision of themes definition and classification of themes and analysis of the content and meaning of the identified themes the illustrative interview excerpts are labeled according to the cancer typesbc cc and pc as well as cities of residencemexico city morelos nuevo león and puebla and patient identifier three researchers assessed the transcribed texts separately individual decisions on emerging themes and classification of responses were crosschecked to ensure consistency and reliability of the coding in the cases of discrepancy the classification of responses into themes was corroborated through discussion and collective agreement during the analysis we looked for common and specific themes for each group of participants finally we summarized the topics in the thematic map with the aim of making the results easier to comprehend ethics the study was approved by the ethics committee of the national institute of public health in mexico researchers also obtained permission to recruit participants from each of the participating hospitals prior to each interview participants received information about the aims and nature of the study and relevant ethical considerations all invited participants agreed to participate and signed an informed consent form results the study included 60 participants 22 with a history of bc 20 with cc and 18 with pc the median age of participants was 51 years for bc 50 for cc and 64 for pc and the median time since diagnosis was 6 4 and 2 years respectively half of bc participants 35 of cc and 72 of pc were urban residents participants with a history of bc were primarily from the states of nuevo leon and puebla those with a history of pc were primarily from morelos and nuevo leon cc participants were equally distributed among the four cities level of education was higher among bc patients than cc among men with pc 17 had completed primary school while the rest had completed high school or higher over 55 of participants lived with a spouse or a life partner and had children all participants had health insurance coverage the majority of bc and cc through seguro popular and the majority of pc through the social security figure 1 summarizes the themes raised by the participants and identified in the thematic analysis the principal themes of the narratives encompass three types of survivorship identity six common lived experiences and two themes specific to women with bc meaning attached to the term cancer survivor one of the central topics of the interview focused on the terminology cancer survivor and its relation to survivorship the term survivor did not appear spontaneously in conversation with participants although almost all the patients confirmed considering themselves survivors there were three interpretations of this term a literal interpretation an interpretation based on health providers reporting on their health status and an interpretation by the majority of participants linking survivorship to gods will and support these interpretations of the survivor term were common among participants with different cancer types do you consider that you are now a cancer survivor well here i am as long as it does not appear again it is fine and if it appears again well itll have to be faced do you consider yourself a cancer survivor well i would say yes because i already had it and now that ive done tests they came out clean which means yes i felt like a survivor when i had surgery first and foremost with the hand of god i am going to pull through do you think you are a cancer survivor yes because god gave me another chance from the moment the doctor told me that my tumor was shrinking with the treatment for some participants faith in god helped them find meaning in life and cope with the physical and emotional challenges during cancer treatment and recovery three participants with pc and one with cc rejected considering themselves as survivors these participants considered themselves cancer patients two of them had a low level of education and the other two had a history of metastasis experiences and challenges of survivorship the participants described diverse physical emotional and social experiences after finishing their primary cancer treatment most of these experiences were negative negative physical outcomes after finishing cancer treatment almost half of participants mentioned having adverse physical outcomes after completing their treatment the most frequent physical problems were lack of strength and pain the negative physical outcomes were more frequent among bc and cc than among pc participants one does not have the same strength nor can one do the same activities as before one gets tired more … everything hurts and im just going to tell the doctor because i cannot even sleep in addition bc cc and pc participants who were sexually active before cancer diagnosis also reported negative consequences to their sexual life what has changed in your life since diagnosis that affects your daily activities well the most important thing for me … is my sexual life i dont know it suddenly took a turn and that affected me a lot my sexual life was over really because they cut everything several women with a history of cc a disease associated with the human papilloma that is sexually transmitted infection blamed their husbands for their illness my husband is the only sexual partner i have ever had so he transmitted the illness to me … i dont want to be with my husband again im a housewife im with my children and i take care of emotional problems additionally several participants mentioned emotional problems such as fear and distress how do you feel emotionally … it was really a small tumor they removed it and thats it but psychologicallythe fear … that hurts terribly the depression came to me after finishing treatment it began on the last day of my treatment … what did you feel well nothing more than pure depression … and tiredness and thats all distress caused by changes in body image a theme specific to bc was distress from changes in body image as almost half of the participants were struggling to accept themselves after undergoing mastectomy cancer stigmas we identified several participants who perceived that their relationships with family and friends and opportunities for returning to work were negatively affected by cancerrelated stigmas these outcomes seem to have been at least partly related to an unfounded fear of contagion this fear could either exist amoung participant communities or have been perceived by the participants as possibly motivating the behavior of others several participants hid their illness from their friends expressing worries about being perceived and treated differently for instance one participant with breast cancer decided not to tell friends about her cancer because she was afraid they would stop buying the food that she sold another participant with prostate cancer was concerned that people would not allow him to enter the public bathroom after finding out about his diagnosis others only mentioned that they did not want their friends and coworkers to know of my friends and coworkers there was definitely no one to support me because i didnt want them to know about my illness another perception of stigma mentioned by some participants was abandonment by friends did you have any support from friends and family not at all they didnt even come to see me i felt very lonely and sad several participants who intended to return to work noted barriers believing that their history of cancer and the possibility of relapse could prevent them from being hired will you return to work i want to return to work in fact i am looking for a job i have already submitted applications and i had some interviews i had a call from one job and they told me that i passed all the screenings and that i just needed the medical check and medical history after that they didnt call me i think they didnt hire me because of my history of cancer financial hardships another shared experience was related to the financial hardships caused by patients and family members losing their jobs and by outofpocket cancerrelated expenditures despite most patients having medical costs covered by the seguro popular or social security the associated primarily nonmedical expenses were a hardship several participants described permanent or temporary job loss typically without any paid leave some who worked prior to their cancer diagnosis described losing their jobs during treatment or had to leave them temporarily nonsalaried workers described lacking financial support from their employers some also discussed loss of income because family members had to give up their jobs to care for them additional causes of financial hardships were outofpocket expenses participants with seguro popular commented on tests and medicines that were temporarily unavailable in hospitals or analgesics and other symptomatic drugs that were either not covered or only covered for the first 5 years of treatment other financial burdens included cost of transportation to treatment and followup consultations and housing costs for patients who had to relocate out of their home cities to be closer to hospitals with oncology services fortunately the seguro popular paid almost everything my operation was free however we had to pay for several tests and medicines as these were not available when i had radiotherapy we had to rent a room here in puebla because the sessions were every day for a month and a half and we couldnt pay for the transportation now im still struggling a bit with the transportation expenses to come to medical consultations for some patients of low socioeconomic status these financial hardships triggered feelings of desperation which led them to borrow or beg for money … when i came to the emergency room suffering severe pain they health professionals gave me analgesics and they prescribed me ketorolac but it was not covered through the seguro popular insurance did you buy it yes i bought it but i struggled to get the money to buy it i have even begged for money i had seguro popular insurance for catastrophic expenditures but they tell me it is only valid for five years and in february it had been five years it is assumed that after five years you are discharged as a cancer patient you stop taking medicines and come for followups every six months but my case is different i had to look for financial help to get the pills oral medicines because they health insurance were no longer filling my prescription … challenges to obtaining healthrelated information the majority of bc and cc and several pc participants reported difficulties in obtaining healthrelated information from their providers throughout the treatment process including diagnosis followup and selfcare … if i didnt ask them health professionals they wouldnt tell me anything … sometimes i would ask questions and the doctors would say im going to give you the information you need and dont ask more … many times they doctors would say shut up do not talk do not say anything this is the prescription you have to take this and the next time you come you have to tell me how you are doing … the unmet need for information on how to address physical emotional and social challenges prompted many participants to search the internet and join support groups family as a source of support the majority of participants spoke positively about their family members as providers of physical emotional and financial support and about the challenges they faced as caregivers she my daughter is my nurse secretary assistant maid everything … they my children took care of the house … for example my son is not studying anymore because he had to clean the toilet wash the bathroom go shopping … many participants indicated that families became united and stronger after their diagnosis and that this support helped their mood and selfesteem the family relationship is strengthened we are more united now the great satisfaction is that my family looked after me the support that he gives me as a husband and father of my children that lifts my selfesteem a lot support groups for women with bc several bc patients spontaneously mentioned the importance of support groups often run by civil society organizations these groups offered emotional and informational guidance training programs related to nutrition physical activity and healthy habits financial support with shelters transportation occupational therapy and employment opportunities in microenterprises i was going to the psychologist at the cruz rosa support group this helped me a lot because i was close to committing suicide … has your life changed after the diagnosis and treatment in what way yes for which im very grateful because before i did not have time for myself i used to work and had little time for rest and now every month i dont fail to come to the support group because its like recharging my batteries … some bc patients joined groups after finishing treatment in order to support other cancer patients i have come to the support group now because i want to help we mostly provide emotional support some cc patients mentioned they failed to find groups for their needs because all the support groups they were for women with bc loss of control over the future and attitudes toward planning the majority of participants expressed three closelyrelated concerns about the future lack of control over their future fear of cancer recurrence and belief that their future was in the hands of god they preferred not to plan for the future and instead focused on the present as a coping strategy for uncertainty we learn to live daytoday when one lives through this disease one learns to value and give thanks to god every day and we no longer make longterm plans because i cannot say if i will have another month … i live in the present i no longer make plans for the future … … the only one who can say how long well live is up there he god has the last word for us and the life that he gives me long or short will be welcome god has already put me on this path and there is nothing else but to be with him i already told god i am in your hands and make of me what you want and give me strength to pull through few participants expressedcontrol over their lives after cancer treatment and plans for the future well we have a lot of opportunities to continue living as long as we do things the way we should … having regular checkups discussion the development and implementation of appropriate health and social strategies to address cancer survivorship in mexico requires an indepth understanding of survivoridentity lived experiences and challenges our study participants individuals with a history of breast cervical and prostate cancer generally accepted the term cancer survivor as a literal interpretation of being alive or as a medical confirmation of treatment completion and achievement of normal laboratory results they linked survivorship to gods help their narratives around lived experiences and challenges encompassed several common concerns 1 adverse physical and sexual experiences 2 emotional problems 3 cancerrelated stigma 4 challenges to obtaining health information 5 financial hardship and job loss and 6 positive experiences of strengthened family ties and support women with bc reported distress caused by changes in body image as well as positive experiences with support groups embracing cancer survivorship and a survivor identity has been cited as important in achieving better physical and emotional outcomes 101422 although our study participants accepted the terminology their responses did not reveal the sense of empowerment that is often associated with it 13 14 15 16 the term cancer survivor seems more of a label for treatment completion the majority perceived both their present and the future to be out of their control and under the will of god as in studies from other countries 3 4 5 6 7 8 9 physical and emotional consequences of cancer and its treatment were often mentioned by participants our participants did not report receiving the continuous longterm recommended professional care to prevent and treat these issues 3132 participants faced serious challenges to obtaining health information the results of our study reveal the urgent need for the development and implementation of comprehensive culturallyrelevant survivorship care programs focused on emotional support and empowerment of cancer survivors yet the findings and an indepth literature review show that the mexican health sector lacks survivorship care programs public programming focus primarily on epidemiological surveillance and screening the national cancer institute in mexico city is the only specialized cancer hospital in the country with a public program for survivorship and it focuses on bc patients the nongovernmental organizations with groups are the only other source of informational emotional and sometimes financial support for people diagnosed with cancer facetoface and online support groups aim to help cancer survivors increase personal control over the illness and its consequences by sharing illnessrelated experiences 33 previous research found that these groups can help improve coping strategies and reduce psychological distress and depression 34 35 36 in our study only bc patients mentioned participating in and receiving help from support groups while cervical and prostate cancer patients struggled to find such groups highlighting the need to develop a focus on different types of cancer our study supports the notion that family support is a key coping strategy to be recognized and encouraged by survivorship programs in response to a cancer diagnosis most of the participants families mobilized and united to provide support previous research has recognized that a positive family response to a stressful situation is usually facilitated by shared beliefs that make meaning of the event and foster mutual support and teamwork to achieve recovery 37 in mexico this phenomenon has been documented in families with children with leukemia 38 faith in god is another important resources that helps many mexican cancer patients cope and find meaning in life during treatment and recovery studies of latino us residents also suggest that survivorship interventions should incorporate spirituality as a bridge to resilience 39 stigma negatively affects social identity and consequently psychological wellbeing and achievement of personal goals 4041 and our study supports others that recommend dissemination of education as a strategy to reduce the silence and preconceived notions around cancer survivorship 42 analogous to findings from other countries our study found that cancer stigma is complex and heterogeneous affecting different components of patient life 43 several participants hid their cancer diagnosis from friends assuming they would be treated as contagious and then felt abandoned several also perceived difficulties getting a job because of assumptions about their productivity after or during treatment 44 universal health care should cover comprehensive cancer treatment includuding survivorship care mexico made remarkable progress towards universal health coverage between 2003 and 2018 2645 all people without social security have the right to health care through the seguro popular health insurance and the fund for protection against catastrophic expenditures also finances cancer care 2645 our participants stressed the importance of this coverage for their treatment however they also noted ongoing financial hardships fpcg covers cancerspecific treatment 5 years after diagnosis but does not cover other burdensome expenses such as symptomatic medication transportation and housing in our study these gaps in coverage disproportionately affected poorer patients as in commonplace in most of la because of overreliance on outofpocket payment 46 recent discusions around closing the seguro popular should consider the importance that cancer patients place on this coverage and not only seek to maintain the program but also expand it to include more aspects of survivorship care strength and limitations to ensure the quality of our study in terms of its methodological rigor and transparency we followed tong et al coreq consolidated criteria 47 to develop and report our research to ensure credibility 4849 we used longlasting engagement of the researchers in the field with participants that allowed building trust and obtaining rich data and we performed qualitative data analysis through investigators triangulation we described the context so that the study participants experiences become meaningful to the readers to allow the transferability of the study results 4849 in addition the study included participants with diverse sociodemographic and clinical characteristics and three types of cancers which allowed for a more comprehensive understanding of a studied phenomenon however our study is limited to bc cc and pc patients with public health insuarence from four mexican states therefore our findings may not be generalizable to other cancer types or states or to those who receive cancer care delivered by private health care providers conclusion this study adds to the sparse survivorship literature in mexico and the la region the results suggest the need to develop and implement comprehensive and culturally consonant survivorship care programs focused on emotional informational and inkind support and the empowerment of cancer patients especially in the face of stigma the findings also point to the importance of increasing access to support groups like those that currently operate through civil society organizations these should not be exclusive to breast cancer patients finally universal health coverage should include comprehensive financial protection for the continnum of careprevention early detection diagnosis treatment survivorship and palliative carethat accompanies patients through their cancer journey abbreviations bc breast cancer cc cervical cancer fpcg fund for protection against catastrophic expenditures la latin american lmics lowand middleincome countries mexcity mexico city mor morelos nl nuevo leon pc prostate cancer pueb puebla p patient us united states authors contributions fmk conceptualisation methodology funding acquisition investigation supervision interpretation of data writingrevised the first draft critically for important intellectual content and editing svd literature review methodology formal analysis and interpretation of data conceptualization and writingoriginal draft writingreview mcgr conceptualisation methodology investigation supervision formal analysis and interpretation of data writingreview ad conceptualisation funding acquisition resources investigation supervision writingreview gsp interpretation of data writingreview fc interpretation of data writingreview hao conceptualisation funding acquisition methodology investigation interpretation of data and writingreview all authors approved the version of the manuscript before submission and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved competing interests the authors declare that they have no competing interests

background qualitative research on cancer patients survivoridentity and lived experiences in lowand middleincome countries is scarce our study aimed at exploring the concept and experience of survivorship for mexicans living with breast cervical and prostate cancer methods we conducted a qualitative study in mexico city morelos nuevo león and puebla the participants were breast cervical and prostate cancer patients ≥18 years of age with completed primary cancer treatment data were collected via indepth interviews and analyzed using an inductive thematic approach results the study included 22 participants with a history of breast 20 cervical and 18 prostate cancer participants accepted the term cancer survivor as a literal interpretation of being alive medical confirmation of treatment completion or achievement of a clinical result possibly indicative of cure the majority of respondents perceived that the future is out of their control and under gods will they linked cure to divine intervention and did not demonstrate the sense of empowerment that is often associated with the survivorship term the principal themes of their narratives encompass 1 adverse physical and sexual experiences 2 emotional problems 3 cancerrelated stigma 4 challenges to obtaining healthrelated information 5 financial hardship and 6 experience of strengthening family ties in order to provide them with support in addition women with breast cancer reported distress caused by changes in body image and positive experience with support groups conclusion in mexico cancer patients report complex survivorship experiences that demand posttreatment followup and support there is the need to implement comprehensive culturallyrelevant survivorship programs focused on emotional informational and inkind support and empowerment of cancer patients

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introduction with the popularity of web 20 millions of smokers have turned to the internet for help in quitting with one avenue being participation in online health communities designed for this aim smoking cessation ohcs are collectives of people who interact with each other over the internet to give up smoking smoking cessation ohcs provide support differently from offline venues ohcs provide aroundtheclock access to an extended social network of exsmokers and current smokers who share similar smoking cessation experiences and the interaction with peers in these communities can be anonymous users may share their experience of the process of quitting related struggles and support for others in the ohcs without disclosing their identity furthermore smoking cessation ohcs can offer a setting free of the social stigma that can arise from social pressure against smoking for instance 8 of respondents in research by stuber and galea reported concealing their smoking status from a health provider because of concerns about smokingrelated stigma in contrast smoking cessation ohcs that promise anonymity may offer an empathic environment where smokers can share quittingrelated information and support each other studies have found that participating in smoking cessation ohcs may lead to positive smoking cessation outcomes such as achieving 30day pointprevalence abstinence after shortterm use of the ohcs and preventing relapse these advantages notwithstanding questions remain as to what motivates users to share their knowledge of smoking cessation in smoking cessation ohcs which is critical for the success of online communities thus it is important to investigate knowledge sharing behavior in smoking cessation ohcs while knowledge sharing in online communities has been subject to research in various contexts smoking cessation ohcs have been largely ignored thus far one factor that sets these online communities apart from others is a shared aim of eliminating what the members share in common that is most users of smoking cessation ohcs are smokers who want to stop using tobacco products some of them might doubt their chances of success in quitting because of past failures in this regard and hence turn to the ohc for support to improve their confidence and coping skills as they attempt to kick the habit also a smoker may suffer from unpleasant withdrawal symptoms during the smoking cessation process such as irritability headaches and cravings and specific personalized information from smoking cessation ohcs might be able to aid in dealing with such struggles in smoking cessation beyond what general guidelines smoking cessation professionals offer unlike clinical diseases that rely primarily on physical treatments and medications smoking cessation could be achieved via nonpharmacological interventions such as interacting with counselors or peers the psychological or emotional additions to smoking can be addressed from negative to positive by engaging in online social networks given smokers unique features and needs the motivation beyond their knowledge sharing in smoking cessation ohcs might differ from those in other online communities as the literature shows knowledge sharing in online communities involves social interactions among people in online social networks and social capital has been posited to be an important determinant of knowledge sharing in this context however researchers have reported conflicting findings on motivations for knowledge sharing when studying different online communities from the social capital view for instance some scholars found a positive impact of relational capital on knowledge sharing in the context of blog and general online communities whereas some research reported a negative impact of relational capital on knowledge sharing in professional online communities or no impact in commercial online communities and prior research also reported a positive impact of cognitive capital on knowledge sharing in general ohcs but no significant impact in specialized ohcs hence more contextaware theorizing is called for in knowledge sharing research this could uncover both differences and common patterns in the context of smoking cessation ohcs past studies have examined knowledge sharing mainly from the technology and the content perspectives while prior research has investigated the effects of social capital on knowledge sharing in different contexts relatively little attention has been paid to the specific context of smoking cessation ohcs all these factors point to a need to study whether social capital built in smoking cessation ohcs can help explain individuals knowledge sharing behavior in the specific context of smoking cessation ohcs according to the transtheoretical model of behavior change smokers pass through a distinct series of cessation stages before successfully quitting smokers have been argued to differ in their characteristics and information needs between stages however few studies have empirically explored whether the impact of social capital on knowledge sharing in smoking cessation ohcs varies among smokers across smoking cessation stages hence we examined the smoking cessation stage as a possible moderator when exploring the relationships involving social capital and knowledge sharing in smoking cessation ohcs to address the aforementioned gaps we developed a research model based on social capital theory for investigating the determinants of knowledge sharing in smoking cessation ohcs we then tested the proposed model empirically via 173 online survey responses from users of smoking cessation ohcs in finland and china this work shed light on individual users knowledge sharing behavior from the social capital perspective and the posited moderating effect of users stage in quitting on the impact of social capital on that behavior in smoking cessation online communities we begin our discussion with a review of prior literature on knowledge sharing in smoking cessation ohcs and social capital theory then we present the hypotheses and research model against this backdrop we describe the research methods and discuss the results the paper concludes with thoughts on theoretical and practical implications alongside the identification of the works limitations and further opportunities theoretical background knowledge sharing in smoking cessation ohcs the concept of knowledge sharing refers to an individual disseminating the knowledge skills or experiences he or she has obtained with others the information systems literature includes investigations of knowledge sharing in various online contexts such as online communities for legal professionals blogs webbased discussion communities and generalpurpose ohcs smoking cessation ohcs are like other online communities in that knowledge sharing is their core activity and also vital for the sustainable development of the ohc those studies investigating knowledge sharing in a smoking cessation context have taken various perspectives one focus has been on identifying what has been shared in smoking cessation ohcs by applying content analysis to the sharing activities in these groups for instance the work of myneni et al identified the following 12 themes social support traditions progress cravings motivation benefits virtual rewards relapse obstacles nicotine replacement therapy specifically friends and family members and conflict in contrast knowledge sharing in smoking cessation ohc cheung et al classified the topics of sharing in smoking cessation ohcs on whatsapp and facebook platforms into three main types sharing views and experience encouragement and knowledge and information the predominant framework applied in these studies for exploring the sharing behavior among the users has been social support theory and knowledge sharing has been identified as one important activity alongside sharing of emotional support esteem support and network support another stream of research has focused on users knowledge sharing patterns in smoking cessation ohcs for instance ploderer et al found that users at different stages of quitting manifest different patterns of knowledge sharing in these ohcs specifically those at later stages in quitting mainly make comments in the smoking cessation ohcs whereas the supportive responses and leadership come mainly from users who have just started the process investigating the knowledge sharing patterns in smoking cessation ohcs from a social support perspective in turn zhang and yang found that those who share knowledge to provide information support have typically been abstinent for a longer time than those who give emotional esteem and network support for instance users further along in quitting exhibit a preference for sharing more advice and personal experiences with users who are in the early stages some scholars have attempted to investigate the motivations for knowledge sharing in smoking cessation ohcs such as li et al have identified the perceived usefulness of smoking cessation ohcs as an important determinant of knowledge sharing li discovered a positive correlation between user satisfaction with smoking cessation ohcs and knowledge sharing table 1 lists some literature on knowledge sharing in smoking cessation ohcs as shown in table 1 the prior literature examines knowledge sharing behavior principally from the content and technology perspectives and the role of social relationships in knowledge sharing in smoking cessation ohcs has been ignored notwithstanding literature stating that social relationships are important reasons for knowledge sharing in online communities in general in addition most of these studies have applied qualitative research methods and research in a quantitative manner is very limited prior research suggests that social capital theory may hold value for explaining consequences of social relationships and community connections this points to a need to investigate what motivates knowledge sharing in smoking cessation ohcs from the social capital perspective social capital theory with its roots in community studies social capital theory focuses on the resources derived through interpersonal relationships among people nahapiet and ghoshal defined social capital as the sum of actual and potential resources embedded within available through and derived from the network of relationships possessed by an individual or social unit and s ocial capital thus comprises both the network and the assets that may be mobilized through that network social capital theory has been widely applied to investigate the effect of resources on social relationships in our lives from both individuals and organizations perspective in various fields with examples being the research contexts of health promotion and management in general prior literature points to an association between social capital and a host of positive outcomes such as better health at the level of the individual and improved performance of organizations social capital theory has been applied specifically to knowledge sharing from both the individual and the organizations angle scholars have posited that it provides a framework to the first refers to the overall structure of connections among people and is regarded as the channel for information flows researchers measure it by evaluating patterns and density characteristics of social networks such as centrality and social ties the notion of relational capital brings in the affective nature of the relationships within a social network such as trust reciprocity and commitment finally cognitive capital denotes resources providing shared interpretations and meanings within a social network such as a shared language and vision the three dimensions of social capital have been applied to explore knowledge sharing in numerous contexts among them a professionbased online community itoriented online communities firmbased commercial online communities blog sites online games user communities work teams firms ohcs and social networking site contexts for instance examining an online community of legal professionals wasko and faraj found both structural and cognitive capital to play important roles in knowledge sharing while relational capital was not a significant motivator of knowledge sharing as for ohc settings structural capital has been found to enhance both the externalization and the combination aspect of knowledge creation in a similar vein sns research by mojdeh et al revealed that one factor in relational capital has a positive influence on knowledge sharing intention while the other factor considered is only marginally significant table 2 presents more details on the research findings connected with the three dimensions of social capital in the field of knowledge sharing we selected social capital theory as our theoretical framework for investigating knowledge sharing for several reasons firstly social capital theory highlights the role of social capital in obtaining different resources to benefit individuals and organizations prior research suggests that this theory may hold value for explaining the outcomes obtained due to social relationships and community connections secondly social capital has been identified as a central theme in explaining knowledge sharing based on the social relationships and community connections inherent to online communities this ties in with the aim of investigating the knowledgesharing behavior of individual users in the context of smoking cessation ohcs in this study thirdly smoking cessation ohcs are collectives of people who have similar concerns about quitting and who are embedded in social networks formed in online communities individual users can develop social capital via social interactions with others in online communities this renders social capital theory suited to explaining knowledge sharing in smoking cessation ohcs taking it as a basic theoretical framework for the study we followed established literature in applying the threedimensional model of social capital for investigating the knowledge sharing in question the research model and hypotheses development of the model prior research indicates that social capital is one of the main factors in individuals sharing of knowledge in online communities below we explain how we developed our use of the framework to address the research phenomenon in light of previous knowledge sharing in smoking cessation ohc findings on the impact of the dimensions of social capital on knowledge sharing at the level of the individual and table 3 lists the definitions of the constructs included in the research model as noted above users of a smoking cessation ohc interact and establish connections with others even though they are anonymous for instance they post messages to seek help reply to others questions or comment on others achievements the users are connected with the other members of the smoking cessation ohc via social interaction activities and users also share information in the connected communities in other words they build a social bond in and with the ohcs studies have validated that this set of social ties is indeed a key factor reflecting structural capital accordingly we assumed that social ties are an element reflecting structural capital in smoking cessation ohcs online communities also provide users with a way of building relational capital according to wasko and faraj reciprocity is an essential feature of online communities users of smoking cessation ohcs contribute to these communities by posting initial messages answering questions and commenting on others contributions thus the content both benefits others and solicits helpfor example via requests for tips or advice thereby reciprocity is evident in online communities furthermore to realize mutuality in smoking cessation ohcs users must maintain their commitment to the online community the literature points to reciprocity and commitment as reflecting relational capital connected with knowledge sharing in online communities so we presumed that the constructs of reciprocity and commitment should capture relational capital in smoking cessation ohcs research has revealed that over time communicating with peers who have shared similar situations and experiences will help users gradually develop cognitive capital such as shared language and a shared vision in smoking cessation ohcs users indeed develop both shared termsjargon and such components of a joint vision as common goals or concerns about smoking cessation since shared language and shared vision have been concluded to constitute the factors best capturing cognitive capital in knowledge sharing within online communities we assumed that these two factors should capture cognitive capital in smoking cessation ohcs hypothesis development members of smoking cessation ohcs can build relationships through both asynchronous methods and synchronous ones the relationships among them provide costeffective information channels suitable for sharing knowledge with thousands of exsmokers and current smokers participating in the ohcs these relationships may be strengthened via frequent and sustained interaction among users the social ties are largely built upon the closeness of users relationships with each other work by chiu et al and by chang and chuang has explicated that the stronger the social ties built the greater the quantity of knowledge shared in the online community likewise chai et al have articulated that social ties constitute a strong driver of knowledge sharing among bloggers proceeding from the foregoing discussion we postulated that the stronger the social bond in smoking cessation ohcs the more the users will share knowledge in their smoking cessation ohc accordingly we formed the following hypothesis h1 social ties are positively associated with knowledge sharing in smoking cessation ohcs shared language pertains to the common codes vocabulary or understandings that users adopt in their communications here in smoking cessation ohcs often the information shared is related to the range and extent of nicotine withdrawal symptoms medical treatments and tobacco products however smokers frequently are confused about the associated terminology for instance alexander et al found that while smokers generally understand electronic cigarette products overall the details of product types often confuse them to build a common understanding for purposes of smoking cessation users create common terms in many cases such as slang that is easy to understand for members of the communityfor instance employing the commonly used ecigarette and vaping to represent electronic cigarettes in a twitterbased group in smoking cessation ohcs shared language promotes effective knowledge sharing by offering an avenue by which users can adopt common terms connected with smoking cessation and thereby avoid certain misunderstandings moreover shared language offers a template with wellestablished codes for new members to follow and learn making them capable of communicating with others more readily research has identified shared language as a motivator that determines knowledge sharing in online communities likewise we expected shared language among the users of smoking cessation ohcs to exert a positive influence on knowledge sharing in the communities so we formed this hypothesis h2 shared language is positively associated with knowledge sharing in smoking cessation ohcs a shared vision articulates common goals values and aspirations among the users of a smoking cessation ohc one key part of the vision shared is to deal with difficult situations caused by the smoking habit and achieve longterm abstinence through supporting one another the shared vision binds previously isolated smokers together and enhances interactions by such means as helping the users see the potential value of sharing medical and experiential knowledge of smoking cessation with others studies have validated shared vision as a significant influence on knowledge sharing in online communities the above reasoning led us to propose that shared vision is one of the main factors determining the knowledge sharing in smoking cessation ohcs and the following hypothesis was developed h3 shared vision is positively associated with knowledge sharing in smoking cessation ohcs reciprocity is an important aspect of relational capital because people expect mutuality of costs in terms of effort and time devoted to contributing knowledge the reciprocity expressed in smoking cessation ohcs provides users with a sense of fairness and some kind of guarantee that their contributions will be rewarded by others in the long run one would expect this pattern to hold irrespective of the use of pseudonyms and indeed there is evidence of reciprocal interactions even though most smoking cessation ohcs provide anonymity for instance a study of a twitterbased smoking cessation ohc found more than 50 of ties to be reciprocal the fairness evidenced by mutuality and reciprocity among users of smoking cessation ohcs might encourage users to contribute knowledge by replying to others questions or promptly supplying information in the ohcs finally findings in previous studies support the conclusion that reciprocity has a positive impact on knowledge sharing in online settings thus it seemed reasonable to assume that h4 reciprocity is positively associated with knowledge sharing in smoking cessation ohcs commitment entails a sense of belonging and positive feelings toward the collective and it nurtures loyalty and citizenshiporiented behavior collectively how do smoking cessation ohcs express this they can provide users with both informational and emotional support which confer a sense of being attached to the ohc the mutual support and the empathy embodied by the online communications with peers might further motivate a user to participate and maintain the relationship with the ohc users with a high level of commitment to a smoking cessation ohc would be expected to possess and convey an ethos of an obligation and duty of helping others and they are likely to remain members and share knowledge of smoking cessation with their peers in the long term in work by yu et al considering knowledgeintensive work teams the commitment was found to be positively correlated with knowledge sharing the above reasoning led us to expect the commitment of the individual users to drive their knowledge sharing in smoking cessation ohcs and we developed the following hypothesis accordingly h5 commitment is positively associated with knowledge sharing in smoking cessation ohcs smokers pass through a series of distinct cessation stages before achieving longterm abstinence characterized as precontemplation contemplation preparation action maintenance and termination smokers needs vary between these stages for example when thrul et al investigated a smoking cessation intervention on the facebook platform they found that users at precontemplation or contemplation stage were concerned more about the pros and cons of quitting while those at the preparation stage were more focused on consciousness raising accordingly prochaska et al recommended providing smokers with information customized for their particular stage in smoking cessation to match their personal needs in addition the smoking cessation stage has been found to be associated with the foci of smoking cessation behavior such as restrictions on smoking in the home concentrating on a facebookbased smoking cessation ohc ploderer et al reported that the smoking cessation stage has a connection also with the social support shared in online communities with the majority of comments being provided by those who had successfully progressed to a more advanced stage such as people at the maintenance or termination stage findings from prior research indeed suggest that the motivation for users knowledge sharing in smoking cessation ohcs might differ with ones stage in giving up smoking for instance for those who have not taken actions to quit smoking such as in contemplation and preparation stages their participation in smoking cessation ohcs might not have developed strong relationships with other users and have a strong sense of commitment and reciprocity but they will share the similar language in the ohcs as well as share the similar vision supporting each other in quitting smoking in the ohcs thus structural capital and relational capital might have a weaker influence on knowledge sharing than cognitive capital for these users and those who are in the process of quitting might have benefited from the ohcs in quitting smoking and relational capital might have a much stronger influence on their knowledge sharing in these ohcs than structural and cognitive capital for those who have quit smoking structural capital and relational capital might have stronger impacts on their knowledge sharing than cognitive capital they have used smoking cessation ohcs for a certain period of time and might have built strong relationships with other users and they have also achieved certain success in smoking cessation which might help them build a strong sense of responsibility and duty for them to help others via sharing their knowledge therefore we considered the smoking cessation stage as a possible moderator of the proposed relationships between social capital and knowledge sharing in smoking cessation ohcs thus the following hypotheses were developed h6 the smoking cessation stage moderates the relationship between knowledge sharing and social ties shared language shared vision reciprocity and commitment in addition prior research has identified gender and age differences in smoking cessation and knowledge sharing literature also suggests that gender differences should be considered in studies in online settings since we collected data from two countries with different cultures there might be cultural differences between the two user groups participating in this study therefore we set age gender and country as control variables in the proposed research model figure 1 presents the proposed research model and hypotheses the questionnaire to investigate the determinants of knowledge sharing in smoking cessation ohcs we employed an online survey for collecting data in finland and china the questionnaire was initially prepared in english and reviewed for content validity by two is researchers then it was translated into finnish by one author whose mother tongue is finnish and into chinese by another of the authors who is a native speaker of chinese for reasons of translation quality the questionnaire was further reviewed by an administrator of the finnish smoking cessation ohc and additional checking for the chineselanguage questionnaire was performed by two chinese is researchers with administrator assistance 20 stumppifi users were invited to participate in a pilot test of the finnishlanguage online survey on the basis of which the questionnaire was revised further questions were reordered to improve the flow and clarity of the questionnaire both in chinese and in finnish construct measurements the proposed research model contains six constructs social ties shared vision shared language reciprocity commitment and knowledge sharing the items for all the constructs in the model were measured via multipleitem scales with instrumentation adapted from items suggested in the literature further rewording was carried out in light of the context of smoking cessation ohcs the metrics for social ties shared language and shared vision were based on contributions from while those for reciprocity were taken directly from work by wasko and faraj the commitment items were items suggested by but in adapted form finally knowledge sharing was measured via four items adapted from items in a study by a fivepoint likert scale from strongly disagree to strongly agree was employed to measure all the items in the research model the set of measurement items for all the constructs included is summarized by the list in table a1 data collection individual users of smoking cessation ohcs were the respondents in our study for this research we selected two nonprofit smoking cessation ohcs the finlandbased stumppifi and one accessed in china via a subbar in baidus post bar that is denoted as for smoking cessation we recruited individual users of the ohcs to take part in the online survey published within the two ohcs the first page of the questionnaire presented potential respondents with a consent form stressing the voluntary nature of participation and stating that respondents may withdraw from the survey at any time only those agreeing to participate in it after acknowledgment via the consent form proceeded to complete the survey the questionnaire presented questions on the respondents background smoking history and opinions and perceptions related to knowledge sharing in smoking cessation ohcs each respondent completing the finnish survey received a free electronic movie ticket as an incentive and each completing the chinese version received a red envelope containing a random amount of money from 1 rmb to 3 rmb before the collection of data the ethics committee of the authors home university granted approval for this study sampling for the online survey began on november 13 2018 in china and december 17 2018 in finland in total we received 235 response forms from 48 individuals in finland and 187 in china after removal of responses that either did not demonstrate informed consent to participate in the survey or suggested unreliable answersfor example from people completing the survey in a very short span of time we had a valid sample of 173 response forms for data analysis roughly 595 of the respondents indicated that they were male 370 specified that they were female and 35 did not disclose their gender most were aged 2567 and all had smoking cessation ohc use experience they represented various stages of smoking cessation table 4 presents their demographic information and some characteristics of the respondents smoking cessation ohc use assessment of common method bias and measurement invariance to check for the presence of common method bias in this study we used both harmans singlefactor test and the unmeasured latent method construct test developed by williams et al specifically first we subjected all the variables to factor analysis to test whether a single factor emerged and no single component was found to account for more than 50 of the total variance explained second the umlc approach was assessed with three models a methodonly model a traitonly model and a trait and method model the results were listed as below m1 was a methodonly model in which all items were loaded on one factor 5 643847 p 5 0000 cfi 5 0680 tli 5 0627 rmsea 5 0189 m2 was a traitonly model in which items were loaded on its expected construct 5 210078 p 5 0000 cfi 5 0925 tli 5 0901 rmsea 5 0079 m3 was a trait and method model in which a common method factor linking to all items was added into m1 5 131902 p 5 0000 cfi 5 0961 tli 5 0938 rmsea 5 0077 comparing these three models m2 and m3 are much better than m1 according to the data and m3 is only slightly better than m2 this indicates that trait rather than the common therefore common method bias is unlikely to be an issue in this study overall there is strong support for concluding that common method bias is not a critical concern in the current study to assess whether differences exist between the respondents from china and finland we conducted an invariance test by applying the measurement invariance assessment procedure proposed by the results show all c value the difference of the mean value and the variance of composites between the two countries fall between the upper and lower bounds of the 95 confidence interval as recommended by henseler et al thus the measurement invariance is established in this study data analysis we employed partial least squares to test the measurement model and structural model testing of the measurement model testing the measurement model involved evaluating the items convergent validity and discriminant validity convergent validity can be assessed via certain standard estimates the factor loading of each measurement item on the respective constructs must be above 07 each constructs composite reliability must be above the cutoff value of 08 and the average variance extracted by each construct must exceed 05 as table 5 shows the factor loadings of all measurement items encompassed by the research model exceed the prescribed threshold of 070 and the cr and ave values for all constructs are above the 08 and 05 cutoffs respectively showing evidence of convergent validity to assess discriminant validity we used two techniques one developed by fornell and larcker and the other proposed by henseler et al firstly we compared the square root of the ave for each construct against its correlation with other constructs as table 6 shows each constructs ave square root value is greater than the estimated correlation with any other constructs secondly we conducted a comparison between items loading for an associated construct and their crossloading on other constructs all items loaded on their corresponding construct more strongly than on other constructs finally we applied a new approach the heterotraitmonotrait ratio of correlations suggested by henseler et al to assess the discriminant validity in variancebased structural equation modeling an htmt of 090 has been posited to be an acceptable upper limit and all htmt values we obtained are below 090 see there is strong empirical support for concluding that discriminant validity exists for all constructs in our theoretical model the multicollinearity of each construct was also examined by assessing the values of variance inflation factor as shown in table 9 the vif values in this study were all lower than the suggested threshold of 33 thus multicollinearity was not a critical issue in this study testing of the structural model a pls bootstrapping procedure was applied in the structural model test including the path significance of the hypothesized effect and the explanatory power of the model via sem techniques as postulated social ties and reciprocity showed significant positive effects on knowledge sharing thus supporting h1 and h4 contrary to expectations shared vision shared language and commitment displayed no significant influence on knowledge sharing accordingly h2 h3 and h4 were not supported our model explains 745 of the variance in knowledge sharing in smoking cessation ohcs indicating that it has good explanatory power the results of the control variable test indicate that gender and country affect knowledge sharing in smoking cessation ohcs significantly while age does not we examined the predictive validity of the model by computing stonegeissers q 2 which is measured via the blindfolding technique of smartpls 30 our q 2 for knowledge sharing is 0573 indicating good predictive relevance finally the goodness of fit was tested by the measurement of the standardized root mean square residual the resulting srmr value 0060 is lower than the acceptability maximum of 008 proposed by hu and bentler therefore our model shows an acceptable fit moderator analysis finally we tested the moderation effects of the users stage in quitting to see whether the strength of the relationships between the proposed antecedents and knowledge sharing varies with the smoking cessation stage of individual users of smoking cessation ohcs we divided the users into three subgroups on the basis of broad stages in ceasing smoking those intending to quit but not taking action including users in the contemplation or preparation stage those in the action stage and those who had succeeded in having not smoked for at least six months including people in the maintenance or temptation stage note that the four responses of users in the precontemplation stage without an intention to quit smoking were excluded we applied multigroup analysis with smartpls 30 in the moderatingeffect test prior to the mga we used micom procedure proposed by henseler et al to assess whether differences existed among three groups since there are three groups in this study every two groups were analyzed at a time overall the analysis was carried out three times the results show that all c values met the criteria suggested by henseler et al but the difference of the mean value and the variance of composites for several constructs did not fall between the upper and lower bounds of the 95 confidence interval thus partial measurement invariance is established which permits mga in this study the mga results are presented in table 10 social ties and commitment emerged as significant determinants of knowledge sharing among group a users who intended to quit smoking but had not yet taken action commitment is the only factor exerting a positive influence on knowledge sharing among those in group b who were actively trying to quit smoking for those in group c who had successfully abstained for at least six months social ties and shared vision were found to be significant predictors of knowledge sharing in the smoking cessation ohcs social ties exhibited a stronger significant influence on knowledge sharing among those who had not smoked for at least six months than on those who only intended to quit a but no significant influence on those actively attempting to quit was found a significant difference was revealed only between groups b and c shared vision showed a significant impact on knowledge sharing among users who had not smoked for at least six months but not on the other two groups knowledge sharing a significant difference was found between group a and group c for commitment a stronger significant influence on knowledge sharing was visible among those actively attempting to quit smoking than among those with only an intent to cease and no significant influence was visible for those who had abstained from smoking for at least six months a significant difference was found between groups b and c in this regard finally neither shared language nor reciprocity was a significant factor predicting knowledge sharing with no significant difference evident among the groups thus h6a h6c and h6e were supported whereas h6b and h6d were not discussion of the several socialcapitalrelated factors we investigated that might affect knowledge sharing in smoking cessation ohcs the results show that two dimensions of social capital have significant impacts on users knowledge sharing in these ohcs structural capital and relational capital the results also offer evidence for the existence of a moderating effect of ones stage in smoking cessation on the relationships between the antecedents and knowledge sharing structural capital was found to be the most important factor in knowledge sharing in smoking cessation ohcs this finding is consistent with research regarding knowledge sharing among bloggers and users of ohcs prior research shows that social ties motivate knowledge sharing behavior among bloggers and support ohc users combination and externalization in knowledge creation in the study chen and shi conducted on specialinterest ohcsfocused on hivusers with stronger online social ties appeared more likely to share informationknowledge than those with weaker social ties in smoking cessation ohcs users establish social ties with other users via social interactions such ties may get strengthened over time in line with the frequency and duration of interactions for instance users might build friendships in ohcs such friendships in turn create peer pressure among users to share more knowledge with their online friends or other contacts for instance they might disseminate more knowledge in the communities to support other smokers efforts to quit whether sharing their own stories providing tips or commenting on posts by other members of the online community our finding that reciprocity is another important factor predicting knowledge sharing in smoking cessation ohcs is consistent with the research results of and of chang and chuang the literature attests that norms of reciprocity have a positive effect on knowledge sharing in blogs and on both the quantity and quality of knowledge sharing in online communities more broadly in their research on hivrelated ohcs chen and shi found reciprocity to correlate positively with information sharing likewise when users of smoking cessation ohcs believe that others care about their contributions and are going to respond to them with similar offerings they will share more knowledge in the communities to support others contrary to our hypothesis commitment did not appear to exert a significant influence on knowledge sharing in smoking cessation ohcs this finding is at odds with those of yu et al and of wiertz and de ruyter in their research on knowledgeintensive work teams yu et al found that commitment positively affects sharing both explicit and tacit knowledge at the level of individuals the research results of wiertz and de ruyter in commercial online communities likewise indicate that commitment to online communities affects the quantity and quality of knowledge sharing significantly one possible reason is that users of smoking cessation ohcs keep anonymous online and do not know each other and their commitment to the ohcs might be weaker than intensive networks prior research has found that anonymity weakens users group identification toward online communities in addition unlike professional or customeroriented online communities users of smoking cessation ohcs often experience a sense of urgency about obtaining social support to cope with difficult situations caused by smoking cessation thus they tend to use smoking cessation ohcs intermittently and irregularly and their commitment to smoking cessation ohcs might also be weaker than other online communities our finding that cognitive capital including shared language and shared vision has no significant impact on knowledge sharing in smoking cessation ohcs is part of a complex picture while this result is at odds with some previous findings on the impact of cognitive capital on knowledge sharing in various online communities such as itoriented online communities and general ohcs it supports the conclusion of zhao et al offered for specialized ohcs in professional online communities expertise and common language in a professional domain and shared values and goals about collective actions are important for users to avoid misunderstanding and improve communication efficiency quitting smoking is a wellknown topic and many individuals are familiar with some terminologies or jargons regarding smoking cessation when users join in smoking cessation ohcs they have the general common goal of stopping tobacco use users of smoking cessation ohcs might have already established the shared language and shared vision when engaging in smoking cessation ohcs in addition the inconsistent findings between prior studies on ohcs indicate that we should be cautious about the research context when studying the impacts of cognitive capital on knowledge sharing in ohcs compared with general ohcs the number of users of smoking cessation ohcs is much smaller and the level of homophily is higher to cope with the difficulties caused by the same health concern forming robust relationships among users in these ohcs might be necessary for motivating knowledge sharing activities rather than developing a shared language or vision the moderating effect of the smoking cessation stage on the relationships between some of the proposed antecedents and knowledge sharing is one of the most valuable contributions of the study a moderating effect was visible on the paths from social ties shared vision and commitment to knowledge sharing but not between other posited antecedents and knowledge sharing this might be due to stagespecific differences in both needs and the users purposes behind using smoking cessation ohcs conclusion the study contributes to research and practice with regard to individuallevel knowledge sharing in smoking cessation ohcs on several fronts contributions to theory this study enriches the knowledge sharing literature by unpacking the context of smoking cessation ohcs and clarifying the role of social capital for knowledge sharing in the specific context of smoking cessation ohcs the literature has largely ignored the knowledgesharing behavior in such ohcs investigating knowledge sharing in this specific ohc context from the standpoint of social capital our work addresses this gap and answers the call from sergeeva and andreeva to bring context back into knowledge sharing research knowledge sharing in smoking cessation ohc secondly the theoretical angle of social capital yields insights into the mechanisms underlying knowledge sharing in smoking cessation ohcs our findings show that structural capital and relational capital built in smoking cessation ohcs can motivate users knowledge sharing in these ohcs the socialcapitalrelated mechanisms identified speak to the potential value of enhancing the social relationships in the networks within smoking cessation ohcs in pursuit of stronger knowledge sharing the insignificant impact of cognitive capital on knowledge sharing in smoking cessation ohcs indicates that though social capital theory can help explain knowledge sharing in online communities it is necessary to consider the research context when applying social capital theory in knowledge sharing research as the roles of different social factors might vary in explaining knowledge sharing in different contexts thirdly investigating the components that construct social capital helps one understand the dimensions of social capitalin our case those specific to smoking cessation online communities this research disentangled the components of the three dimensions of social capital structural capital cognitive capital and relational capital specifically our empirical evidence of positive effects of structural capital and relational capital on knowledge sharing in smoking cessation ohcs provides further support for concluding that structural and relational capital can facilitate users knowledge sharing behavior in an online environment the findings also inform the literature on smoking cessation ohcs with new insights that may assist in optimizing the mechanisms of users knowledge sharing behavior in light of the structural capital and relational capital built in smoking cessation ohcs the findings connected with the smoking cessation stages moderating influence constitute a fourth contribution they provide evidence that user context is a critical factor for explaining how social capital affects knowledge sharing in smoking cessation ohcs this represents new insight for a greater understanding of knowledge sharing in these ohcs among different user groups practical significance the results offer insights through which practitioners can better promote knowledge sharing activities in smoking cessation ohcs firstly these findings from the social capital perspective indicate that it is critical for those managing smoking cessation ohcs to exploit the power of social capital in these online communities in pursuit of enhanced knowledge sharing through such means as employing strategies to help users with socialbond development and to encourage reciprocal activities in the ohc secondly this work highlights the salient role of social ties in determining knowledge sharing accordingly those who run smoking cessation ohcs should develop strategies and mechanisms to enhance relationship development on users part so as to promote knowledge sharing in smoking cessation ohcs for instance the administrators could arrange smokingcessationrelated online social events or campaigns associated with the ohc to help the users interact with each other this would promote the formation of new social ties and sustain existing online relationships in these communities thereby potentially enhancing knowledge sharing in them the managers of smoking cessation ohcs could also invite smoking cessation experts to join in their smoking cessation ohc not only to provide professional knowledge but also to facilitate interaction among the members of the community that may nurture the development of social ties among users too a third relevant contribution is the finding of a positive effect of reciprocity on knowledge sharing in response managers should develop approaches that boost the reciprocity in smoking cessation ohcsfor instance adding functions that allow users to reward knowledge contributors or respond to others postings conveniently in addition those managing smoking cessation ohcs should motivate members of the ohcs to support their peers by sharing information and knowledge through invitations to establish a dedicated discussion forum or thread doing this should increase the likelihood of other users contributing actively to the ohcs on account of reciprocity considerations fourthly because we found the users stage in smoking cessation to moderate relationships between social capital and knowledge sharing managers should consider user context such as the needs and goals of users at various stages on the journey of quitting for instance smoking cessation ohc service providers could offer custom content that is based on users stage of ceasing smoking to meet their personal needs this may help with knowledge sharing in the communities while offering insights that inform scholars and practitioners understanding of knowledge sharing in smoking cessation ohcs this study has certain limitations firstly because of the limits inherent to online surveys the data we collected may not add indepth information for explaining the nuanced features of social capital with regard to sharing knowledge in smoking cessation ohcs therefore further methods could be employed to enrich the findings in this special domain for instance one could combine quantitative and qualitative research secondly the five social capital factors proposed in our research model may not fully capture social capitals effects on knowledge sharing in these ohcs other facets of each dimension that may be connected with knowledge sharing in smoking cessation ohcs could be taken into consideration in future research another possible avenue for further research would be to examine the moderating effects of other noteworthy elements such as socioeconomic status which has been found to be closely connected with smoking finally researchers could consider collecting data from ohcs focusing on different health concerns and various countries to generalize our findings to addiction cessation ohcs

purpose although knowledge sharing in online communities has been studied for many years little is known about the determinants for individuals knowledge sharing in online health communities ohcs surrounding smoking cessation examining the determinants of knowledge sharing in such ohcs from the social capital perspective may prove particularly enlightening designmethodologyapproach a questionnairebased online user survey of two smoking cessation ohcs one based in finland and one based in china was performed performing data analysis with partial least squares smartpls 30 the authors developed a model conceptualizing the structural cognitive and relational dimensions of social capital as drivers for knowledge sharing in smoking cessation ohcs with users stage in giving up smoking as a moderator findings the results show that structural capital social ties and relational capital reciprocity are important motivators behind knowledge sharing in smoking cessation ohcs and the authors found a moderating effect of the stage in quitting on the antecedents relationship with knowledge sharing in these ohcs originalityvalue the study enriches understanding of knowledge sharing in smoking cessation ohcs contributing to theory and identifying practical implications for such groups administration

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introduction agent based social simulation is applied as a tool for the study of the evolution of social systems this has proved to be successful for a considerable number of cases usually involving simple agent models following the kiss principle proposed by axelrod and extended over many wellknown examples gilbert troitzsch however some systems cannot be easily modelled with just a set of numeric or enumerated variables and very simple agents closer to the classical cellularautomata approach the introduction of increasing complexity is an open debate in the community and several lines are being explored some problems where the agents need complex planification and decisionmaking may need cognitive models based on psychology but others where the key obstacle to overcome is the degree of uncertainty that must be considered constitutes a difficult issue in the field for instance we can analyse the evolution of values in human societies when considering sociological surveys such as the european values survey which is run periodically it can be observed that although there is an effort to categorize the possible answers to questions such as do you trust political parties there is always this mentioned degree of uncertainty this is even more evident when considering the evolution of values in individuals this evolution is a consequence of multiple factors which are strongly intertwined in this paper it is proposed the fuzzy logic as a helpful tool to deal with such kind of approximate or uncertainty knowledge more specifically it analyses how fuzzy logic can be useful when building models for abss this analysis comprises different aspects that can be fuzzificated from an agent based social model so it gets better adapted to reality and more specifically to facilitate the study of the evolution of values in human societies in concrete this work has been applied to model and simulate the evolution of religiosity in european societies based on a sociological study menendez although this has been implemented on repast a wellknown abss tool some additions have been made to the existing software library in order to be able to model and operate with fuzzy logic attributes and relationships the following section discusses the adequacy of agent based modelling for social systems simulation and introduces some of the characteristics of the system under study that require the consideration for using fuzzy logic section 3 introduces fuzzy logic concepts related to this environment section 4 presents each part of the model that is fuzzificated finally the final part summarizes the main results and contributions of this work and some issues for improving this framework modelling and simulation of social systems social phenomena are extremely complicated and unpredictable since they involve complex interaction and mutual interdependence networks a social system consists of a collection of individuals that interact among them evolving autonomously and motivated by their own beliefs and personal goals and the circumstances of their social environment a multiagent system consists of a set of autonomous software entities that interact among them and with their environment autonomy means that agents are active entities that can take their own decisions in this sense the agent paradigm assimilates quite well to the individual in a social system so it can be used to simulate them exploring the complexity of social dynamics with this perspective agentbased simulation tools have been developed in the last years to explore the complexity of social dynamics gilbert troitzsch an agentbased simulation executes several agents which can be of different types in an observable environment where agents behaviour can be monitored observations on agents can assist in the analysis of the collective behaviour and trends of system evolution this provides a platform for empirical studies of social systems as simulation is performed in a controlled environment on one or several processors this kind of tools allows the implementation of experiments and studies that would not be feasible otherwise as axelrod stands there are however some limitations when trying to simulate real social systems the main issue is that the real individual with regard to a software agent is by itself a complex system whose behaviour is unpredictable and less determined than for an agent whose behaviour and perception capabilities can be designed with relative simplicity moreover it is not possible in practice to consider the simulation of countless nuances that can be found in a real social system with respect to agent interaction characterization of the environment etc for this reason it is impractical to intend the simulation of a social system in all dimensions on the other hand we should limit to simulate concrete social processes in a systemic and interactive context therefore the simulation of social systems should be considered in terms of focus on a specific process in spite of these limitations the agent paradigm offers many advantages to express the nature and peculiarities of social phenomena however existing agent based simulation tools promote the use of rather simple agent models basically as a kind of cellular automata wolfram this may be valid to study emergent behaviour that results from deterministic behaviour of agents but as it has been already explained when considering the evolution of complex mental entities such as human believes and values that approach is rather limited as an example of a system that requires further considerations on agent modelling think about some sociological analysis derived from the european value survey and of the world value survey by norris inglehart in these surveys there are many questions about the degree of happiness satisfaction in different aspects of life or trust in several institutions although there is some kind of categorization for the possible answers such as very much or partially there is always some degree of imprecision which is difficult to model with discretecrisp categories even more when the individual is evolving to different positions some of these values get even more undefined this issue arises also when modelling agent relationships such as friendship is it possible to measure a degree of friendship between two persons agent fuzzification has been already applied for social network analysis as in the work of carbó molina and dávila but considering mainly relationships among agents here we are considering five aspects of the multiagent system agent attributes functions for similarity and evolution of agent behaviour relationships among agents in social networks and inheritance fuzzy logic in this context fuzzy logic is useful in environments with vague and uncertain information and reasoning zadeh as it has been discussed above for some aspects in the study of human societies in the modelling of abss we have counted with the help of an expert in sociology who has been consulted repeatedly along the process and frequently he uses linguistic variables and terms to express his knowledge that can be better represented with fuzzy sets given a universe of discourse u a fuzzy set µ u→ 01 on u is a mapping that gives a membership degree in the interval 0 1 to every element of u note that classical sets are particular cases of fuzzy sets there are many human characteristics that have not a clear boundary or depend on the interpretation or context as tall or beauty that can be represented by a fuzzy set on the set of human persons and gives a membership degree of the characteristic that can be for example 08 given some fuzzy sets representing characteristics sometime it is needed to model algebraical operations on them as tall and beauty that must also be modeled for example to fire a rule in approximate reasoning systems we need to use different operators to define those algebras or logics generalizing the classical intersection union and complement of classical sets a binary operator t schweizer sklar if it satisfies the following axioms 0 1 × 0 1 → 0 1 is a triangular norm 1 t x 2 t t 3 t t z 4 if x ≤ x and y ≤ y then t ≤ t the tnorm operators can be used to define the intersection of two fuzzy sets a and b as follows µ a∩b t µ b for all x in u in a similar way the union and complements of fuzzy sets can be defined using triangular conorms schweizer sklar and negation operators which define different fuzzy logics the most used fuzzy logics in applications use continuous tnorms and tconorms as the zadeh logic from zadeh that uses the minimum tnorm and maximum tconorm to generalize the and and or classical logic operators the product logic and the lukasiewicz logic fuzzy relations r uxu or to model implications rules to make inference with uncertainty imprecision or lack of knowledge the classical concept of transitivity is generalised in fuzzy logic by the ttransitivity property of fuzzy relations let t be a tnorm a fuzzy relation s is ttransitive if t s ≤ s for all a b c in e a tindistinguishability fuzzy relation s on a universe e is a mapping sexe→ 01 satisfying the reflexivity symmetry and ttransitivity properties a similarity relation zadeh is a minindistinguishability the similarity fuzzy relations generalise the classical equivalence relations that are so useful to define partitions in a set the ttransitive closure r t of a fuzzy relation r is the lowest relation that contains r and is ttransitive of course it generalises the classical transitive closure when all degrees are in 0 1 there are many proposed algorithms to compute the ttransitive closure naessens et al an algorithm used to compute the ttransitive closure r t of a fuzzy relation r is the following 1 r r ∪ m ax 2 if r r then r r and go back to 1 otherwise stop and r t r in this work we define fuzzy sets and fuzzy relations on the universe of individuals u individual i1n to represent different characteristics linguistic variables and relations between persons fuzzification of agent model fuzzy agent relationships the analysis of the evolution of values in a human society is not a trivial case for agent based modelling this has been already studied in a previous work in pavón et al by considering the evolution of religiosity in spanish society as there is considerable research on this issue in the domain of sociology menendez the simulation of the model has proved alignment with survey data however abstractions for the agent model are in some aspects oversimplistic and do not allow the social scientist to interpret results in the same terms that the survey data are expressed furthermore some simplifications produce some divergences of results with respect to survey data these facts have motivated the use of fuzzy logic to get agent models that are closer to real system in this way agent models have been enriched with the use of fuzzy logic in five aspects relationships among agents some variable attributes that determine agent states functions of similarity evolution of agent states and inheritance the cited multiagent system of pavón et al defines two possible relationships among individuals friendship and family friendship is naturally predisposed to be fuzzyfied because if the relation friendship is defined as a boolean two individuals can only be or not to be friends which is unrealistic in real life therefore it is a closer model to represent this relation using a continuous range of grades of friendship therefore friendship is defined as a fuzzy relation with real friendship degree between 0 and 1 for every couple of individuals let r f riend uxu → 01 be the fuzzy relation on the set of individuals that give a degree of friendship this fuzzy relation gives a degree of friendship in the interval 0 1 for every couple on individuals let ind be an individual in u the classic set friends is defined as the set of all the individuals x in u whose r f riend is greater than 0 and so every individual will have a range from true close friends to just known people with the rest of individuals of course some restrictions to this definition could be introduced in order to suit context needs the family link relation is also fuzzificated by following the condition that this relationship would be 1 in direct family lower with further familiars and 0 with people that is not family at all thus the family link characteristic on couples of individuals is modeled with the r f amily uxu → 01 fuzzy relation a fuzzy method to simulate matchmaking the social system also simulates matchmaking once a couple is made a stable couple can be defined as a crisp relation two persons are a couple or are not we propose to learn this classical relation r couple uxu → 01 by using approximate reasoning and fuzzy inference techniques of course if we know a r couple relation we also know a single and married classical set on u defined as married 1 ∃ind2r couple 1 0 otherwise simple n ot married it does not exist a specific process for finding a couple in previous social simulation models we decided to ask our sociology expert and build up a general definition for it an agent will find a couple between the friends that have different sex are adults and have not yet a couple the chosen one will be the most compatible one where compatibility is defined as the aggregation of how friends are they and how similar are they this important information of how couples can me made can be obtained by infering a fuzzy relation r compatible uxu → 01 which can be obtained using a fuzzy aggregation operator yager and operations on the classical set has not coupleu → 01 the fuzzy set adultu → 01 the classical relation has different sexuxu → 01 and one fuzzy rule of inference where the premise is the conjunction of the classical sets an ordered weighted averaging is a family of multicriteria combination procedures by specifying suitable order weights it is possible to change the form of aggregation for example to get the arithmetic average give the value 05 to both weights of the owa we can formally define the r compatible uxu → 0 1 fuzzy relation using the r similarity uxu → 0 1 and the r f riend uxu → 0 1 fuzzy relation as the following mapping r compatible owa r similarity w 1 r f riend w 2 r similarity for all ind ind2 in u where w 1 w 2 1 after computing the r compatible fuzzy relation a r couplecandidate uxu → 0 1 fuzzy relation can be computed by using the single set and the adult fuzzy set on u as follows r couplecandidate adult and adult and single and single and r compatible note that the and conjunction is implemented by a tnorm it can be done many times because of the associative property of tnorms so t t z then the method to marry an individual ind is to find ind2 such that it maximizes the fuzzy relation r couplecandidate then it is possible to compute r couple 1 measuring the similarity between two agents to compute the fuzzy relation r compatible used to marry individuals we have used a fuzzy relation r similarity uxu → 0 1 that deserves a deeper study in the original mas the similarity was modelled and implemented through a not normalized crude gratification algorithm based on the amount of points gathered from the comparison of the agents crisp attributes by defining fuzzy sets over these variables and fuzzificating the similarity operator based on them we will be able to have much more accuracy in the determination of similarity between individuals moreover with those fuzzy set we will be able to make inference based on them therefore we continue defining these fuzzy sets based on the variables that define each individual even though there are some of them that are not fuzzificable like the sex the most part of them will let us define a fuzzy set over them for example let µ religious u → 01 be the fuzzy set that gives a religious grade based on the religiosity variable of the individual this fuzzy set can be defined by segments with different growth or by a linear function thus µ religious 02 would mean that this person is mainly not religious the same way we could continue with other fuzzy sets now with fuzzy sets over the attributes we can define the fuzzy similarity using a tindistinguishability which generalizes the classical equivalence relations it can be obtained from the negation of a t distance where t is the dual tconorm of the tnorm t this way by aggregating the normal distance of each couple of fuzzy sets allows to obtain the total similarity between two individuals by using a strong negation schweizer sklar operator n a set of fuzzy sets m representing human characteristics a distance d and an owa operator as follows r similarity ow a µ i the influence as the result of the interaction among agents we can focus now on the direct interaction between the agents in this system there are some attributes that influence each other some attributes such as sex or age are not affected by other attributes but some as ideology are influenced by the political trends of friends this local influence is by definition a fuzzy concept the influence on a person cannot be easily quantified but after a deep analysis and with the help of the sociological expert we can dare this mathematical definition let x be a fuzzy set on u expressing a human characteristic the fuzzy set variation of the attribute x on u denoted ∆ x u → 01 determining the influence of the characteristic x by the environment of each individual ind can be defined as the aggregation of the influence of all its relatives friends and couple this influence is determined by the proximity of the person the distance d between the attribute selected and how young ind is ∆ x owa i1n and d x and µ young we use the product tnorm to compute the and conjunction let r proximity uxu→ 01 be the fuzzy relation on the set of individuals that give a degree of proximity this fuzzy relation is defined by the aggregation of the classical relation couple with the fuzzy relations r f riend and r f amily r proximity owa r f riend r f amily w 1 r couple w 2 r f riend w 3 r f amily and of course the evolution of an attribute is determined by each individual as x owa ∆ x other applications with continuous influence the global average of the variables will change over time but there is another source of change demographic evolution as time steps go on agents will find couples and have offspring those descendants must inherit their parents characteristics in some way in the crisp mas we solve this problem in a rough way we obtain the new variables from the average of the parents but with the use of fuzzy sets on those variables it is possible to use fuzzy operators between them thus we decided to use the fuzzy connectives o for obtaining the variables of the new individuals ∀ x attribute of ind µ x µ x o µ x another important side of the agents is their states the state of an agent is defined by its age and determines its behaviour therefore an agent in the state of child cannot influence adults and cannot find a stable couple while an old agent will not have children and will have greater probability of dying but where are the limits between states in the crisp systems there are threshold limits that determine that change for example if an agent has an age over 27 it is in the adult state but if it is under it it is in young state with a radical different behaviour this is not realistic in reality the changes are gradual as people get older so this is another case for applying fuzzy logic again even though this time is quite difficult it is easy to define how young is an individual but it is difficult to change gradually its behaviour the last improvement we propose is for extracting new knowledge from the system using a fuzzy operation the ttransitive closure the repeatedly application of transitive property of a relationship facilitates the discovery of the influence of some variables in other far ones this operation suits perfectly with the natural transitivity of the friendship relation the friend of my friend is not very friend of me in this way it is possible to infer inferior friendship grades in others for instance if a and b are friends in a 08 and b and c in 06 it can be deduced that a and c are friends in a 048 this could continue inferring how an agent d is friend of a and so on we are extracting new knowledge from the system which would be impossible with a crisp relation for friendship we have imposed ttransitivity to the friendship fuzzy relation as a learning process of friendship of individuals with a common friend and also as a coherence method the zadehs logic works well but we did not choose it because the friendship of a and c is either the friendship of a and b or the friendship of b and c and there is no reason for that a and c are probably not as friend as with the common friend this logic looses information in this context the lukasiewicz logic uses the lukasiewicz tnorm schweizer sklar defined by w max it works well when the common friend is a good friend of both but it infers no friendship when the common friend is not a very good friend of both individuals so the best logic to use to infer friendship is the product logic it works well for high and low friendship with a common friend and it does not loose information for example if we have a common friend with degree 12 the product logic would decide that we are friends with degree 14 which makes more sense in human reasoning than infering a friendship degree of 12 or 0 in the classical world with only 0 and 1 values all the logics and transitivity closure are the same but when we dial with the uncertainty of friendship the product logic seems to be the most similar to human reasoning another approach not referred here is to take into account the space and time dimensions even though space is implicitly covered when we let an agent to communicate only with its nearby ones we ignore if an agent is closer than other geography this could be seen as another fuzzy relation where 1 is closest neighbor and 0 not known at all about timing it must be said that all the definitions here should be taken into account because in the simulated system continuous time does not exist time is discretised in time steps this way all the operations require a step of time for example a right way would be x s1 x s ∆ xs where s is the number of time steps the motivation for this work is the observation that certain characteristics of social systems are poorly modeled with crisp attributes this has been illustrated with a concrete agent based system for the analysis of the evolution of values in a society starting from a previous model of pavón et al abstractions for the agent model can oversimplify the view of the reality and complicate the social scientist to interpret results in the same terms in which the survey data or other observations are expressed furthermore some simplifications produce divergences of results with respect to survey data the use of fuzzy logic can improve agent models that get closer to reality this has been explored in five aspects relationships among agents some variable attributes that determine agent states functions of similarity evolution of agent states and inheritance some aspects are appropriate for fuzzification such as the friendship relation but not for all such as the family relation also the compatibility concept for matchmaking with all the restrictions has needed changes in the similarity algorithm to a fuzzy version besides we extracted new knowledge through the ttransitive closure at the moment this work is not implementing the fuzzy influence the fuzzy inheritance and the fuzzy states anyway with the actual changes the similarity operation has improved substancially its accuracy the couples found are more logical due to two facts agents know more people than before thanks to the closure and the cited improvement in the measure of similarity and the friendship is more realistic instead of being boolean it is graded and it considers more knowledge thanks to the ttransitive closure for more information about this work and a deeper analysis of its results including graphs and tables of results please refer to the works of hassan salgado pavon the proposed fuzzification can be applied to other abss systems for instance the example has shown how to fuzzify relations that determine agents interactions even mixing fuzzy and crisp values also agents attributes can be defined in terms of fuzzy sets contextdependant functions like inheritance were modelled too as well as a typical fuzzy similarity operation life states of agents are frequent in systems that evolve over time especially in task solving environment sometimes it is convenient to fuzzify those states finally a global fuzzy operation over all the agents was defined on a fuzzy relation to make inference with coherent results other operations could be needed and applied in a similar way in order to adapt these definitions to other systems new constraints that suit context needs could be introduced fuzzy logic facilitates modelling to domain experts because the linguistic terms can be easily transformed into fuzzy sets of course there will be parts of an abss system that cannot be fuzzified but we think that fuzzy agents in social simulation can be extremely useful future lines of research include empowering inference and approximate reasoning using fuzzy sets fuzzy implications represent a tool with great potential and have solid foundations because they generalize the classic logical implication as an interesting path to explore their only special need is that the social scientist has to decide rules from his knowledge and operators that work well in each context should be selected

agent based models are useful to study emergent behaviour in social systems in general existing agent models tend to be quite simple but there are social problems that require the consideration of some aspects with uncertainty as human thinking does those characteristics can be addressed by using fuzzy sets theory in the specification of the attributes that describe agents representing individuals and in the functions that model the evolution of individual change of mind the relationships among individuals in a social network the inheritance and the similarity between individuals this paper discusses the fuzzification of agentbased models and analyses experimentation results for a specific case of the study of the evolution of human values in a society

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aims mental health answers salud mental responde is a crisis telephone line that was developed during the first months of the covid19 pandemic in the autonomous city of buenos aires argentina it is also a point of entry to mental health services providing assisted referrals to the appropriate level of care the aim of this paper is to evaluate the profile of the callers to the line during the first three waves of covid19 methods retrospective case analysis of calls made to the telephone line throughout the different covid19 waves under study for this analysis the time frame for the first three waves was as follows first wave from 1 august to 30 of november 2020 second wave 15 of march to 30 of july 2021 third wave from 20 of december 2021 to 25 january 2022 results the first wave lasted 122 days 4601 calls were recorded 27 calls were discarded for missing data womens mean age 5179 sd 173 n 3355 mens mean age 4329 sd 1552 n 1219 significant differences were found in age being men younger women made the majority of calls fear and anxiety represented 451 of calls depression 273 and psychosis 9 the second wave lasted 138 days and there were 4051 calls again most of calls were made by women there were significant differences in age being men younger womens mean age 4668 sd 1872 n 2872 mens mean age 3805 sd 1634 n 1138 the three most common detected problems were fear and anxiety 533 depression 149 and psychosis 183 the third wave lasted 36 days it had 1117 calls most calls made by women 705 men were younger and this difference was significant problems detected fear and anxiety 376 depression 45 and psychosis 327 conclusion there was a change in the caller profile throughout the studied period the callers from the first wave were older than the ones from the second and third waves there was a change in the motivation to call the most noticeable changes the drop in the number of calls related to depression and the increase in calls related to psychotic problems this last change might be related to the shift in the use of the phoneline from a crisis line to a point of entry to mental health services fathers where feelings of helplessness and marginalisation are common prevalence of paternal pmi is thought to be 1016 with higher risk demonstrated when their partner too experiences pmi the importance of this topic was highlighted in the nhs long term plan which recognised the disparity in service provision between males and females and the need to address this aim to conduct a systematic review to establish the knowledge beliefs and experiences of males with pmi and whose partners had pmi and to understand the barriers associated with helpseeking for paternal pmi methods five databases including embase web of science ovid medline scopus and psycinfo were searched for qualitative studies investigating the experiences of males affected by pmi personally or through their partners illness the research question and inclusion criteria were determined using the picoss method 11 studies met criteria for inclusion and were appraised for quality using the critical appraisal skills programme and joanna briggs institute qualitative checklists evidence was synthesised using thematic analysis and study quality and risk of bias were assessed using the assessing the methodological quality of systematic reviews checklist and risk of bias in systematic reviews too results 5 main themes and 17 subthemes were identified and demonstrated lack of knowledge and preparation for fatherhood and distress and isolation experienced by males with pmi males were reluctant to seek help and factors including stigma and lack of awareness regarding pmi and available support services were identified as barriers the option to remain anonymous flexibility of appointments and an emphasis on peer support were considered facilitators to engagement conclusion unhelpful and potentially damaging stereotypes regarding masculinity and pmi still exist prohibit helpseeking for pmi and promote the marginalisation of males in perinatal settings support for males with pmi is warranted but lacking and effective communication and education regarding paternal pmi for both professionals and the public is needed to allow successful expansion of services to include males abstracts were reviewed by the rcpsych academic faculty rather than by the standard bjpsych open peer review process and should not be quoted as peerreviewed by bjpsych open in any subsequent publication medical students perceptions of factors associated with their mental health and psychological wellbeing mrs aisha ali hawsawi 12 dr neil nixon aims in light of growing evidence suggesting that medical students are particularly susceptible to stress and ill health the need to enhance their psychological wellbeing has been highlighted as a priority concern in medical education and policy however only a few studies have comprehensively addressed both positive and negative contributors to medical students psychological wellbeing therefore this study aims to provide a more holistic understanding of medical students psychological wellbeing the coping strategies they use and any barriers they face in seeking support as well as outline potential areas of improvement within provisional wellbeing support methods this qualitative study involves semistructured interviews with 25 medical students to gain indepth insight into their experiences and perspectives on the factors influencing their psychological wellbeing during their medical training the interviews were transcribed and analysed using thematic analysis results the studys results revealed that positive and negative factors influence medical students psychological wellbeing positive factors such as studylife balance academic achievement meaningful relationships with staff and peers and time spent with close friends or family positively influenced students psychological wellbeing while adverse educational organisational and cultural factors negatively impacted students wellbeing additionally covid19 had negatively affected students academic personal and social lives medical students mainly used active coping strategies including planning acceptance positive reframing and seeking support however some students reported facing barriers in seeking support such as fear of stigma lack of timesupport confidentiality concerns and difficulty in accessing support at the same time there was an expressed need to improve wellbeing services or resource provision students have recommended various solutions to improve mental health support in schools including addressing cultural and organisational changes within schools increasing access to resources reducing the stigma surrounding mental health and promoting positive factors that support psychological wellbeing conclusion the findings highlight the importance of adopting a holistic approach that considers a variety of contributing factors affecting positively as well as negatively medical students wellbeing it also highlights the need to provide a supportive and nurturing environment in medical schools and offer appropriate support and resources to help students cope with the stress and challenges of medical training abstracts were reviewed by the rcpsych academic faculty rather than by the standard bjpsych open peer review process and should not be quoted as peerreviewed by bjpsych open in any subsequent publication weight change following diagnosis with psychosis a 25 year perspective in greater manchester uk doi 101192bjo2023192 aims weight gain in the monthsyears after diagnosistreatment severe enduring mental illness is a major predictor of future diabetes dysmetabolic profile and increased cardiometabolic risk in people treated with antipsychotic agents there is limited data on the longer term profile of weight change in people with a history of smi and how this may differ between individuals we here report a 25year perspective on weight change postsmi diagnosis in greater manchester uk an ethnically and culturally diverse community with particular focus on a history of psychosis vs bipolar affective disorder methods we undertook an anonymised search in the greater manchester care record we reviewed the health

physical activity sleep mental health physical health wellbeing quality of life cognition and functioning are interconnected factors compared to general population average people experiencing psychosis have lower levels of physical activity high levels of sedation and more sleep problems soundy et al 2013 vancampfort et al 2015 this is linked to symptoms of depression lower wellbeing hopelessness lower quality of life and physical health conditions such as cardiovascular disease cvd stroke hypertension osteoarthritis diabetes and chronic obstructive pulmonary disease copd rhodes et al 2017 schuch et al 2017 engaging in physical activity is associated with improved quality of life psychotic symptomatology cognition functioning and physical health for people with psychosis experience mittal et al 2017 to be effective interventions need to be individualised griffiths et al 2021 an early intervention in psychosis eip service intervention was delivered the provision of a fitbit and its software apps sleep hygiene and physical activity guidance motivational interviewing workbook goal setting through three sessions with a clinician eip service staff used fitbits themselves sharing experiences with patients aim was to improve sleep physical activity wellbeing and prevent weight gain methods outcome measure data collection from baseline to 6 week followup change in physical activity sleep mental health wellbeing and physical weight were assessed in 50 participants and fifteen participants were interviewed people with lived experience of psychosis were part of the research team and contributed to design analysis and reporting results improvements were found in physical activity sleep mental health and wellbeing and there was no weight gain most patients actively used the fitbit and its software apps guidance and workbook to set goals and to make positive changes to their lifestyle and daily routines to improve motivation quality of sleep and level of physical activity conclusion healthy effective sleep and physical activityexercise is important to eip service patients wellbeing and mental and physical health eip staff successfully and fully integrated the welltrack intervention into routine service provision the project has better allowed staff to effectively engage with and discuss issues around sleep physical activity wellbeing and mental health and reducing weight gain the intervention was beneficial relatively easy and low cost to implement and wellliked by patients and staff and therefore could be offered by all eip services eip services should consider and assess sleep and physical activityexercise issues and promote healthy effective sleep and physical activityexercise within recovery focused practice abstracts were reviewed by the rcpsych academic faculty rather than by the standard bjpsych open peer review process and should not be quoted as peerreviewed by bjpsych open in any subsequent publication